Does Nursing Science Exist? A View from Seattle Margaret Heitkemper, RN, PhD, FAAN Elizabeth Sterling Soule Chair in Nursing University of Washington.

Does Nursing Science Exist? A View from Seattle

Margaret Heitkemper, RN, PhD, FAANElizabeth Sterling Soule Chair in NursingUniversity of Washington

University of Bergen University of Bristol University of California,

San Diego University of Illinois,

Urbana-Champaign University of Leeds University of

Manchester Nanjing University University of Oslo Pennsylvania State

University

University of Sheffield University of

Southampton University of Sydney University of Toronto Universiteit Utrecht University of

Washington, Seattle University of

Wisconsin, Madison University of York Zheijang University

Task at Hand

To open a dialogue about international nursing science

To focus on mutual interests

To consider multi-site studies

To enhance graduate student education

Trying to summarize our dialogue to date and/or create vision for the future is like trying to drink from a firehose

WUN: Nursing Contributing to the national and

international health research agenda Impacting health policy Ensuring the next generation of

nurse scientists Modeling scientific behavior How can we utilize the framework of

WUN to provide nursing research leadership?

Our National Agendas

National Institutes of Health (NIH) – Predictive– Personalized– Pre-emptive– Participatory

On-Going Dialogue Chronic Illness/Chronic Disorders End of Life Care Health Promotion Self Management Health Disparities Methodologies Mentorship of the next generation

Chronic Illness By the 1990s, chronic disease

had superseded communicable diseases as the leading cause of death in all parts of the world except sub-Saharan Africa & Middle East.

Chronic diseases will be the predominant global source of morbidity, death, and disease during the 21st century.

http://www.cdc.gov/pcd/issues/2007/apr/07_00.24.htm

Approximately 1800 US troops are now suffering from traumatic brain injuries caused by penetrating wounds. 30% of those who are engaged in active combat for 4 months or longer are at risk for disabling neurological disorders from IEDs. (Washington Post 4/8/07)

Disability

World Prevalence of IBS

New Zealand 17%New Zealand 17%

UK 22%UK 22%Denmark 7%Denmark 7%

Nigeria 30%Nigeria 30%

Japan 25%Japan 25%

Australia 12%Australia 12%

China 23% China 23%

Canada12%

Germany 12%Germany 12%Netherlands 9%Netherlands 9%

France 20%France 20%Spain 13%Spain 13%

US10–20%

US10–20%

Sweden 13%Sweden 13%Belgium 8%Belgium 8%

End of Life Research

EOL is poorly understood, leaving many to struggle through this life event.

↑ in older adults needing EOL care warrants research infrastructure & resources.

Current EOL interventions need validation.

Subgroups (race, ethnicity, culture, gender, age, disease) experience EOL care differently.

Enhanced communication among patients, families, & providers is crucial to high‑quality EOL care.

State of the Science (NIH, 12/04)

Health Promotion “We will discover, in the next 10 or 15 years,

hundreds of genes that predispose to disease – we will be able to take a snippet of blood, analyze the genes and write out a health history for that person – what would happen in his or her life without interventions. By so doing, we can move into a preventive mode, by knowing what is likely to happen and how to prevent it. What’s created is an opportunity to extend the life span by 10 to 30 productive and creative years.” Leroy Hood, September, 2002

The Challenge will be to enhance the quality of those extra years

“If I had known how long I was going to live, I would have taken better care of myself”

Eubie Blake (1883-1983)

•Linked with Type 2 diabetes, heart disease, cancer, arthritis, liver disease, body image disturbance, social discrimination•Does obesity speed the aging process?

‘The obesity epidemic is even beginning to affect children, whose obesity rates have doubled in the past two decades’ (NIH)

19961991

2003

Obesity Trends* Among U.S. Adults(*BMI 30, or about 30 lbs overweight for 5’4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

•65% of Americans overweight or obese•31% meet criteria for obese•Disproportionately affects minorities & those with low SES

2005

2005

Health Promotion

•Screening: breast cancer, colorectal cancer

•But is there equal access?•Decision-making

•But do the provider’s or family’s beliefs match the patient’s

•Managing symptoms•During & after treatment

•Survivorship•Family support

Self Management: Patient-Centered Care

‘My view you know is that the ultimate destination of all nursing is the nursing of the sick in their own homes…I look to the abolition of hospitals and workhouse infirmaries. But no use to talk about the year 2000.’ F. Nightingale

Self Management

Diet, exercise, self-monitoring Adherence Delivery mode: telephone, web-

based For whom do they work best?

– BIOLOGY– CULTURE– SOCIOECONOMIC STATUS

Miaskowski & Dodd (UCSF) examining characteristics of those who respond to a psychoeducational intervention for cancer pain management to those who don’t

• Is it dose (number of minutes/hours)? • Or duration? • Or patient baseline characteristics?• Which component?

