Available online at www.sciencedirect.com
Nurs Outlook 62 (2014) 159e161
www.nursingoutlook.org
From the Editor
Revisioning the science of nursing
Marion E. Broome, PhD, RN, FAAN
“Think not what I do, but what I am a part of.” dDon Berwick Conventional wisdom suggests that financial crises produce a window of opportunity for shifting processes, procedures, and even outcomes for any organization. This past decade we have seen significant reductions in research funding (both in the number of grants funded and real dollars allotted each grant) at the National Institutes of Health, a traditional funder of much of the basic and, more recently, translational research in the United States. Higher education is experiencing its own financial pressures with caps on tuition increases; the increasing cost of decaying buildings on older campuses; shrinking state appropriations; and now decreases in indirect cost recovery dollars that helped fund the research for which many senior universities, especially those housing academic health professions schools, are known. Finally, in academic health centers, changes in health care financing threaten the very viability of these institutions, which often bear the disproportionate burden of both conducting research and educating health professionals for the future. Thirty-two R01 grants were awarded last year to investigators from the National Institute of Nursing Research. Even as the economy seems to improve slowly, with at least 25 schools of nursing in the
country that consider themselves research intensive, we clearly need new strategies for maximizing the continuing conduct and translation of our science. Indeed, over the past several years, additional funding sources have evolved that are potential sources for funding nursing research, including the PatientCentered Outcomes Research Institute (www.PCORI. org/funding) and the Centers for Medicare and Medical Services (www.cms.gov). The purpose of the funds from the Patient-Centered Outcomes Research Institute is to support comparative clinical effectiveness research designed to help patients and those who care for them to make informed health care decisions. The Centers for Medicare and Medical Services are interested in funding innovators who can rapidly deploy care improvement models through new ventures or the expansion of existing efforts to new populations of patients in conjunction with other public and private sector partners. These are certainly areas/topics/populations that nurse scientists are experienced in, especially when leading interdisciplinary teams of researchers with complementary expertise. Yet, few nurse investigators have been funded by either of these sources. So, why is this so hard? I would suggest that this funding dilemma is not just about shifting our choices of sources, processes, procedures or outcomes for getting money to support the incredibly important work nurse scientists do. It is about how we must engage in some conversations on how we measure our “success,” what counts for “real research,” and even the measures of our usefulness, as a profession, to society. Those who came before us, those nurse leaders who fought hard for the National Center (and later Institute) of Nursing Research, left us an incredible legacy of leadership in science. It was they (and some of you reading this) who created the space and lobbied hard for the funding for nursing science to grow, flourish, and make major contributions to the science of health. It is now time, with shifts in funding amounts, priorities, and sources, to use the experience, skills, and wisdom of funded nurse scientists and nursing science leaders to develop the next generation, not for our world but for theirs. However, that world will look, feel, and be different, and nurse scientists have so much to offer.
