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research on the management of symptoms experienced by Alzheimer's disease patients. The National Institute of Diabetes and Digestive and Kidney Diseases and the NCNR are co-sponsoring a request for applications for studies on diabetes in minority populations. Two other Institutes (NICHD & NIMH) have joined NCNR in a request for applications for an exploratory center grant initiative targeted to investigations of health behavior developnent in children and adolescents.

Because nursing research cross-cuts so many disease areas, NCNR staff are constantly watching for viable research opportunities that may be of interest to other NIH Institutes, Centers, or Divisions for possible cofunding opportunities.

In FY 1990, funds totaling $1.6 million were received from other agencies for cofunded projects. NCNR will continue to work with colleagues in other Institutes to foster interdisciplinary research.


Question. A recent New England Journal of Medicine (Feb 28, 1991) article projects that of persons who turned 65 in 1990, 43% will enter a nursing home before they die. Is NCNR supporting any studies to improve the quality of care in nursing homes?

Answer. Concern about the quality of care in nursing homes has been an ongoing interest of NCNR and the nursing research community. Recognizing that with the increasing growth of the elderly population the numbers of older persons requiring some time as a nursing home resident will also increase, NCNR has targeted long-term care as a priority area. Several studies have been funded by NCNR that focus on the development and evaluation of specific intervention strategies for nursing home residents. In one such study, an investigator is examining the effectiveness of a dressing behavior intervention designed to maintain functional independence among cognitively impaired nursing home residents as long as possible. Preliminary information from this study has enabled this investigator to expand the work to other behavioral strategies that could assist demented older persons.

Another investigator who is investigating factors that Influence recovery from hip fractures, has followed patients from the hospital to nursing homes or to home care. Preliminary analysis shows that increased age, the presence of more than one health problem, ability to be mobile after surgery for the fracture, and whether or not the patient lived alone influenced return to full functional status and admission to a nursing home. A third investigator has designed a nursing intervention for nursing home residents at risk for declining functional status and is evaluating its effectiveness in adverting this decline among residents.

As some of the intervention studies have been completed new areas for investigation have been identified. One such intervention study was targeted toward one of the more difficult care problems occurring in nursing homes, urinary incontinence. In this study a regimen of prompted voiding as a strategy to

increase continence was examined and found to be successful for a considerable number of residents. However, the success of this intervention requires the full attention and motivation of nursing home staff to maintain the regimen which was not forthcoming once the investigative team withdrew after the study was completed. A new area of possible inquiry for the investigator is to examine ways to effectively implement interventions that are experimentally successful but not as effective in clinical practice.

Long-term care will continue to be a priority for NCNR. One important area for emphasis will be the examination of ways to facilitate the transition of older persons in nursing homes back to successful community living. Studies that focus on interventions to maintain and improve functional abilities, avoid the onset of disabilities, and to maintain the health of those with chronic illnesses should assist in delaying, or avoiding the need for, nursing home care among older persons in the future.




Question. I understand that the Center for Nursing Research is collaborating with other institutes on an initiative to study adolescents and risky health behaviors. Can you tell us more about that?

Answer. Several recent reports highlight the significance of behaviors which compromise health. These patterns of behaviors including diet, physical activity, alcohol and tobacco use, risk taking, and sexual behaviors begin in childhood and adolescence, Little is known about the natural history of such behaviors. Healthy alternatives to meeting the needs of adolescents need to be identified and tested. In collaboration with other funding agencies, NCNR is seeking research that will form the foundation for testing theory based interventions critical for nurses and other health professionals working with children in schools and other settings that encompass knowledge of behavior, learning, and psychological and cognitive development.


Question. When the NCNR was created, this subcommittee hoped that the center would help foster a strong supply of nurse researchers. What can you tell us about the numbers of nurse researchers who are applying for support from NCNR? Are there other actions this subcommittee should take to ensure that 'nurses enroll in doctoral programs and have sufficient support and encouragement to seek a career in research?

Answer. A major initiative of the NCNR is to develop a strong cadre of nurse investigators to address the complex problems related to improving patient care. These initiatives have been successful in encouraging more nurses to choose both predoctoral and postdoctoral training. There is a strategic plan for systematically increasing the number of supported trainees and fellows to 320 per year.

This number is based on the recommendation of the Institute of Medicine 1985 report on Personnel Needs and Training for Biomedical and Behavioral Research. By FY 1990, the number of supported trainees/fellows had increased from 165 in FY 1986 to 257. However, in 1992, in order to increase funds for research project grants, it is not possible to continue to increase the number of individuals supported for research training.



Question. Dr. Hinshaw, I understand that one of the priority areas of study established by the Center is the Prevention and Care of Low Birthweight Babies. You discussed this briefly in your testimony. Dr. Hinshaw, this is an extremely serious problem in this country, would you elaborate further on the Center's research agenda in this area, particularly as it concerns efforts to prevent low birthweight babies?