Why and How Interventions Work

Therapeutic Gap

Implementation

Evidence Based Practice

Evidence-Based Practice is the search for and critical appraisal of the "best evidence" to answer challenging clinical questions; single studies with strong clinical practice applications; or evidence-based strategies to improve practice so that the highest quality, up-to-date care can be provided to children and their families. (Melnyk, 2006)

Will it take 17 years to implement?

Creating Opportunities for Parent Empowerment (COPE)

Disparities in sepsis incidence

Seattle Times 4/10/07

Disparities in health care access

Disparities

Is it biological, environmental,acculturation?

Women’s Health

In 1871 Holbrook wrote that . . . “It appears that the process of childbearing is essentially necessary to the physical health and long life, the mental happiness, the development of the affections and whole character of the women. Women exist for the sake of the womb.”

Methods International

data sets Statistical

models Biobehavioral

measures

Vasomotor Symptoms by Menopausal Transition Stage & CYP 19 - 11r

0

0.2

0.4

0.6

0.8

1

1.2

middle late post all stages

11r - none11r +11r ++

Woods, Mitchell et al., 2006

•Can we determine who is most likely to develop symptoms?•Or benefit from treatment?•Can we target therapies based on genetic markers?

Methods

History of any depressive episode or dysthymia by high and low risk

0%

20%

40%

60%

80%

100% High Risk (n=41)

Low Risk (n=123)

P = < .001

History of recurrent depressive episode or dysthymia by high and low risk

0%

20%

40%

60%

80%

100% High Risk (n=41)

Low Risk (n=123)

P = < .001

Serotonin Reuptake Transporter Protein (SERT) & Depression in Patients with Irritable Bowel

Syndrome

High Risk (s/s homozygotes or STin2.9 allele carriers); Low Risk (carriers of at least one l allele plus STin2.10 or STin2.12). Jarrett et al. (in press)

Similar work with stroke patients to determine who is at risk for depression (Mitchell, Kirkness)

1422 1221 1023N =

OCC: 3 6 mo

SERT2

l/ls/l, s/s9

5%

CI

A8

D

.5

0.0

-.5

-1.0

-1.5

-2.0

-2.5

TREATGRP

Usual Care

Telephone CSM

In-Person CSM

Treatment Effectiveness Those with the

l/l allele most likely improve (↑ quality of life) with in-person cognitive behavioral therapy (CBT)

Questions Ethical considerations

– Who and when– Conditions for which no cure is available– Quality of life

Decision-making– Resource allocation

Health services impact

Storefront Technology

Challenges

How can technology be used to provide interventions & enhance outcomes

What is the impact of increasing technology on outcomes (patient safety, reduction of clinical errors, enhance patient satisfaction)?

Preparing the Next Generation ‘The need to dramatically increase,

even double, the number of nurse scientists is acute, especially at earlier points in their careers.’

Recommendations: – need to enhance the productivity of each

investigator’s study for nursing practice & for shaping health policy

– increase the number of nurse investigators to respond to the investigator and faculty shortages

– Emphasize the need for research training with strong research-intensive environments. National Research Council of the National Academies, 2005

Louis Pasteur (in regard to making observations)

“chance favors the prepared mind.”  

Line drawing of Louis Pasteur drawn by David Wood from Genentech, Inc. Graphics Dept.

Does Nursing Science Exist?

The Discipline of Nursing

“…is characterized by a unique perspective, a distinct way of viewing all phenomena, which ultimately defines the limits and nature of its inquiry.” Donaldson & Crowley, Nursing Outlook, 1978

Dorothy Crowley

Professional Perspective• ‘The nursing profession abounds with problems of concern to it. Why, then, does it not also abound with inquiry – research – on these problems?’ (1969)

•‘As nursing gropes for its maturity, it is coming to recognize its responsibility as a profession to search for and to build a broader and sounder knowledge base for its professional practice.’

Marge Batey Communicating Nursing Research

Societal Mandate

‘…in deciding future directions for nursing research and science, it better fits nursing’s societal mandate to have as the highest priority the understanding and improving the health status of those whom we serve.’ S. Donaldson, J. Professional Nursing, 2003

Sociocultural/Environment

al

Behavioral/Psychological

Organ Systems

Cellular

Molecular

(NIH, 2000)

Interdisciplinary Health Research ‘…the development of scientific

knowledge in nursing depends on research-oriented individuals who are capable of both collaboration and competition in the search for new ideas. To date, nurses in research have demonstrated considerable proficiency in the art of collaboration …’

• Communicating Nursing Research, 1973

But are we leading these interdisciplinary research efforts?

Jeanne Benoliel

Are we prepared…. To out expose or share our work

outside the discipline? To develop new therapeutics

that blend the biological with social and spiritual domains of health?

To consider ourselves contributors in the broader arena of health research.

Does nursing science exist?Is it nursing research or is it

health research?