160
Nurs Outlook 62 (2014) 159e161
These nurse scientists have spent decades studying health problems. They generated (and still generate) knowledge, interventions, and measurement models for important and relevant health issues such as transitions of care, caregiving stress and stress management, improving quality of life in chronic illness, pain assessment and management, and normalization in families of individuals with a chronic illness. These issues remain highly relevant. Yet, the environment in which that knowledge was generated was often isolated from the systems. Patients and providers struggle with recurring problems, fragmented care, and transitions in which patients and families was left to self-manage, resulting in mismanagement and dissatisfaction. In the future, funding bodies will expect that research is conducted within these systems of care. In order to train the next generation of nurse scientists, we all (senior, mid-career, and early career academics) must challenge our own assumptions clearly shaped by how we were trained, how we think we must train future scholars/researchers, and what we need to learn next to contribute to the current crises in U.S. health care. To their credit, many of these same nurse scientists have also worked tirelessly with their professional associations to develop guidelines for care based on the evidence in the literature. They have published systematic reviews of the literature in their area of science, but this has not been enough to move the needle on translation. The transfer of research is affected by a number of historic, political, economic, scientific, cultural, and organizational factors (Mitchell, Fisher, Hastings, Silverman, & Wallen, 2010). Although we cannot control all the factors, we can begin to assess those we live with everyday. Most large schools of nursing are now comprised of 100% doctorally prepared facultydtenure track and clinical track, those with PhDs and DNPs. The good news is that in most schools these individuals are collegial and committed to their own as well as their organization’s success. The bad news is that when it comes to research, we remain divided, still just talking about joining in teams to make the differences in care we all want to see. But the culture and work environment tend to get in our way. Our “busyness” and traditional styles of addressing challenges impede our progress. At the risk of generalizing here, I think we tend to be incrementalists in how we approach new ways of doing things. We tend to seek solutions that are not disruptive, but additive (i.e., more curricula, more research content, more degrees, more grant submissions, and so on). Finally, we tend to expend too much energy getting to a solution that ends up creating more work and barriers, which then exhausts us. As I reflected on this topic earlier this year (in preparation for a keynote), I came across two very interesting articles that stimulated my thinking about the future and the need for teams of
“knowledge workers” (intraprofessional as well as interprofessional) to solve the many wicked problems we are facing related to health. In the first article, “The Future: Academic Health Centers” (Dzau et al., 2013), the authors talk about the urgent need to develop highly differentiated clinical programs of distinction that are fully integrated with translational research and advanced training. This integrated infrastructure that provides for education, research, and care can be used as the vehicle to achieve the goals of the Institute for Healthcare Improvement’s Triple Aim Initiative (i.e., to improve health of defined populations, share the patient’s experience, and reduce cost). Dzau et al. also call for academic researchers to develop meaningful measures of research success related to scientific and societal impact, rather than funding obtained or number of articles published. This is a tall order but one conversation in which nurse scientists must become actively engaged in shaping or risk being relegated to scientific obscurity. Or do we leave all of these conversations, and action, to our physician colleagues? In another article in the Harvard Business Review around the same time, Porter and Lee (2013) describe the concept of “integrated practice units.” Provider/ researcher teams within these integrated practice units will not just treat disease but also engage individuals in care, encourage their adherence with evidence-based interventions, provide health education, and support needed behavioral change. The teams will have just one focus and the following convergent goals: to improve patient outcomes through review of data on their own performance, to continuously develop and test new protocols, and to collect data to personalize care and assess changes in both patient and provider performance. Doctorally prepared nurses with extensive experience in research methods, outcomes measurement, and intervention models designed to improve health have much to offer in this new world of health care. For health system entities to survive and then thrive, these teams of providers/researchers will be funded to continuously study their effectiveness in improving health outcomes. Given the constrained and reduced resources of the traditional sources of funding, we must build on our current strengths as nurse researchers, expand and evolve our skill base to include newer methods, and we must work with younger colleagues in and outside of nursing to build teams to “fill these new spaces” for care delivery and research. To do any less will be to squander the investment of those who paved the way for nursing science and scientists to develop these past 30 years.
references
Dzau, V., Cho, A., ElLaissi, W., Yoediono, Z., Sangvai, D., Shah, B., . & Udayakumar, K. (2013). Transforming academic health
Nurs Outlook 62 (2014) 159e161
centers for an uncertain future. New England Journal of Medicine, 369, 991e993. Mitchell, S., Fisher, C., Hastings, C., Silverman, L., & Wallen, G. (2010). A thematic analysis of theoretical models for translational science in nursing: Mapping the field. Nursing Outlook, 58, 287e300. Porter, M & Lee, T. (2013). The strategy that will fix health care. Harvard Business Review, October, 2013. Retrieved from www. hbr.org/2013/10.
Author Description Marion E. Broome is the Editor-in-Chief of Nursing Outlook.
