In the field of neuroscience nursing, research was well established in 1990 as documented by DiIorio (1990) in her first evaluation of neuroscience studies published from 1960 to 1988 in four scientific nursing journals (Nursing Research, Journal of Neurosurgical Nursing later called the Journal of Neuroscience Nursing, Research in Nursing & Health, and Western Journal of Nursing Research). From her evaluation, neuroscience nursing research had increased substantially between 1960 and 1988, was mainly oriented toward rehabilitation and acute care, and focused on physiological variables. Studies on prevention of neurological injuries and insults, neurological chronic conditions affecting the older adults, and also the need to consider psychosociological variables were recommended because of the first evaluation of the neuroscience nursing research.
In her second evaluation (DiIorio et al., 2004), the same four journals were examined (Nursing Research, Journal of Neuroscience Nursing, Research in Nursing & Health, and the Western Journal of Nursing Research). Comparing the results obtained against the earlier results, from 1989 to 2000, more publications emerged, oriented mainly toward patients with neurological problems and less on neurotrauma, mainly focused on the rehabilitation phase, with greater attention on psychosocial and combined variables (psychosocial and physical). The development of experimental studies was strongly encouraged at the end of the second evaluation (DiIorio et al., 2004). The purpose of this study is, therefore, to extend the previous evaluations (DiIorio et al., 2004) while assessing the emerging trends in the field of neuroscience nursing research in recent decades and providing a framework on which to guide future research.
Aim and Research Questions
Evaluating the trends of neuroscience nursing research from 1989 to 2010 in studies published during the 2000s was the main aim of the study. The research questions were the same stated by Dilorio and colleagues (2004), as reported following:
First research question: Was there an increase from 1989 to 2010 in the number of neuroscience studies, in the number of authors involved in each study, in their level of education and academic position as well as in the number of studies supported by funding, in the selected nursing journals? If so, what trend is emerging?
Second research question: Did the focus of neuroscience research shift in subspecialty areas (e.g., neurosurgery, neurology) and in care orientation (e.g., prevention) from 1989 to 2010? If so, what trend is emerging?
Third research question: Is there a primary setting and are there study design methods employed for the development of neuroscience knowledge from 1989 to 2010? Was there an increase in the number of the participants involved from 1989 to 2010 or a shift in their average age or gender predominance? If so, what trend is emerging?
Study Design and Methods
A multimethod study design articulated in two phases was adopted in 2011.
Permission of the author Colleen DiIorio and the list of variables adopted in her previous studies were obtained. Among the initial 61 variables included in the previous evaluations (DiIorio 1990; DiIorio et al., 2004), those variables (a) relevant to the research questions of this study, (b) stable over the years to ensure comparability of data, and (c) not implying a judgment by researchers, which might be affected by developments in research methods (Polit & Becker-Tatano, 2010), were selected. Thus, 16 variables (Table 1) were included in a grid prepared by two researchers (FM, DB) and therefore assessed for face and content validity (Polit & Becker-Tatano, 2010) by a third researcher (AP).
A literature review was performed by two investigators. Journals considered in the previous reviews (Nursing Research, Journal of Neuroscience Nursing, Research in Nursing & Health, and the Western Journal of Nursing Research [DiIorio et al., 2004]), to explore the trend in a consistent manner, were selected. In each article from among those published from 2001 to 2010 (December 31), including its title, abstract, and/or text, a research question/aim in the field of neuroscience nursing was included. According to the previous review developed by DiIorio and colleagues, neuroscience nursing research was defined as research that addresses problems of importance to neuroscience nurses and patients and published in the selected journals during the review period (DiIorio et al., 2004, p. 59). A content analysis of each included article was carried out by three trained researchers. Each article was coded according to the variables on the basis of the operational definition given to each variable (Table 1). Fifty of the selected articles were evaluated by two researchers to test interrater concordance for all variables, which was >0.90. To ensure consistency of review with previous ones, there was constant contact and feedback received by the author of the original research (Professor DiIorio) during the process.
Data analysis was performed with the SPSS Statistical Package v18. According to the research questions of the study, two levels of analysis were conducted:
Descriptive statistic (frequencies, percentages, averages, median, and standard deviations) of the number of articles published from 1989 to 2010 and their principal characteristics (Table 1) as published in homogeneous periods (e.g., 1989–1992, 1993–1996) in accordance with previous publication (DiIorio et al., 2004) were evaluated. When appropriate, descriptive comparison between the results documented in the first version encompassing the years 1989–2000 (DiIorio et al., 2004) with those obtained from 2001 to 2010 was described.
