NATIONAL CENTER FOR NURSING RESEARCH

STATEMENT OF DR. ADA SUE HINSHAW, DIRECTOR

SUMMARY STATEMENT

Senator HARKIN. National Center for Nursing Research, Dr. Hinshaw? I am glad to have you with us this afternoon. I look forward to hearing the overall status and health of the nursing profession in America today.

Your Center is requesting $35.127 million for next year, for a 4.82-percent increase. Please proceed.

Dr. HINSHAW. Thank you, Senator Harkin. It is an honor to appear before you again to discuss the programs of the National Center for Nursing Research and several important scientific opportunities that will provide information for guiding nursing practice.

The National Center has made considerable advances in the past year: first, the award of the first four research center grants; second, the establishment of a new collaborative intramural research program; third, the completion of the second step of the research training initiative; fourth, release of the reports of the first two priority expert panels for the National Nursing Research Agenda on the nursing research needed for low birth weight infants and on patients with HIV infection; the development of research initiatives for these two areas; the development of a rural health initiative; and finally, the establishment of a new program of research in bioethics and clinical practice.

The initiative which we have begun in research on the prevention and care of low birth weight infants has several major foci: strategies for preventing low birth weight infants through prenatal care; care of the infant in the neonatal intensive care nursery; and followup care of the infant and mother after discharge.

A major health challenge facing our Nation of course is the AIDS epidemic, and the Center is strongly committed to research on the physical, psychosocial and ethical problems central to the prevention of HIV infection at the care of individuals with AIDS, their partners and their fami": Our newly established intramural research program will begin in March with research in this field.

The increasing age profile of the Nation is focusing growing attention on Alzheimer's disease and other dementias, frailty, and injuries among older persons.

The NONR is defining and prioritizing nursing issues primarily dealing with the broader problems of family caregiving and the difficulties facing both formal and informal caregivers in this particular field. We also have begun a research initiative with the NIA to prevent falls in the frail elderly.

PREPARED STATEMENT

Finally, we are very interested and concerned, given the opportunity from the Senate Appropriations Committee in last year's appropriation language, to be able now to begin an initiative in health care in rural areas, and are working with several other public health agencies to develop a research and demonstration initiative to address the health issues of rural Americans with a special focus on minorities and native Americans.

Mr. Chairman, the fiscal year 1991 budget request for the Center is $35,127,000. 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, and the challenges facing us in patient care and the promotion of health in this country.

The National Center has made considerable advances in the

past year: the award of the first four research center grants; establishment of a new collaborative intramural research program; completion of the second step of the research training initiative; completion of the reports of the first two priority expert panels for the National Nursing Research Agenda -- on the nursing research needed for low birthweight infants and on patients with HIV infection; development of research initiatives for those two areas; development of a rural health initiative; and the establishment of a new program of research in bioethics and clinical practice.

Since prevention of and the care of low birthweight infants is a major area of scientific challenge and potential for nursing research, a major initiative has begun. This research has four major foci: preconception health, prenatal care, care of the infant in the hospital, and follow-up care of the infant and mother after discharge.

One NCNR-supported scientist is testing the effectiveness of prenatal and post partum nurse home visitation services as a means of enhancing the health and well-being of unwed poor women and their first-born children. Visiting nurses will teach the young mothers to improve their diets, to identify complications in pregnancy, and to care for their babies, including cognitive skill development and emotional development. The nurses will also encourage the mothers to return to school and find employment after the birth. For the mothers, the study will measure changes in prenatal health habits, infant caregiving skills, and other behaviors and skills. For the children, the study will measure the occurrence of prematurity and low birthweight, several types of growth and nutritional problems, and instances of child abuse and neglect. The preliminary study showed positive outcomes from the nurse home-visitation services.

Methods of caring for low birthweight infants in neonatal intensive care nurseries are another priority area for the NCNR. Physical care of these infants such as feeding, respiratory care, skin care, and positioning needs further study, to identify optimal care practices during hospitalization and after discharge. In December 1989 NCNR issued a program announcement, in collaboration with the National Institute of Child Health and Human Development, inviting applications to address these issues.

The most ominous health challenge facing our Nation is of course the AIDS epidemic. NCNR is strongly committed to research on the physical, psychosocial, and ethical problems central to prevention of HIV infection and the care of persons with AIDS, their partners and families. We are especially pleased with the establishment in 1990 of our new Intramural Research Program in

this field, in collaboration with the National Institute for Allergy and Infectious Diseases and the NIH Clinical Center.