161
Marion E. Broome, PhD, RN, FAAN Corresponding author: Dr. Marion E. Broome Indiana University Dean & Distinguished Professor School of Nursing 1111 Middle Drive NU 132 Indianapolis, IN 46202-5107. E-mail address: [email protected] 0029-6554/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2014.04.008
Nurs Outlook 62 (2014) 159e161
www.nursingoutlook.org
From the Editor
Revisioning the science of nursing
Marion E. Broome, PhD, RN, FAAN
“Think not what I do, but what I am a part of.” dDon Berwick Conventional wisdom suggests that financial crises produce a window of opportunity for shifting processes, procedures, and even outcomes for any organization. This past decade we have seen significant reductions in research funding (both in the number of grants funded and real dollars allotted each grant) at the National Institutes of Health, a traditional funder of much of the basic and, more recently, translational research in the United States. Higher education is experiencing its own financial pressures with caps on tuition increases; the increasing cost of decaying buildings on older campuses; shrinking state appropriations; and now decreases in indirect cost recovery dollars that helped fund the research for which many senior universities, especially those housing academic health professions schools, are known. Finally, in academic health centers, changes in health care financing threaten the very viability of these institutions, which often bear the disproportionate burden of both conducting research and educating health professionals for the future. Thirty-two R01 grants were awarded last year to investigators from the National Institute of Nursing Research. Even as the economy seems to improve slowly, with at least 25 schools of nursing in the
country that consider themselves research intensive, we clearly need new strategies for maximizing the continuing conduct and translation of our science. Indeed, over the past several years, additional funding sources have evolved that are potential sources for funding nursing research, including the PatientCentered Outcomes Research Institute (www.PCORI. org/funding) and the Centers for Medicare and Medical Services (www.cms.gov). The purpose of the funds from the Patient-Centered Outcomes Research Institute is to support comparative clinical effectiveness research designed to help patients and those who care for them to make informed health care decisions. The Centers for Medicare and Medical Services are interested in funding innovators who can rapidly deploy care improvement models through new ventures or the expansion of existing efforts to new populations of patients in conjunction with other public and private sector partners. These are certainly areas/topics/populations that nurse scientists are experienced in, especially when leading interdisciplinary teams of researchers with complementary expertise. Yet, few nurse investigators have been funded by either of these sources. So, why is this so hard? I would suggest that this funding dilemma is not just about shifting our choices of sources, processes, procedures or outcomes for getting money to support the incredibly important work nurse scientists do. It is about how we must engage in some conversations on how we measure our “success,” what counts for “real research,” and even the measures of our usefulness, as a profession, to society. Those who came before us, those nurse leaders who fought hard for the National Center (and later Institute) of Nursing Research, left us an incredible legacy of leadership in science. It was they (and some of you reading this) who created the space and lobbied hard for the funding for nursing science to grow, flourish, and make major contributions to the science of health. It is now time, with shifts in funding amounts, priorities, and sources, to use the experience, skills, and wisdom of funded nurse scientists and nursing science leaders to develop the next generation, not for our world but for theirs. However, that world will look, feel, and be different, and nurse scientists have so much to offer.
