put, nurses were not being given the opportunity to fully use their professional training and were often not listened to as a member of the health care team. As a response, I understand that

the Nursing Center has developed so-called innovative practice models, or recommended job structure and content for nurses, and in fact the implementation of these innovative practice models may well affect patient outcomes.

What can you tell us about the success you are having in. encouraging the use of these innovative practice models and what evidence is there that the implementation of these models could in fact affect the outcome of patients?

Answer. The recent activities carried out by both public and private sector organizations to examine the shortage of nurses helped to provide evidence that the factors influencing their availability was more complex than anticipated, and would require responses from all levels of the health care system. The timing of the current shortage corresponded with a decline in enrollments in schools of nursing across the country. Recognition that the enrollment changes could compound the shortage in the future increased concern that the quality of patient care in the settings and communities where nurses practice, particularly rural and other underserved areas, would be seriously and deeply compromised. Understanding how to protect patient care and assure the appropriate utilization of nurses became the aim of the activities of nurse researchers, clinicians and managers.

The National Center for Nursing Research (NCNR), in conjunction with the Division of Nursing, HRSA, examined the relationship between the availability and allocation of nursing resources and their impact on the delivery of quality patient care. The proceedings of this conference, titled "State of the Science Invitational Conference: Nursing Resources and the Delivery of Patient Care, were published in November 1988. In addition, NCNR staff worked with the DHHS Secretary's Commission on Nursing (SCN) to investigate the factors influencing the national shortage of registered nurses. The SCN Interim Report published in July 1988 indicated that the current shortage, while demand driven, was also a reflection of nurses discontent with their perceived in bility to practice nursing in a manner appropriate to the standards of the profession. These findings corresponded to findings of earlier studies that examined factors related to turnover and retention of nurses in various health care settings.

Only a small number of studies have reported on the influence of nurses on patient outcomes. From these studies there is evidence that clinical collaboration between physicians and nurses influences the outcomes of care in intensive care units, that a higher proportion of registered nurses providing care in hospitals lowers patient mortality, and that the care in freestanding community-based Birth Centers, where care is predominately provided by nurse midwives, is safe and has a lower cesarean section rate than hospital care provided to low-risk pregnant women.

The position of NCNR has been that there is evidence that the quality of patient care is influenced by the clinical practice of nurses. The findings from several studies identify factors that stimulate nurse satisfaction with employment in clinical practice settings, increase retention and decrease turnover. Finding how best to configure the clinical practice settings so that high quality patient care is given and highly competent nurses are retained and professionally flourish requires considerable study which has only recently begun.

With this information as background, NCNR stimulated the systematic study of the effects of restructuring nursing practice environments on patient outcomes and on nurses practicing within them. The NCNR has funded three studies (two Cooperative Agreements and a research grant) to evaluate the impact of innovative nursing practice models in hospitals on the quality of care that is provided, on nurse retention, and on the costs to the institutions of the changes that are put in place. These models are designed to foster professional practice in clinical settings, to increase the ability of nurses to practice to the full expression of their clinical competence by designing patient care delivery methods that recognize the independent and interdependent functions of nursing and medical practice, and to expand the extent to which nurses are participating in clinical and managerial decisions. These five year studies are now into the second year; it will be some time before findings are available.

NCNR STAFFING

Question. It is our understanding that in FY90, NCNR expected to fill 29 full time equivalent (FTE's) positions out of 30 allowed. Have all staff vacancies been filled to date?

Answer. Early estimates of FY 1990 FTE usage, from

projections based on on-board position strength at that time, predicted that NCNR would use 29 full time equivalent (FTE) manyears out of its ceiling of 30 FTEs. The Center has been actively recruiting to fill needed positions, in order to establish an Office of Planning, Analysis and Evaluation, and to continue staffing the new Collaborative Intramural Research Program. We expect to have a total of 34 positions filled by the end of FY 1990. The effort to fill 34 positions by year's end is also in keeping with the NCNR's plan to utilize 37 FTEs of staffing in FY 1991.

MINORITY STAFF

Question. Of the number of staff you currently have on board, how many are minorities and what positions do they hold?

Answer. The Center currently has four minority employees, equivalent to 14 percent of the on board staff, and is also assisted by a minority college student on a stay-in-school appointment. The staff members are a Personnel Management Specialist, an Administrative Clerk, and two Secretaries. The Center is also assisted by three retired scientists, one of whom is a minority. Efforts are continually underway to seek

additional minority employees to work in the extramural programs of the Center. The pool of minority nurse researchers form which we can draw is very limited.

AIDS RESEARCH

Question. How much funding are you requesting to continue your projects in AIDS research? Are you planning to make any new

awards in FY91?

Answer. The President's Budget request of $1,148,000 in 1991 will allow the NCNR to continue to support noncompeting AIDS research projects and research training. New AIDS projects will be awarded if the percentile scores achieved during review are high enough to merit funding.

Question.

How is your research in this area progressing?

Answer. The physical problems of AIDS victims can be devastating shortness of breath, diarrhea, disorientation, frequent infections, fatigue and pain. NCNR has a commitment to support intramural and extramural research investigating

strategies to reduce discomfort from physical symptoms associated with HIV infection.

