interdisciplinary research: developing strong partnerships kathleen a. dracup, rn, dnsc, faan...
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Interdisciplinary Research:Interdisciplinary Research:Developing Strong PartnershipsDeveloping Strong Partnerships
Kathleen A. Dracup, RN, DNSc, FAANKathleen A. Dracup, RN, DNSc, FAANProfessor and Dean Professor and Dean
University of California, San FranciscoUniversity of California, San FranciscoSchool of NursingSchool of Nursing
Interdisciplinary ResearchInterdisciplinary Research
• Everyone talks about it
• Many groups fund it
• Few people share what they know about the process
Interdisciplinary ResearchInterdisciplinary Research
• Historical perspective
• Benefits
• Models
• Barriers
• Strategies
Collaboration - The Foundation of Collaboration - The Foundation of Interdisciplinary Research?Interdisciplinary Research?
• A research effort carried out by a team composed of members from different disciplines
• Examples:– Nursing – Economics – Bench science– Medicine – Social/behavioral – Statistics– Psychology
* Niles, JONA 2001;31:411
Collaboration: The Collaboration: The Alternative ViewAlternative View
To cooperate with an To cooperate with an enemy invader of enemy invader of
one’s territoryone’s territory
Historical PerspectiveHistorical Perspective
Traditional Model
Physician
Registered Nurses
Ancillary Personnel
Patients
Historical PerspectiveHistorical Perspective
Many physicians are aware of the nurse ‘doing her [sic] job over there, while I do mine over here; as long as they carry out my orders, and we get along….’
Tellis-Nayak, Soc Sci Med 1984
Turf WarsTurf Wars
Collaboration
Inclusion
Turf
Exclusion
RN-MD CollaborationRN-MD Collaboration
• Physician’s role as ‘gatekeeper’ has changed• Nurse scientists are often better prepared
educationally to conduct research than the physicians with whom they collaborate
• In today’s fiscal environment, academic physicians have heavy clinical burdens and little protected research time
Increased scientific role for RNsIncreased scientific role for RNs
Collaboration LandmarksCollaboration Landmarks
1970s IOM foundedNINR (Center)
1980s AHCPR (AHRQ)
2001 Crossing the Quality Chasm (IOM)
2003 Summit on Health Professions and Education
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BENEFITSBENEFITS
Why Do We Need Why Do We Need Interdisciplinary Research?Interdisciplinary Research?
• Growth in knowledge and technology– Advances in biology, genetics, physiology,
pathophysiology, disease processes
– Increasing complexity in diagnosis, treatment, prevention
– 10,000 published clinical trials/year
– Need for large sample sizes
Why Do We Need Why Do We Need Interdisciplinary Research?Interdisciplinary Research?
• Demographics– aging population
– increase in prevalence of chronic illness
– 50% of population has more than one disease
Why Do We Need Why Do We Need Interdisciplinary Research?Interdisciplinary Research?
• To bridge the gap between
– the behavioral and biological sciences
– clinical trials and application in practice
– scientists and the community
GapsGaps
• Efficacy of interventionsin trials
• Potential
• Intention
• Information
• Effectiveness of interventions in practice
• Reality
• Action
• Behavior
Hill, Circ. 1998;97:807-810
Example: NHANESExample: NHANES
Trends in Awareness, Treatment, & Control of High Trends in Awareness, Treatment, & Control of High Blood Pressure in Adults: US, 1976-1994Blood Pressure in Adults: US, 1976-1994
1976-19801976-1980 1988-19911988-1991 1991-19941991-1994Awareness 51% 73% 68%68%
Treatment 31% 55% 54%54%
Control 10% 29% 27%27%
Hill, Circ. 1998;97:807-810
Why Do Gaps Exist?Why Do Gaps Exist?
• Emphasis on basic science and translation into clinical research has led to struggles in funding priorities and handicapped our understanding of how to implement interventions shown to be effective in RCTs
Hill, Circ. 1998;97:807-810
Why Do Gaps Exist?Why Do Gaps Exist?• We assume that:
– practice guidelines will be followed and patients will improve
– if we know the cause of illness, therapies can be applied, patients will adhere, the problem will be solved
REALITY:REALITY:• Healthcare providers and patients are influenced by
several factors, many beyond their control• Physical and social environments, health care systems &
policies influence adoption of therapiesHill, Circ. 1998;97:807-810
Why Do Gaps Exist?Why Do Gaps Exist?
• Organizational structures, staffing, and reimbursement of academic medical centers do not encourage interdisciplinary work, despite results from large, interdisciplinary RCTs
Hill, Circ. 1998;97:807-810
AHA Awards - 2001AHA Awards - 2001BASIC SCIENCE $826 72.4%
Genetics Vascular Cardiac pathology Obesity CV repair and remodeling
500 167
65 20 74
CLINICAL SCIENCE $264 23.1%
Gene interaction, bioinfomatics Translational/applied genomics Proteomics Misc
189 37
8 30
POPULATION SCIENCE $51 4.5% Lifestyle/Metabolic risk factors Psychosocial CV risk disparities Genetics/Prevention QOC
22 2 9
11 7
Interdisciplinary Research-Interdisciplinary Research-BenefitsBenefits
• Promotes different theoretical perspectives
• Brings diversity of talent
• Access to special populations
• Shared resources augment capabilities
• Wider dissemination of research results
• Increases opportunities for funding
Wider Dissemination of ResearchWider Dissemination of Research
• Jean Johnson
– Most widely cited nurse researcher
– Published in nursing, medical, psychology journals
• http://isi2.isiknowledge.com
Increased Opportunity for FundingIncreased Opportunity for Funding
• NIH* – NINR - $118M– NIA - $880M– NIMH - $1.2B– NHLBI - $2.6B– NHGRI - $427M– NIAAA - $382M– NIDDK - $1.5B– NCCAM - $100M
• AHRQ• Specialty organizations• Private foundations
* $ amounts = total budget requests for FY 2002
Current Funding in Current Funding in Interdisciplinary ResearchInterdisciplinary Research
MIND-BODY INTERACTIONS AND HEALTH: Exploratory/Developmental Research Program (R21) – “A central goal of this program is to facilitate facilitate
interdisciplinary collaborationinterdisciplinary collaboration and innovation in mind-body and health research while providing essential and cost-effective core services in support of the development, conduct, and translation into practice of mind-body and health research based in centers or comparable administrative units.”
