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A conversation with Sandra Edwardson

by Heddy Bishop Hubbard and Barbara Elisse Najar

Sandra Edwardson

Sandra Edwardson, RN, PhD, FAAN, former dean of the University of Minnesota School of Nursing, recently concluded a one-year fellowship under the Senior Nurse Scholar-in-Residence Program of the Agency for Healthcare Research and Quality (AHRQ). The senior scholar position is supported by AHRQ in collaboration with the American Academy of Nursing (AAN).

The authors spoke with Edwardson about her experience at AHRQ and her thoughts regarding doctoral education for nursing—specifically PhD training—and how it relates to the current nurse faculty shortage, student selection, curriculum development and funding. In addition, because of her prominent role as a member of the task force on clinical doctorate education of the American Association of Colleges of Nursing (AACN), Edwardson was also asked about the newly proposed doctor of nursing practice degree.

“My reason for coming to AHRQ,” says Edwardson, “was to become completely immersed in scholarly work, which is difficult to do when one is faced with the pressures and time commitments of a university dean position. My experience as a nurse scholar afforded me the luxury of being able to explore large databases, such as AHRQ’s Healthcare Cost and Utilization Project (HCUP) and Medical Expenditure Panel Survey (MEPS). I also wanted to learn what projects are being funded in order to summarize the state of the research to date and to look toward improving the variables that researchers are examining.”

Edwardson’s research focus at AHRQ was patient education and self-care, particularly in relationship to heart failure and its associated costs. Heart failure has been identified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services as a target diagnosis for quality measures.

“Preparation for self-care is commonly recognized as the responsibility of nursing, since it is in chronic conditions that nurses often have a significant coordinating role,” says Edwardson. “In the past, the field has relied on discharge teaching, and I believe this is not enough. Preparing a patient for self-care is a very sophisticated skill. Most successful strategies begin well before release and combine cognitive preparation with behavioral supports, such as telemonitoring of symptoms and telephone follow-up of the patient. However, maintaining the follow-up needed for chronic conditions requires a tailored support system and interdisciplinary teamwork that includes nurses, pharmacists, social workers and physicians. I believe we’re moving in that direction because the task of tailoring patient support systems cannot be accomplished by one discipline alone.”

Chronic heart failure is a good example of a health condition with many attendant problems, including possible language barriers, cognitive impairment and emotional anxiety. “We don’t know all the reasons why patients experience adverse outcomes,” says Edwardson, “but we suspect it is a combination of interrelated factors.” As an example, she noted that when patients suffering from chronic heart failure experience fluid accumulation, nurses intervene to monitor blood pressure and weight. But patient involvement in this process is critical.

“The outcome is absolutely dependent on patients’ ability to care for themselves,” says Edwardson. “We must understand their concerns and to what extent they do or do not understand what is being communicated. We don’t know all the reasons why we get certain outcomes, but we suspect it is a combination of many factors working together. For example, if a patient is taking the prescribed drugs but stops, we must ask why. Is cost a factor associated with this intermittent use of the drug or its discontinuation? Does the patient have assistance in resolving these issues? What is the patient’s physical and emotional state?”

Patient supports, such as reminder systems, are being used to help them integrate and utilize what they have learned. To enhance this possibility, a growing number of facilities have instituted computerized clinical information systems. “I am confident that once these systems become more commonplace,” says Edwardson, “the health field will be able to explore what kind of care actually took place with patients. Also, compared to medical care by physicians, nursing has fewer verified ‘best practices’ for specific health conditions, but that is important and I believe we are making progress.”

During her tenure at AHRQ, Edwardson reviewed nursing studies funded by the agency to better understand their conceptual frameworks and the variables used. She found little consistency in definitions of common variables. Nurse staffing, for example, is measured differently from one study to another. Some researchers define it as the ratio of nurses to patients, others by the types of nurses assigned to patients, and still others in terms of how well patients’ needs are met with various staffing patterns. These inconsistencies make it difficult to build the knowledge base through cross-study comparisons.

Edwardson identifies lack of sufficient data as a major problem. She states: “Most challenging is the lack of large data sets to evaluate nursing variables. While we are making progress as a discipline—for example, there are more nurse-sensitive quality outcomes—these are not yet integrated into management system reporting at the national level. Most national data on nursing outcomes are administrative and include such things as diagnoses, cost of procedures, drug protocols and data on individual hospitals. Inclusion of recognized nursing measures such as falls, pressure ulcers, certain infections and failure to rescue would permit large-scale studies of what is and is not effective.