Because the link between knowledge and behavior change is often weak, NCNR is also committed to conducting and supporting implementation strategies for community-based outreach and intervention programs to help people recognize the behaviors that place them at high risk for HIV infection, and then take the difficult step of changing them. Both the House and Senate committees and the Institute of Medicine's study of NIH AIDS research programs have stated the need for the scientific community to increase the quantity of HIV behavioral research. As of 1989, the majority of NCNR HIV/AIDS grants are studying behavioral research issues, such as prevention of HIV transmission, self care in the home, parental acceptance and care of gay men with AIDS. Examples of NCNR's behavioral research portfolio in AIDS prevention and patient care follow.

Studies are determining the extent of condom and spermicide use in two high-risk populations, sexually promiscuous adolescents and college students. NCNR is interested in funding further research to investigate other high-risk populations, such as persons using psychoactive drugs and partners of infected individuals.

NCNR

Other investigators are identifying determinants of highrisk sexual practices among school and college-age persons. is interested in funding additional research in this area, particularly the study of sexual partners of HIV-infected, highrisk persons, minorities, prostitutes and individuals with learning disabilities.

MINORITIES IN NURSING RESEARCH

Question. How many minorities are involved in nursing research? What progress has been made, if any, in getting minority involvement in nursing research through minority institutions? Have the recommendations of the ad hoc advisory committee on minority training been acted upon? If so, what are some of the results? If not, when do you plan to pursue this

effort?

It was indicated in last year's appropriation's hearings that an ad hoc advisory committee on minority training had advised NCNR take steps to supplement institutional training awards in order to gain more positions for pre- and post-doctoral fellows from minority applications.

Answer. In November 1989, the NCNR hosted a conference on Research and Research Training Opportunities at the NIH for Directors of Research from schools of nursing with graduate programs, and invited participants from those schools of nursing at minority institutions. All participants were informed about research and training grant support available through the NCNR and NIH, and procedures for successfully applying.

The Ad Hoc Advisory Committee on Minority Training recommended that the NCNR make special administrative supplements to existing institutional training grants specifically for minority nurse trainees, in instances where the training institution could demonstrate availability of suitable minority candidates. The 11 active institutional training grantee institutions were contacted, and two institutions succeeded in bringing three qualified minority candidates into their programs through supplemental awards. This strategy will be pursued

further in FY 1990 and 1991.

The Committee also recommended that application procedures for new institutional training awards include special provisions for recruitment of minority nurse trainees. NIH guidelines require a minority recruitment plan as an essential component of the institutional training grant application. NCNR is working to clarify what the critical elements of such a plan are.

Overall, minority trainees increased from three in 1988 to nine in 1989. One of these is located at a minority institution. There are at least nine principal investigators on R01 research awards who are minority nurses and several others who are coinvestigators.

The Center has also invited the nursing research community to apply for administrative supplements to existing research projects in order to involve minority investigators in the ongoing conduct of research. In 1989, one such supplement was awarded, several are under review, and it is expected that this tool will be employed more extensively in the future.

ALZHEIMER'S DISEASE AND THE BURDEN OF CARE

Question. What has been the response to your cosponsored program announcement with the National Institute on Aging concerning Alzheimer's disease and caregiving? Did a large number of applications come in for research concerning this issue?

Answer. There has been an increase in inquiries to NCNR about research opportunities related to Alzheimer's disease and caregiving, as a result of the program announcement, and potential applicants have been pleased to learn that this is an area of interest to NCNR. Program staff have visited one of the NIA supported Alzheimer's Disease Research Centers and have encouraged nurse scientists to link with scientists from all disciplines at these centers in an effort to develop interdisciplinary research on caregiving. It is too early to Identity specific numbers of applications that are in response to the program announcement. However, the support of research and research training in this field by the NCNR rose from $1.4 million in 1988 to $1.9 million in 1989.

Question. How much funding are you requesting for research to study the burdens of caregivers in FY91? What was the response

in FY90?

Answer. Within the requested budget for FY 1991, the NCNR expects to support about $3,400,000. Special efforts are being devoted to encouraging research and training in this field on the part of the nursing research community, because of the vital importance of this work to elderly patients and to the persons providing their care.

In 1990, we estimate that research and training in this field may total about $2,400,000. A number of excellent research proposals are being received and funded.

NATIONAL NURSING RESEARCH AGENDA

Question. We understand the first major research priorities have been developed from the NCNR's long term planning endeavor, the National Nursing Research Agenda. Could you describe the

scientific priorities? What program activities have been initiated for these scientific priorities?

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Answer. The first two major nursing research priorities within the National Nursing Research Agenda are Low Birthweight Mothers and Infants, and HIV Infection Prevention and Care. A Priority Expert Panel for each of these areas has reviewed and refined the vital health questions relevant to nursing science. Reports on the promising areas for nursing research will inform the nursing and biomedical communities of each panel's findings and will be taken into consideration by NCNR in allocating resources. The report on HIV Infection close to completion and will be forwarded spring. The report on Low Birthweight also be completed in FY 1990.

Prevention and Care is to Congress in the Mothers and Infants will