•http://grants.nih.gov/grants/guide/rfa-files/RFA-OB-03-005.html
Participating InstitutesParticipating Institutes• Fogarty Center• NCI• NCCAM• NEI• NHLBI• NIAAA• NIAID• NIAMS
• NICHD
• NIDCR
• NIDDK
• NIMH
• NINDS
• NIA
• NIDA
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Interdisciplinary ModelsInterdisciplinary Models
Interdisciplinary GroupsInterdisciplinary Groups
• Often begin opportunistically
• Depend on like-minded people having related aspirations and complementary skills
Interdisciplinary Research Interdisciplinary Research Models Are CircularModels Are Circular
Psychologists
Sociologists
Physicians
Statisticians
Economists
Patient care advocates Community leaders
Dietitians
Anthropologists
Nurse scientists
Interdisciplinary ModelsInterdisciplinary Models
psychology
Interdisciplinary
nursing medicine
nutrition
Intradisciplinary ModelsIntradisciplinary Models
Intra-disciplinary
Example:Study of cognitive functionin elderly patients on chemotherapy
Might include nurse scientists in:•Cancer•Geriatrics•Genetics•Neurology
ModelsModels
Answered by
Interdisciplinary TeamAnswered by
Interdisciplinary Team
Research QuestionResearch Question
ModelsModels
Interdisciplinary Team
Interdisciplinary Team
Develops the
Research QuestionDevelops the
Research Question
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BarriersBarriers
Interdisciplinary Research-Interdisciplinary Research-BarriersBarriers
• Historical
– competition– territorialism– traditions/stereotyping
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Interdisciplinary Research-Interdisciplinary Research-BarriersBarriers
• Structural
– institutional organization – lack of role models– academic reward system that focuses
on independence
Interdisciplinary Research-Interdisciplinary Research-BarriersBarriers
• Interpersonal
– ineffective communication– poor conflict management– lack of collaboration etiquette
Strategies and Solutions-Strategies and Solutions-Structural & Historical BarriersStructural & Historical Barriers
• Structural
– Establish supportive structures within the institution (e.g., centers, advisory boards)
– Give priority for space and funding allocation to interdisciplinary teams
– Frequent meetings and/or conference calls
Strategies and Solutions- Strategies and Solutions- Interpersonal BarriersInterpersonal Barriers
• Investigator-based – At the first project meeting discuss:
• ground rules• strengths, skill sets, and responsibilities of all members
– Encourage direct communication between team members– Acknowledge contributions of all team members– Publications - establish guidelines at the beginning for:
• authorship• topics
Criteria for Success for SurgeonsCriteria for Success for Surgeons(also apply to interdisciplinary research!)(also apply to interdisciplinary research!)
•Ability•Affability
•Availability
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A Case Study in A Case Study in Interdisciplinary ResearchInterdisciplinary Research
Exercise and Heart Failure:
Effects on the Autonomic Nervous System, Immune Function, Health-
Related Quality of Life, Clinical and Cost Outcomes
(funded by American Heart Association)
Purpose & DesignPurpose & Design
• Delineate the safety and efficacy of using a combination of aerobic and resistance exercise training modalities in a population of adults with decreased left ventricular systolic function and clinical HF
• Randomized, prospective trial
Aerobic + Resistive Exercise
EF
Autonomic Function
Immune Function
Hemodynamics
Functional Status
Rehospitalization
Mortality
Quality of Life
Figure 1. Underlying theoretical framework for study
= interruption of pathophysiologic processes
Inter/Intra-disciplinaryInter/Intra-disciplinary• echocardiography,
electrocardiogram, heart rate variability
• cardiopulmonary exercise stress testing with expired gas analysis
• muscular strength determination
• pulmonary function testing• serum norepinephrine (NE) • skin tests to recall antigens • immunologic assay• health-related quality of life• clinical outcomes/costs of care
nurses
physicians
economists
immunologists
exercise physiologists
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Survival Curves for All Survival Curves for All Cause MortalityCause Mortality
0102030405060708090
100
0 1 2 3 4 5 6 7 8 9 10 11 12
ControlsExercise
Breslow p = 0.010
Tarone-Ware p = 0.018
Log Rank p = 0.043
ConclusionConclusion
• Historical, structural, and interpersonal barriers can impede effective interdisciplinary collaboration
• The benefits to overcoming these barriers are great
• Interdisciplinary collaboration in science must also be rooted in education and practice
Interdisciplinary PotentialInterdisciplinary Potential
Research
Practice
Education
It is not the strongest of the species that survives,And not the most intelligent,But the ones most responsive to change
Charles Darwin