methodologies for the comprehensive study and evaluation of health-related quality of life.

The intramural program also conducts research on symptoms and side effects of treatments faced by individuals with HIV infection. Examples include muscle wasting, compliance issues, nausea, and fatigue.

The fourth area of expansion, health promotion among children and adolescents, is also a designated priority of the National Nursing Research Agenda. This will address dominant, preventable health problems in emerging lifestyles related to diet, physical activity, alcohol and smoking, and sexual behavior to achieve healthpromoting behavior changes in children and adolescents. We judge that if we would intervene at an earlier age, one might have a better opportunity to achieve health-promoting behaviors. We know how difficult it is at our age to try to maintain diets or to quit smoking. It would be better to start very early in life as lifestyles are emerging, to achieve these health-promoting behaviors.

Other areas of research are currently undergoing substantial program development. They include nursing interventions and women's health. In this area we stress midlife health issues and longitudinal studies of health and disease across the context of a woman's life.

An initiative on low birthweight has resulted in a cluster of studies. This will continue to be expanded. About 9 percent of our portfolio is currently in this area of study. This initiative targets studies that look both at care of the premature infant within the neonatal ICU's and studies which provide prenatal care in the community in a culturally sensitive way. I would be glad to speak to several of those studies later if you would like.

Rural health is another major focus for us, thanks to the directive and the encouragement of the Senate from the last 2 years. In addition, two task forces are being established which will advise us on policies regarding native American health care issues and on the issues of rural health.

PREPARED STATEMENT

I was also interested in the earlier points that you made about research training, because as a rapidly growing research discipline, a strong emphasis has been placed on establishing a cadre of wellprepared nurse investigators. Approximately 11 percent of our budget is invested in nurse research training, which is comparable to about 4 percent that is invested by NIH overall in biomedical research training. We have placed extra emphasis and dollars in order to expand the cadre of well-prepared nurse investigators. We are building post-doctoral programs supporting research intensive environments for training, and also creating training opportunities for our minority colleagues.

The fiscal year 1992 budget request for the National Center for Nursing Research is $43,747,000.

I would be pleased to answer any questions that you may have. [The statement follows:]

STATEMENT OF DR. ADA SUE HINSHAW

Mr. Chairman, I am honored to appear before you again to discuss the programs of the National Center for Nursing Research, the current state of knowledge for nursing practice, the challenges facing us in patient care, and the promotion of health in this country.

As the Center moves into its fifth year, our efforts show substantial progress--in the establishment of productive programs of research and training, in important preliminary findings achieved by our grantees, and in continued planning for growth and expansion. Clusters of studies are being

assembled in areas central to nursing care and practice--low birthweight, symptom management, long-term care of the elderly, and health promotion across the life span. The following are examples of very promising research:

Acute

A group of NCNR grantees has developed an instrument called the NEECHAM Scale to assess problems with information processing in older patients. confusion, defined as a disturbance in information processing, is an extremely serious condition that frequently develops in older people during hospitalization. Confusion increases the complexity of treatment, is associated with increased mortality and complications, and results in medical and nursing interventions that have associated risks, such as sedation, restraints, and catheters.

Preliminary findings from comparisons with three

In

other commonly used clinical assessment tools indicate that the NEECHAM Scale is more sensitive to early or mild disturbances in information processing. addition, this tool can be used at the bedside with minimal stress on the patient. The ability to detect confusion at a very early stage and to identify specific patterns in confusion development are prerequisites to prevention, early intervention, and effective management of this condition among older hospital patients.

In another NCNR-supported study, researchers are investigating a common problem among low birthweight infants--compromised breathing from immature lungs. These infants require mechanical assistance to help them breathe, along with suctioning to clear air passages. Early results from this study

suggest that turning the infant's head during the suctioning procedure does not improve the outcome and may actually be harmful. Data also suggest that repeated passes with the suction tube are not beneficial and can decrease the

infant's oxygen level. This information is critical to the effective care of these infants in the many neonatal intensive care units in our hospitals.

A third study addresses risk-taking behavior among adolescents. These behaviors are being examined among 1500 young people in grades eight through twelve in four rural Maryland counties. Personality characteristics, family backgrounds, and social interactions of those who engage in risky behaviors are being compared with those who do not. Initial data indicate surprisingly high levels of risk-taking behavior, such as drinking, speeding, and sexual activity at very early ages in this group of essentially middle-class

adolescents.

Preliminary analyses also show ethnic and gender differences in these behaviors. This study should provide important direction for fostering health-promoting behaviors in young people.