160
Nurs Outlook 62 (2014) 159e161
These nurse scientists have spent decades studying health problems. They generated (and still generate) knowledge, interventions, and measurement models for important and relevant health issues such as transitions of care, caregiving stress and stress management, improving quality of life in chronic illness, pain assessment and management, and normalization in families of individuals with a chronic illness. These issues remain highly relevant. Yet, the environment in which that knowledge was generated was often isolated from the systems. Patients and providers struggle with recurring problems, fragmented care, and transitions in which patients and families was left to self-manage, resulting in mismanagement and dissatisfaction. In the future, funding bodies will expect that research is conducted within these systems of care. In order to train the next generation of nurse scientists, we all (senior, mid-career, and early career academics) must challenge our own assumptions clearly shaped by how we were trained, how we think we must train future scholars/researchers, and what we need to learn next to contribute to the current crises in U.S. health care. To their credit, many of these same nurse scientists have also worked tirelessly with their professional associations to develop guidelines for care based on the evidence in the literature. They have published systematic reviews of the literature in their area of science, but this has not been enough to move the needle on translation. The transfer of research is affected by a number of historic, political, economic, scientific, cultural, and organizational factors (Mitchell, Fisher, Hastings, Silverman, & Wallen, 2010). Although we cannot control all the factors, we can begin to assess those we live with everyday. Most large schools of nursing are now comprised of 100% doctorally prepared facultydtenure track and clinical track, those with PhDs and DNPs. The good news is that in most schools these individuals are collegial and committed to their own as well as their organization’s success. The bad news is that when it comes to research, we remain divided, still just talking about joining in teams to make the differences in care we all want to see. But the culture and work environment tend to get in our way. Our “busyness” and traditional styles of addressing challenges impede our progress. At the risk of generalizing here, I think we tend to be incrementalists in how we approach new ways of doing things. We tend to seek solutions that are not disruptive, but additive (i.e., more curricula, more research content, more degrees, more grant submissions, and so on). Finally, we tend to expend too much energy getting to a solution that ends up creating more work and barriers, which then exhausts us. As I reflected on this topic earlier this year (in preparation for a keynote), I came across two very interesting articles that stimulated my thinking about the future and the need for teams of
“knowledge workers” (intraprofessional as well as interprofessional) to solve the many wicked problems we are facing related to health. In the first article, “The Future: Academic Health Centers” (Dzau et al., 2013), the authors talk about the urgent need to develop highly differentiated clinical programs of distinction that are fully integrated with translational research and advanced training. This integrated infrastructure that provides for education, research, and care can be used as the vehicle to achieve the goals of the Institute for Healthcare Improvement’s Triple Aim Initiative (i.e., to improve health of defined populations, share the patient’s experience, and reduce cost). Dzau et al. also call for academic researchers to develop meaningful measures of research success related to scientific and societal impact, rather than funding obtained or number of articles published. This is a tall order but one conversation in which nurse scientists must become actively engaged in shaping or risk being relegated to scientific obscurity. Or do we leave all of these conversations, and action, to our physician colleagues? In another article in the Harvard Business Review around the same time, Porter and Lee (2013) describe the concept of “integrated practice units.” Provider/ researcher teams within these integrated practice units will not just treat disease but also engage individuals in care, encourage their adherence with evidence-based interventions, provide health education, and support needed behavioral change. The teams will have just one focus and the following convergent goals: to improve patient outcomes through review of data on their own performance, to continuously develop and test new protocols, and to collect data to personalize care and assess changes in both patient and provider performance. Doctorally prepared nurses with extensive experience in research methods, outcomes measurement, and intervention models designed to improve health have much to offer in this new world of health care. For health system entities to survive and then thrive, these teams of providers/researchers will be funded to continuously study their effectiveness in improving health outcomes. Given the constrained and reduced resources of the traditional sources of funding, we must build on our current strengths as nurse researchers, expand and evolve our skill base to include newer methods, and we must work with younger colleagues in and outside of nursing to build teams to “fill these new spaces” for care delivery and research. To do any less will be to squander the investment of those who paved the way for nursing science and scientists to develop these past 30 years.
references
Dzau, V., Cho, A., ElLaissi, W., Yoediono, Z., Sangvai, D., Shah, B., . & Udayakumar, K. (2013). Transforming academic health
Nurs Outlook 62 (2014) 159e161
centers for an uncertain future. New England Journal of Medicine, 369, 991e993. Mitchell, S., Fisher, C., Hastings, C., Silverman, L., & Wallen, G. (2010). A thematic analysis of theoretical models for translational science in nursing: Mapping the field. Nursing Outlook, 58, 287e300. Porter, M & Lee, T. (2013). The strategy that will fix health care. Harvard Business Review, October, 2013. Retrieved from www. hbr.org/2013/10.
Author Description Marion E. Broome is the Editor-in-Chief of Nursing Outlook.
161
Marion E. Broome, PhD, RN, FAAN Corresponding author: Dr. Marion E. Broome Indiana University Dean & Distinguished Professor School of Nursing 1111 Middle Drive NU 132 Indianapolis, IN 46202-5107. E-mail address: [email protected] 0029-6554/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.outlook.2014.04.008
