What if I had listened?

Christine Tassone Kovner |

Among the enduring questions in nursing research are “What is nursing research?” and “Can a non-nurse conduct research about nurses?” I never thought about either of those questions until I entered the nursing PhD program at New York University (NYU). Faculty stressed that research about nurses was not nursing research. The faculty charged us to develop nursing theory with an emphasis on Martha Rogers’ work. I didn’t think that I could do that. But NYU was two blocks from where I lived, and I couldn’t beat the tuition discount I received because my husband worked for the university. 

I tried to fit in, but as a public health nurse by education and experience, I saw my work as public health nursing research. I was (and still am) concerned about people receiving equitable access to satisfactory healthcare including health promoting care. For all people to have equitable access to nursing care, there needs to be enough nurses. And we need to understand the relationship of nurses and organizational characteristics that lead to quality nursing care that is satisfactory and equitable. 

Long story short, I failed my first proposal review. Research about nurses was not “nursing research,” remember? 

I didn’t let that stop me, even if I did have to change the focus of my dissertation a bit in order to finish my PhD. Ironically, I ended up with a job back at NYU, even though what I was passionate about wasn’t consistent with nursing research there. I was pretty sure I could change everyone’s mind about my research. My research has been team based with other nurses and people from non-nursing disciplines. 

In an effort to understand the cyclical nurse shortages experienced in the US, I conducted a study about nurse retention with a one year follow up to assess whether intent to leave was associated with actually leaving. It was, but not perfectly. More nurses intended to leave than actually left. That was intriguing, and I couldn’t stop thinking about it.

Based in part on that work, I obtained funding from the Robert Wood Johnson Foundation (RWJF) to study a nationally representative cohort of new nurse graduates for the first 10 years after their graduation from a nursing program. To my knowledge, it is the only panel survey of nurses ever conducted in the US with the exception of Harvard’s Nurses Health Survey. In addition to the panel sample, we also surveyed several cohorts of new nurses and surveyed some of the nurses about the quality of nursing care. We dispelled the myth that nurses were leaving nursing, which had primarily developed from observing nurses leaving organizations. By hearing from nurses over time, we found that most nurses were leaving organizations and going to other healthcare organizations, not to unemployment or other careers. We published over 30 articles on that work, but then life interfered. 

Superstorm Sandy hit New York City on 27 October 2012. Water from the East River flooded NYU’s medical center hospital. The hospital lost commercial power as the water killed its back-up generators. Without power, staff immediately took to the stairs to evacuate all patients, including babies from the Neonatal Intensive Care Unit. The Sandy disaster was sudden and severe. In the aftermath of that storm, we surveyed the nurses who had worked at the vacated hospital about their experience in the hope of gathering information that would help nurses and patients in future disasters. I couldn’t agree to do the research fast enough.

When COVID-19 hit New York City in March 2020, we realized this was a different type of disaster, but a disaster nonetheless—one that spread exponentially and quickly overwhelmed the city’s health industry. My colleague, Nancy Van Devanter, suggested we replicate the Superstorm Sandy study with the nurses who were experiencing this pandemic disaster to compare our findings. Maybe we could identify factors that ameliorated their stress to help inform responses to future disasters. Our team included a sociologist, a statistician with extensive public health training, and the former chief nurse executive of New York University Langone Health (NYULH). 

In mid-March, the university switched to remote learning, and we could not access our offices or meet in person. Nancy and I would be on sabbatical beginning fall 2020, but we thought if we could hang on teaching our classes remotely through the end of the spring semester, we could get the study done. We decided to proceed quickly so that we could hear from nurses in the midst of the pandemic. Primarily because of the time-consuming process of obtaining human subject permissions in many different settings, we limited the study to the 7,500 nurses who worked at NYULH’s four hospitals—a major medical center, an urban teaching hospital, an urban specialty hospital, suburban hospital, and in ambulatory settings- A new nurse executive joined NYULH as Chief Nursing Officer and Senior Vice President, Patient Care Services, in April 2020. Her availability and cooperation while in the midst of the pandemic made the study possible. She gave us access to the email addresses of all nurses at NYU Langone Health. NYULH generously provided money with which we paid the NYU Langone Health information systems department to set up the survey on Red Cap, produce the emails with a link to the survey, and provide us with a data set. With the institutional review board’s approval, we managed to get the survey up and running by May 2020. 

We stopped collecting data in early July 2020, by which time we had more than 2,500 respondents. Our first manuscript was published in Nursing Outlook during the spring of 2021—12 months from research conception to publication. 

Not surprisingly the nurses reported enormous stress in caring for people with COVID-19. Some highlights of the study include:

  1. Increased time caring for COVID-19 patients was associated with the more depression and anxiety.
  2. Conflict between home and work responsibilities was associated with higher levels of depression and anxiety. 
  3. Perceived mastery (self-efficacy) had the strongest negative correlation with depression and anxiety. 
  4. Co-worker support, training in proper PPE, and support from family/friends were the most common responses to what helped the nurses to carry out their care for patients. 
  5. Fewer than 25% of respondents wrote that their professional nursing education was helpful in caring for the COVID-19 population. 

We analyzed the more than 500 narrative comments and submitted the manuscript in early June 2021. We have not yet written a manuscript comparing findings from our Superstorm Sandy papers with data from the COVID-19 study, but that is next on the list. 

What if I had listened back when they tried to tell me “research about nurses was not ‘nursing research’?”

I think it is time to stop asking “What is nursing research?” and “Can a non-nurse conduct research about nurses?” I have come to see the blurry boundaries among fields and how much we can learn from each other. We should be training people to work together and learning how to speed the process of basic science discoveries to implementation of research findings. Our goal needs to be improving global health without regard to one’s research discipline. And I think that’s only attainable if we work with other disciplines and get over the “What is nursing research?” questions.

 

Christine Tassone Kovner, PhD, RN, FAAN, is the Mathy Mezey Professor of Geriatric Nursing at New York University Rory Meyers College of Nursing and a senior faculty associate at the Hartford Institute for Geriatric Nursing, both in New York City, New York, USA. Kovner is also a professor at the Grossman School of Medicine at New York University. She is a member of Sigma’s Upsilon Chapter. 

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