Analysis for Trend
To identify a trend (Streubert & Carpenter, 2007), two homogeneous periods in length were preliminarily identified by researchers (2001–2008 [8 years] and 1993–2000 [8 years]). Thus, a comparison was performed of the articles (and their characteristics) published in the period of 2001–2008 with those published from 1993 to 2000 (odds ratio [OR], 95% confidence intervals [CIs]). The more recent period was considered a reference in the trend analysis to capture the emerging trend (2001–2008 vs. 1993–2000). Trend analysis (Polit & Becker-Tatano, 2010) allows us to evaluate the increase (or decrease) in the occurrence of a phenomena of interest (e.g., the number of studies published) in two or more different periods, homogeneous in length. The results are reported in ORs (e.g., in the case of the number of studies published: OR = 2.1), referring to the ratio of the odds of a phenomena occurring in one group compared with the odds of occurrence in the other group. The results are also expressed in confidence interval (95% CI [1.33, 3.29]), which allows us to understand if the increased trend is statistically significant (as in the case of the number of publications, p = .00) or not.
First research question: Was there an increase from 1989 to 2010 in the number of neuroscience studies, in the number of authors involved in each study, in their level of education, in their academic position, and in the number of studies supported by findings, in the selected nursing journals? If so, what trend is emerging?
As reported in Table 2, from 1989 to 2010, a total of 607 articles were published, 2.2 articles per month (607 for 264 months). A constant increase in the studies published has emerged, except for the period from 1997 to 2000 in which there was a reduction in the number of publications (n = 55). Comparing homogeneous periods (2001–2008 vs. 1993–2000), a significantly increased number of publications on neuroscience nursing research have emerged (OR = 2.1, 95% CI [1.22, 3.29]; p = .00).
From 1989 to 2000 (DiIorio et al., 2004), the number for authors per article ranged from 1 to 11; 34% of the articles were written by a single author, whereas 27.3% of the articles were written by two authors. In the most recent period (2001–2010), the number of authors ranged from 1 to 15, on average, 1.87 (standard deviation = 0.8) per article. Some 127 (29%) articles were written by only one author, whereas 104 (23.7%) were written by two authors.
At an overall level, from 1989 to 2010, the first author was most likely to have a PhD (399, 65.7%), and there was a steady growth of authors holding the highest academic qualification although there was a contraction in the number of articles published by nurses with master’s degrees. Comparing homogeneous periods (2001–2008 vs. 1993–2000), a significant increase in the number of articles written by nurses with a PhD has emerged (OR = 1.55, 95% CI [1.02, 2.38]; p = .01). At an overall level, among the first authors, 55 (9.1%) were fellows of the American Academy of Nursing (FAANs): in any case, comparing homogeneous periods (2001–2008 vs. 1993–2000), the proportion of FAANs was almost unchanged (OR = 0.56, 95% CI [0.29, 1.07]; p = .05).
At an overall level, the position occupied by the first author (e.g., professor) was academic for 299 (49.3%), clinical for 183 (30.1%), research for 49 (8.1%), students for 21 (3.4%), other (e.g. nursing directors) for 17 (2.8%), and not determinable for 38 (6.3%) authors. Comparing the periods of 2001–2008 and 1993–2000, there is less likelihood in the recent years to have articles written by the first author occupying an academic position (OR = 0.45, 95% CI [0.29, 0.69]; p = .00). Regarding the affiliation (e.g., university, hospital as clinical wards), it is also less frequent to find studies written by a first author working at university (OR = 0.56, 95% CI [0.36, 0.89]; p = .00) although there is a progressive increase in the number of articles written by nurses working in clinical settings.
At an overall level, less than half of the studies were supported by funding. From 1989 to 2000, more than the 50% of the studies received at least some financial support; in recent years, funding seemed to be gradually reduced: in fact, it is less probable in recent years (2001–2008 vs. 1993–2000) to have found support (OR = 0.33, 95% CI [0.21, 0.50]; p = .00).
Second research question: Did the focus of neuroscience research shift in subspecialty areas (e.g., neurosurgery, neurology) and in care orientation (e.g., prevention) from 1989 to 2010? If so, what trend is emerging?
At an overall level (Table 3), neurological problems were the predominant object of study (389 articles, 64.1%), followed by neurotrauma (156, 25.7%) and neurosurgical (31, 5.1%) problems. However, some articles have also addressed combined issues (20, 3.3%), and 11 studies (1.8%) did not relate specifically to clinical problems. Moreover, when comparing two homogeneous periods under study (2001–2008 vs. 1993–2000), a progressive reduction of articles focusing on neurological problems (OR = 0.42, 95% CI [0.26, 0.68]; p = .00) has emerged. The care orientation of the articles were mainly devoted to chronic/rehabilitation (393, 64.6%), followed by acute care (148, 24.7%), prevention (44, 7.2%), and unspecified areas (22, 3.5%). Moreover, between the periods (2001–2008 vs. 1993–2000), a substantial homogeneity in care orientation has emerged (OR = 0.93, 95% CI [0.60, 1.43]; p = .37; Table 3).