Answer. The NCNR, in collaboration with the National Institute of Child Health and Human Development (NICHD),. is encouraging Interdisciplinary teams of basic and clinical scientists to address issues related to caring for very low birthweight babies in intensive care units as well as issues related to the prevention of LBW.

Neonatal intensive care units are an important factor in the survival of LBW infants, especially those weighing less than 2,500 grams. A major problem in neonatal clinical practice is the balance between prompt implementation of new technologies, procedures, and treatments and the demonstration of their safety and efficacy Studies that focus on problems of infant feeding, respiratory support, body temperature and skin care are needed to advance our understanding of the underlying explanatory biobehavioral mechanisms that determine the health of these infants.

Another initiative is encouraging the study of factors which may be effective in preventing preterm delivery and intrauterine growth retardation, particularly those related to nursing practice. Risk factors associated with LBW include maternal age, poverty, race, low educational levels, multiparity, and inadequate prenatal care. Maternal behaviors such as substance abuse, smoking, alcohol consumption, and excessive exercise or standing Increase the incidence of premature labor. Innovative studies related to maternal behavior and life style, environmental risks, and the biobehavioral interface are needed.


Question. Dr. Hinshaw, maintaining an adequate pool of well trained nurses is essential to the delivery of efficient and affordable health care. This Committee has particularly been concerned and has provided strong support for nurse training programs over the past several years. Has progress been made in addressing the shortfall of trained nurses?

Answer. Progress has been made in addressing the shortfall of trained nurses. The aggregate supply of registered nurses is at an all-time high and is projected to increase until about 2005. In recent years enrollments in schools of nursing have increased significantly. Preliminary data from the National League for Nursing indicates the enrollments in the fall of 1990 totalled about 230,000, a 12 percent increase over the number enrolled in the fall of 1989. Preliminary estimates of graduations also showed significant increases. These data, along with the findings in the March 1988 National Sample Survey of Registered Nurses, suggest that the nurse supply will remain at fairly high levels, at least in the near future. However, by the year 2010, the picture changes markedly. Significant declines are noted for the supply of registered nurses at a time when the need for nurses is exacerbated by the increase in the elderly and vulnerable populations.

The Secretary's Commission on Nursing assessed the cause of the nursing shortage as stemming from the increases in employer demand which could not be satisfied by the available supply. The latest available data from surveys of employers in various fields suggested a continuing high level of budgeted vacant positions. Based on these data there may currently be about 126,000 - 158,000 additional full-time equivalent registered nurses needed.

Furthermore, a HRSA study of the need for nurse advanced trained specialties made at the request of the Senate Appropriations committee in 1988 indicated that the need for nurses with master's degrees would be more than 4 times that of the full-time equivalent supply in 1988.

Question. In your professional judgment, should the federal government continue to support nurse training programs?

Answer. This is not my area of expertise. It may be more appropriate to ask this question of the Director of HRSA's Division of Nursing. Nonetheless, through my work with the Commission, it is my professional judgment that there is a continuing need for the support of nurse training programs and for the support of the data collection efforts to monitor the nursing shortage.


BUDGET REQUEST Şenator HARKIN. Dr. Watson, it is good to see you here again today and welcome. I am sorry for all the delays we have had today.

I have been following the center's work with much interest. As you know, I am one of the more enthusiastic supporters of the human genome project.

I see that your request this year is for $110.5 million, which is an increase of approximately $23 million over the 1991 appropriations.

Would you briefly describe what initiatives you are planning to undertake in 1992 and the overall status of the effort to map and sequence the human genome?

Dr. Watson. Mr. Chairman, I am delighted to have this second opportunity to share with you and members of the committee my enthusiasm for what I believe is one of the most exciting and significant biomedical research undertakings of this century. With the strong support from the Congress and from the Department of Health and Human Services, the human genome project officially began on October 1 of last year.

Very simply the goals of the human genome project are to develop biological maps for each human chromosome and then to read the genetic text written in the chemical sequence of human DNA.

Why should we do this? We want to do it because this is the way that we can come to a much deeper and complete understanding of all the many diseases of human beings to which genetic predispositions contribute. We believe there are many thousands of genes which affect human health in very significant ways.

I have been very pleased over this past year with a number of developments. Because of the strong support we received from Congress and from the administration, we have been able to attract a very strong staff of people who are helping administer these funds, as well as a group of scientific advisors who are really first-class. So, I think the people who are managing the program are really as fine as you can find in our country. That they have joined in is due to, I think, the excitement they have and the fact that sufficient money has been appropriated to let the project get started in a big way as distinct from a small way.

We want to complete the project in roughly 15 years, and we believe we can do this within a budget of $3 billion. That would mean roughly $200 million per year. We are still building up to a sort of steady state, and that is why the increase of 26 percent, which is in this budget, is necessary for us to maintain the momentum of the program.

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