“When I looked at nursing outcome measures in the HCUP database,” says Edwardson, “I was surprised to find only staffing issues mentioned. I think the nursing field would benefit immensely by including more process measures. For instance, whether a nurse is certified in the area in which he or she is working could serve as a marker to measure the quality of care given by individual nurses. These kinds of data are not collected by most hospital administrators and yet would be enormously helpful. But before we can do that, we must first develop the language to describe problems nurses are working on. The evidence will emerge naturally once that is in place.”

Nursing education at the PhD level
Because of Edwardson’s 14 years’ experience as dean of a school of nursing, we asked about her views on doctoral education, particularly the PhD in nursing, the paramount aim of which is to stimulate scientific study research experience.

“While core nursing courses are important for strengthening the student’s expertise in nursing, I believe the main concentration should be research,” Edwardson responded. “Students should take courses that inform and enhance the dissertation and that lead to specialized training and pilot studies.”

A critical challenge in nursing doctoral education, she notes, is attracting the right faculty members and students. Insufficient supply of nurse educators has become a serious problem for nursing and health care in general, she says. Nursing schools often reject qualified applicants because appropriately trained faculty members are not available.

A survey in late 2004 by the American Association of Colleges of Nursing revealed that 32,797 qualified applicants were not accepted at schools of nursing last year, due primarily to faculty shortages and resource constraints. This includes 2,748 students who were turned away from master's programs and 202 turned away from doctoral programs (see Faculty Shortages). The latter data are particularly disturbing, since these graduate students potentially could have served in faculty positions after completing their advanced degree programs.

AACN has proposed legislation to increase the number of nurses prepared to assume faculty positions at U.S. nursing schools. The Nurse Faculty Education Act seeks to increase enrollment and graduation from doctoral nursing programs and to increase the number of doctorally prepared nurses who serve as nurse educators. Faculty members with doctoral degrees fill critical roles serving as educators of master’s and doctoral degree nursing students. These educators are important for strengthening the nursing work force, serving as role models and providing the leadership needed to implement evidence-based practice and improve patient outcomes.

In addition to a lack of qualified educators, nursing education can also be negatively affected when those who are on staff do not have sufficient teaching experience. Students should gravitate to universities that have or can draw faculty who can teach as well as mentor in the student’s area of interest, says Edwardson. This does not always happen, she points out, as it may be geographically or socially difficult for students to relocate. Ideally, students should be in an educational milieu where there is a strong research program in the student’s chosen field.

If existing faculty members display strength in either research or teaching but not both, the university may be able to borrow qualified faculty from other schools to fill the gap. Edwardson particularly notes the University of Minnesota’s remedial program to train and mentor faculty, especially those new to teaching the necessary skills. This model, developed at the University of Minnesota (U of M), might also be helpful at other schools.

“I believe in recruiting as many stars as you can or growing your own stars and keeping them at your university,” Edwardson says. “You need stars for funded research and to support graduate students as research assistants,” she explains. “Stars can hire PhD students as research assistants, and this becomes a win-win situation. But incentives are needed to keep stars. One approach is to obtain funding for research centers that focus on specific topics, such as the U of M’s Center for Children with Special Health Care Needs and its Center for Adolescent Nursing. It is also appealing to potential faculty members if a university has a focused research agenda. At the U of M, these two fully funded research centers maintain a financial and operational infrastructure to support scientific investigation.

“Health services research is a particularly important area for students and faculty to explore because of health care’s increased complexity and subsequent reliance on interdisciplinary collaboration,” says Edwardson. “For students to be encouraged to enter the field of health services research, faculty must be available who understand issues such as outcomes and effectiveness research, cost and decision analysis, and the science related to access and quality.”

Selection of students for doctoral programs is another important consideration. “I feel strongly that students should be selectively recruited so that there is a strong match between faculty and students,” Edwardson emphasizes. “A table at a conference with glossy brochures advertising doctoral programs is not a mechanism for developing solid alliances between faculty and students. Ideally, faculty should be assertively involved in student recruitment.”

Another issue that concerns Edwardson is that nurses typically enter PhD programs later in life, usually after they have been in clinical practice for a number of years. This late start shortens their research career trajectory and reduces the time they have to launch a major grant application and research program.