At an overall level, the variables studied were predominantly combined (physiological + psychological) for 383 (63.1%) studies. Only 118 (19.4%) investigated only physiological variables, whereas 86 (14.2%) investigated those psychological; fewer studies (20, 3.3%) focused on teaching/learning variables. A significantly higher frequency of studies studying combined variables (2001–2008 vs. 1989–2000) has emerged (OR = 3.87, 95% CI [2.52, 5.95]; p = .04).
Third research question: Is there a primary setting and are there study design methods employed for the development of neuroscience knowledge? Was there an increase in the number of the participants involved from 1989 to 2010 or a shift in their average age or gender predominance? If so, what trend is emerging?
The settings chosen for the studies (Table 3) were mainly the hospital (211, 34.8%) followed by long-term care (125, 20.6%) and the home environment (77, 12.7%). Comparing homogeneous periods (2001–2008 vs. 1993–2000), studies performed at the home level were lower (OR = 0.27, 95% CI [0.15, 0.47]; p = .00), whereas those carried out at the hospital and at the long-term care level have increased.
At an overall level, 343 (56.5%) were descriptive studies followed by literature reviews of studies (139, 22.8%), and quasiexperimental studies (61, 10%), whereas RCTs were less frequent (24, 3.9%). However, differences in the categorization of the studies have emerged from the first review (Dilorio et al., 2004) and this review; therefore, trend analysis regarding the research strategies adopted during different decades was not performed.
Analyzing the period from 1989 to 2000, the number of participants involved in the studies ranged from 4 to 3,116, and the median sample size was 52.5. There were a total of 24,167 reported participants across all the studies included. The median number of women involved in the studies (n = 29) was slightly higher than the number of men (n = 23; women-to-men ratio = 1.26). From 2001 to 2010, an average of 125 participants were involved (median sample size = 39, range = 1–4,334); a total of 37,403 subjects in the studies were involved, on average, 78.7 women and 33.8 men (women-to-men ratio = 2.32).
From 1989 to 2000, the average age of the participants was 50.7 years (range from 0 to 104 years). From 2001 to 2010, the participants’ average age was 52 years (range of 0–87 years). Only 63 studies (32.4%) from 1989 to 2000 reported the ethnicity, whereas from 2001 to 2010, ethnicity was specified in 125 of 281 studies (44.4%).
This study extends an earlier publication (DiIorio et al., 2004), which investigated the nursing research in neuroscience over the period from 1989 to 2000, and repeats the analysis for the period between 2001 and 2010 using the same procedures. Historical significance of the literature review evaluating trends, in its aim to provide a framework on which to guide future neuroscience nursing research, is well recognized among researchers and clinicians (Polit & Becker-Tatano, 2010).
Over the last 2 decades, the number of articles dealing with neurological problems has increased especially in the Journal of Neuroscience Nursing, whereas it has decreased slightly in the other nonspecialized journals. Although it included only four nursing journals in a landscape that is much richer in recent years (at least 88 are those with an impact factor in 2010) and, thus, the number of studies emerged is underestimated for neuroscience nurses, with the possibility of furthering knowledge to base their decisions on evidence, there is, on average, more than 2.2 articles per month available in their field.
It is now more likely to have articles prepared with the first author holding a PhD and less commonly working in an academic position: this might indicate that the progressive increase in the requirements of scientific publications requires greater competency such as those in possession of a PhD, although research seems to be promoted especially among the clinical settings where nurses might develop relevant queries while taking care of patients. Likewise, a reduction in the number of the first authors who are fellows of the Academy of Nursing has emerged over the years and in the trend analysis. It should also be considered that we have analyzed the academic education and work position only of the first author according to his or her relevance in developing the research questions and the research protocols (Rennie, Yank, & Emmanuel, 1997). However, many authors have been involved in the last 10 years, and other trends might emerge if their education and work position were to be analyzed. The increased number of authors over the last decade might indicate that neuroscience nursing research is more cooperative, designed and conducted involving many partners who offer their scientific credentials to the published work.
The decrease in those studies supported by funds is striking. In a review of research articles published in nursing journals, Anderson and colleagues (2003) found that 40.8% of studies reported were at least partially supported, whereas in ours, there were 54.4% in 1989–1992 and 27.5% in 2009–2010. This reduction might be explainable from different perspectives: the most probable, considering the global financial crisis that has occurred in the last years, is the decrease of resources dedicated to research (Bestini, Garatini, & Rappuoli, 2008); also, changes in journal policies related to how funding must be declared might have occurred over the years. Finally, according to the affiliation and position of the first authors, as emerged in our study, research originating in clinical practice is probably driving this change.