NCNR intramural investigators will conduct basic and clinical research in symptom management of AIDS patients, seeking to minimize the harmful effects of the infection and treatments, such as unintentional weight loss, diarrhea, fatigue, oral complications, dementia, anxiety, pain, and depression. For example, as NIAID clinicians treat asymptomatic HIV-infected persons with AZT or alpha interferon, NCNR nurse scientists will quantify changes in nutritional status, and then develop nursing interventions to minimize nutritional problems such as anorexia, nausea, and weight loss. As long as HIV infection remains incurable and advanced treatments allow individuals to live longer, it is important to discover ways to decrease morbidity, to diminish the economic and personal costs of infection and treatment, and to promote an optimal quality of life.

An NCNR extramural investigator is studying health characteristics of infants of high risk mothers who remain HIV antibody positive over a three year period, as compared with infants who show no HIV antibody or who seroconvert from positive to negative. Many of the high risk mothers decline to be tested for antibodies to the virus but permit testing of their infants. However, HIV antibody testing of newborns is not reliable. Some infants who test positive later convert from seropositive to seronegative, and develop no symptoms associated with HIV infection. They may have had only transient maternal antibody and may be free of the virus. Developing better methods of detecting which children are actually infected is crucial to offering earlier, more effective care. Physiological and psychosocial growth and development measures as well as biological indices of HIV seroconversion are being tested, and may prove useful to nurses caring for high risk infants in the future.

The increasing age profile of the nation has focused growing attention on Alzheimer's Disease and other dementias, frailty and injuries among older persons, and the broader problems of family caregiving. The Center is defining and prioritizing nursing issues related to formal and informal caregiving practices. The Center has issued both a research training program announcement and a research support program announcement relevant to Alzheimer's Disease and related disorders, reducing frailty in the elderly, and issues in caregiving. One of the NCNR's new research centers focuses on related patient care issues with the elderly, for example, assessment of activities of daily living in determining the risk of falling in the elderly.

Some data suggest that informal caregivers (relatives, friends, or others who are not paid) experience extensive physical, emotional, and financial costs related to caregiving. One project focuses on refinement and testing of a model of caregiver perceptions of the burden and measures of the quality of caregiving. This study will assess changes in these relationships over time, to indicate points at which interventions by nurses may be most effective. This model should enable nurses to assist families in increasing the quality of care and identifying coping strategies.

The new Exploratory Center for Nursing Research at the University of Minnesota specializes in long term care of the elderly, particularly factors which influence the autonomy and independent functioning of older persons. Studies include clinical nursing interventions for aggressive behavior by cognitively impaired older people in nursing homes, prevention of falls among hospitalized elders, assessment of the needs of older persons after hospital discharge, and the mix of formal and informal caregiving services best for the home.

Behavioral research related to health is a key part of the mandate of the National Center for Nursing Research, and accounted for over one third of Center-supported research in 1989. Our research addresses the behavior of patients and care providers related to health and illness. Our new Specialized Center for Nursing Research at the University of Pennsylvania emphasizes advancing care in serious illness, including behavioral research efforts. One study characterizes depressive signs and symptoms experienced by stroke patients at three points in time after occurrence of the stroke. The location of the stroke within the brain will be related to the depressive symptoms observed. The results of this research should give nurses caring for stroke patients a tool for detecting depression, in order to make timely referrals for treatment.

We are especially interested in the development and maintenance of health promoting behaviors and the measurement of positive outcomes correlated to those behaviors. One of our grantees is studying the validity of the Health Promotion Model for explaining health promoting behaviors in adult populations of various ages with or without a recent catastrophic illness. The issues to be studied include exercise adherence among working adults, exercise adherence after myocardial infarction, ambulatory cancer patients' health promoting behaviors, and health promoting behaviors among older adults.

The adequacy of health care in rural areas is a growing challenge to the Nation. NCNR is working with other PHS agencies to develop a research and demonstration initiative that will address health issues of rural Americans, with a focus on the special needs of American Indians, native Alaskans and native Hawaiians, native Samoans, and other Pacific basin populations. Access to nursing services for rural populations is critical at this time.

NCNR is funding a study of home care, continuity of care and community support for older adults in two rural areas of Colorado. The investigator is describing the types and patterns of professional, family and community home health care services, the continuity of care from hospital discharge through home care, and problems with the services. It is expected that a comprehensive understanding of rural home care will provide a foundation for improved health care services to the rural elderly.

NCNR will be collaborating with the Agency for Health Care Policy and Research on the newly mandated Medical Treatment Effectiveness Program. The NCNR has emphasized the importance of quality of care and patient outcomes in its clinical research programs.