“Well-prepared faculty, carefully selected students, adequate funding and a curriculum that emphasizes a specific and focused research trajectory are imperative for university schools of nursing,” Edwardson says. “These educational elements help to advance nursing science, including evidence-based practice and quality improvement, and also enhance research expertise and development of the new knowledge that is so critically needed.”

The doctor of nursing practice
In March 2002, the AACN board of directors convened a task force charged with revising quality indicators for doctoral programs. Edwardson was chair of that task force. Among its recommendations for the future of nursing was espousal of the clinical doctorate as a distinct model of doctoral education that provides an additional option for attaining a terminal degree in nursing (American Association of Colleges of Nursing, 2004). Originating in education, clinical psychology and engineering, the clinical or practice-focused doctoral program emphasizes clinical work rather than research (Ellis & Lee, 2005). Because of the controversial nature of this degree and ongoing dialogue about this topic in nursing education circles, we wanted to know what Edwardson thought about the subject and how she had come to endorse this program.

“Initially, I decided to compare the University of Minnesota’s master of science degree in nursing with the pharmacy doctorate (PharmD),” she responded. “I was amazed to see that the master’s-level students had the same number of required credits as the doctoral students. In other words, if the nurses were going to be involved in such a rigorous educational challenge and consequently match a doctoral program in credit hours, I felt that a clinical doctorate in nursing should be considered.”

“Not all nurses with doctoral degrees want to teach or conduct research,” Edwardson points out. “Therefore, this alternative offers options and other career choices. This advanced degree program will meet the needs of professionals concerned with advancing evidence-based practice, translating research into practice and transforming practice into research,” she asserts. The controversy over this new program continues, however, and some feel that this degree will divert nurses from PhD programs.

Edwardson counters that argument by noting, “Sometimes a nurse’s heart is in the clinical area. This degree gives nurses an opportunity to reach the pinnacle of their profession in an area other than research. Nurses with clinical or practice-related doctorates will be able to assist in the development of much-needed clinical nursing measures. These nursing indicators will be a tremendous help in identifying and measuring nursing-related outcomes. But whether they are prepared for research or clinical practice, nurses with doctoral degrees play a significant role in advancing nursing and are the profession’s future voice.”

Conclusion
Finally, we asked Edwardson for her thoughts on the AHRQ nurse scholar program and what she had gained from her experience at the agency.

“My tenure provided me with the opportunity to focus on my own growth through my work and attending lectures and seminars. This has helped to sharpen my skills tremendously,” she replied. “I expect that my experience at AHRQ will inform the work that I do at the University [of Minnesota] to support research and help develop better process and outcome measures. Now that I know how to access the databases for secondary analysis and know what is available, I plan to collaborate with master’s and doctoral students to continue this effort. I hope to see a twofold effect: helping students to learn more about available measures while also helping to move the field to the next level.”

Edwardson notes that it is not always easy for nurse scholars to take a year out of their professional careers to devote to this program, especially if there is no financial support for the candidate.

“The program is so important,” she says. “If it is not feasible to continue supporting a senior nurse for an entire year, an alternative approach might be to give senior and junior nurses a six-month opportunity and help to keep this important program alive. Those of us who have been nurse scholars can now advocate for AHRQ and the work it does within the nursing community.

“AHRQ has much to gain. Most nurses know about the nursing groups within the Health Resources and Services Administration and National Institutes of Health [both are agencies within the U.S. Department of Health and Human Services], but very few know about AHRQ. I am looking forward to sharing my experiences with colleagues and representing AHRQ and health services research at national events. I’m very grateful for the experience.” RNL

Heddy Bishop Hubbard	Barbara Elisse Najar

Heddy Bishop Hubbard, RN, MPH, FAAN, senior advisor for nursing and senior advisor for patient safety legislation in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality (AHRQ), is a PhD candidate in the Graduate School of Nursing, Uniformed Services University for the Health Sciences, Bethesda, Md. Barbara Elisse Najar, MPH, is a senior communications advisor for AHRQ’s Office of Communications and Knowledge Transfer.

The views expressed in this article are those of the author, and no official endorsement by the U.S. Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the Uniformed Services University of the Health Sciences is intended or should be inferred.

References

AHRQ. (2005). Senior nurse scholar in residence. Retrieved August 1, 2005.

American Association of Colleges of Nursing. (2004). AACN position statement on the practice doctorate in nursing. Retrieved August 16, 2005.

Ellis, L., & Lee, N. (2005). The changing landscape of doctoral education: Introducing the professional doctorate for nurses. Nurse Education Today, 25(3), 222-229.