At an overall level, neurological issues remain the most studied according to the diffusion of the neurological problems (Mayeux, 2003; Ziegler-Graham, Brookmeyer, Johnson, & Arrighi, 2008), although greater attention to neurotrauma is emerging. In fact, from the trend analysis, the interest of neuroscience nursing research is more on neurotrauma and less on neurological and neurosurgical problems. One reason for this shift might be that authors publish their articles on neurological/neurosurgical patients in different scientific journals, whereas the occurrence of neurotrauma and related issues may have stimulated the need for more research in the field.
Studies remain quite focused on rehabilitation, and those focused on prevention have increased progressively, but no significant new trends in the care orientation of the studies have emerged. In the last 20 years, healthcare policies have recommended taking care of people with neurological and neurotrauma problems with long-term conditions outside the hospitals, and the results emerged seem to be consistent with this recommendation. Despite this, most of the studies (34.8%) were developed at the hospital level, whereas significant negative trends have emerged in favor of studies considering the home as a research setting: this suggests the need for greater investment in studies that are home based as well as studies taking place in long-term care settings; such studies should be encouraged.
Among the nature of the variables studied, those combined (physiological and psychosocial) were more represented (>60%) according to the multidimensionality of the problems of the patients and the increased complexity of nursing care in the field of neuroscience. Unfortunately, most of the study designs adopted were descriptive, and a limited proportion of RCTs or quasiexperimental studies aimed at assessing the effectiveness of nursing care have emerged.
An increase in the sample size and in the representation of women rather than men in studies in the second period (2001–2010) compared with the first have emerged. Research has identified gender differences in both physiological and psychosocial behavioral responses to injury and disease; therefore, neuroscience nursing research should address the gender differences to contribute to the advancement of knowledge concerning individual variability and how to maximize outcomes for both genders.
Data on ethnicity are reported infrequently over the years, with increased occurrence in the last decade as compared with the previous; this is probably because of the different requirements in the study protocols, which regarding ethnicity has only recently been standardized (Institute of Medicine, 2009), as well as differences in journal author guidelines. Ethnicity would need to be further included as data to gather accurate results: research is a priority also in the process of understanding inequalities among different ethnic groups and the consequent policy decisions (DiIorio et al., 2004).
There are several trend analyses published in different fields and periods (e.g., Agustsdottir, Holcombe, Wright, Daffin, & Ogletree, 1995; Goldrick, Baigis, Larsen, & Lemert, 2000; Froggatt, Field, Bailey, & Krishnasamy, 2003; Haylock, 2008; Scholes, 2010; Yang, Liu, Ni, Chang, & Chen, 2009). Moreover, no analyses for trend in neuroscience nursing research are available, and this study seems to be the first. However, it has several limitations. First, only four journals were included: neuroscience nursing research has changed over time, and a significant portion of research is published in journals not included in this study and in the previous. Therefore, the results are not representative of all the current Neuroscience Nursing Research. Further studies should address this limitation, including additional journals.
Second, over time, only those variables that could not have been influenced by changes in the methods and research approaches were considered (Polit & Becker-Tatano, 2010). In the future, there is a need to include new study designs and variables such as those evaluating the effectiveness of complex intervention, which has been introduced recently (Petticrew, 2011).
Third, the involvement of a different research group from that involved in the previous review has assured international cooperation (United States and Italian) but, at the same time, may have introduced some problems of accuracy in the interpretation of variables. A strict comparison procedure of the variables under study was assured also with multiple contacts between the Italian researchers and Professor DiIorio.
Finally, in the analysis for trend, only quantitative data were considered, excluding the influences that may have been determined by the evolution of nursing education, research, and other factors as recommended by Leino-Kilpi and Suominen (1988). Future studies in this field should also analyze the social and historical influences and include the broader context to explain emerging trends.
Research in neuroscience continues to grow. Over the past 20 years, it has progressed consistently to offering new knowledge for practical nurses. Looking ahead, it will be necessary in the coming years to further develop research studies based on complex intervention as needed by patients with neuroscience problems or based on quasiexperimental or experimental designs. It will be also necessary to involve various care settings along the illness trajectories of patients in an acute phase but especially in a long-term phase, thus increasing attention on patients of any age, gender, or ethnicity. It will also be important to rely on international studies to compare strategies, nursing intervention, and clinical pathways of effective care.
We thank Professor Coleen DiIorio for her substantial supervising during the research process, data analysis, and manuscript preparation/development.