For future scientific opportunities, NCNR will focus heavily on healthpromotion and disease-prevention issues at each stage in the life span. Many health problems are in large part behaviorally determined and can be prevented or significantly improved through changes in behavior. The incidence of low birthweight, which accounts for nearly two-thirds of the 45,000 infants who die each year in the United States, can be considerably reduced through changes in maternal behaviors and lifestyle. One of the most significant factors in pregnancy outcomes is the expectant mother's social support system and its influence on her maternal behavior. An NCNR investigator is determining sources of positive support for low-income black women with input from members of the black community--nurse midwives, community workers, and pregnant women. The objective of this study is to design a culturally sensitive support intervention for these women, one that includes acceptable substitutes when their mothers or partners are not available.

Children of racial and ethnic minorities and those of lower socioeconomic status are especially vulnerable to adopting early risk behaviors that lead to diseases in later life. Three interventions to reduce cardiovascular risk

The

factors are being compared in a group of 1600 rural and urban children. interventions are (1) a large-scale information program to be taught in the classroom, (2) an individualized program to be provided by nurses for at-risk children, and (3) provision only of baseline screening results and their implications in a control group.

Results of this study will help to delineate

the role of nurses in individualized and population-based interventions for school-aged children aimed at reducing high risk behavior.

More attention must be paid to health issues at midlife, especially for women. Changes in gut function, menopausal symptoms, sleep disturbances, the stress of multiple roles resulting from careers and responsibilities for both children and aging parents--all require intensive research to improve the health and well-being of this age group. In one study, more than 450 women aged 35 to 55, including ethnic minorities and those with low-income lifestyles, will be tracked over a three-year period. The objectives are to determine demands made upon these women and their resources (including their health), specific stressors, attitudes about their multiple roles, and the steps they take to promote and maintain their health. This information will help determine the specific nursing interventions necessary to promote and maintain optimal health in this age group.

of independence.

Deficits in mobility, strength, balance, and endurance can pose serious physical problems for older people and increase their risk of injury and loss Among elderly nursing home residents, falls account for the major portion of reported injuries. Many of those who sustain hip fractures die from complications within a few months. The National Center for Nursing Research and the National Institute on Aging are cosponsoring "Frailty and Injuries: Cooperative Studies of Intervention Techniques" (the FICSIT project). This project involves an innovative mix of exercise, nursing, and rehabilitation techniques designed to reduce the loss of functional capacities and fall-related injuries in older persons. The NCNR component of the FICSIT project focuses on determining the benefit obtained from assisting high-risk nursing home residents to and from the toilet and the effectiveness of hip, protective garments in reducing injuries from falls.

Hypertension continues to be a serious problem among the black population, where the incidence is higher, the rate of control lower, and the likelihood of complications greater. One grantee is utilizing the resources of black churches for educational programs for members of their congregations who have high blood pressure. Nurse members are trained to educate people with hypertension about the meaning and management of their illness.

The NCNR's long-term care initiative focuses on nursing interventions for

clinical conditions associated with the need for long-term care among people aged 65 and over. Such conditions include, among others, oxygen deficit associated with chronic respiratory disease, impaired mobility, urinary incontinence, and cognitive dysfunction. The Nursing Center supports several studies concerned with interventions for these conditions. An NCNR grantee is investigating the effective delivery of supplemental oxygen to patients who require continuous oxygen therapy from a portable oxygen device. In this study, comparisons among three methods for providing supplemental oxygen are based on measures obtained during exercise performed at home. Early findings indicate that oxygen delivery through a tube in the neck is clearly better than through a nasal tube. These findings have important implications for management of respiratory conditions.

Another study is underway to determine the effect of a family-based intervention on the cognitive stimulation of patients with Alzheimer's disease. Effects on the well-being of their caregivers and caregiver-patient interactions are also being observed. A technique to provide cognitive stimulation is being taught to caregivers, who then use the technique with their patients every day at home. Preliminary data show trends toward improvement or maintenance in the treatment group and decreased cognitive functioning in the control group. Other early results indicate a trend toward

improved family interaction in the experimental caregiver group.

As numbers of rural residents of the United States have become proportionately smaller, their vulnerability to illness, disability, and poor pregnancy outcomes has increased. Research is needed to determine the health status of these individuals, their health-care requirements, and effective methods of delivering health care to them. NCNR is supporting two projects in a special initiative to study health care needs in rural and minority populations. One is designed to improve birth outcomes through Improved prenatal care to Native Americans and Hispanics living in rural communities in Oregon. The other is evaluating interventions for providing prenatal care to Hawaiian, Filipino, and Japanese women living in a rural district of Hawaii. These projects are intended to provide models of culturally sensitive, affordable, and cost-effective prenatal care for minority women in rural