Expanding Areas of Clinical and Basic Sciences
Ann K. Cashion and Joan K. Austin
Translating the rapidly emerging scientific and technological advances from the basic science and clinical research arenas into improved patient care practices requires significant policy changes, and has been a major challenge. It has been suggested that it takes 17 years to translate science into practice (Morris, Wooding, & Grant, 2011); reasons for this extended lag time are multifactorial and include time for research-related processes as well as time for translating the research to the clinical setting. Science led and conducted by nurse scientists is key to building the body of basic science and clinical knowledge that can lead to more rapid integration into patient care practices. The purpose of this chapter is to present ways in which inclusion of basic science and clinical studies into nursing science agendas can shape and guide health policy, and to provide examples of how nurse scientists active in basic and clinical research are actively participating in the formation of health policy.
WHY ARE NURSE SCIENTISTS UNIQUELY QUALIFIED TO CONDUCT CLINICAL AND BASIC SCIENCE RESEARCH THAT TRANSLATES TO POLICY?
Nursing science has changed over the years, especially in regard to developing science that is relevant for changing nursing practice. Early research in nursing primarily focused on nurses, including the nursing role, nursing process, and quality of care (Gortner, 1983, 2000). About 40 years ago, the focus of nursing research shifted to nursing practice issues especially in adults, with about two thirds of the studies being assessment of patient populations and one third being interventions. Approximately half of early nursing studies tested a theory or framework from another discipline, with most coming from the discipline of psychology (Moody et al., 1988). In the 1970s and 1980s, progress in building nursing science was evident. Increases in multiauthored publications demonstrated that nurses were engaging in more team science, the larger number of references to funding sources on publications reflected that nursing studies were being funded by outside sources, and the larger number of studies in one area by the same author indicated that nurses were developing programs of research rather than doing isolated studies (Gortner, 2000; Moody et al., 1988).
A review of nursing research between 1985 and 2010 (Yarcheski, Mahon, & Yarcheski, 2012) showed growth in the building of nursing science related to patient care. There was a decline in use of theories from other disciplines and an increase in use of empirical findings from prior research to provide a foundation for nursing studies. Although psychological variables continued to be prominent, there was more diversity in the type of variables investigated, with more biological, physiological, and biopsychosocial variables being included in studies. In addition, there was continued growth in team science and external research funding. For example, 91% of publications had multiple authors and 72% of published articles cited funding sources in 2010. Finally, the review showed greater numbers of methodological studies, qualitative studies, and use of multivariate statistics by nurse scientists, which indicated advances in the research methods being used (Yarcheski et al., 2012).
The National Institute of Nursing Research (NINR) and its predecessor, the National Center for Nursing Research, which was created in 1986, have played a key role in stimulating nursing research that addresses important health and illness challenges such as promoting health and healthy lifestyles, reducing risk factors, enhancing quality of life in persons with chronic conditions, and improving care at the end of life (Gortner, 2000). In 2016, the NINR, which is a part of the National Institutes of Health (NIH), celebrated its 30th anniversary. NINR continues to set the national agenda for nursing research through regularly developing a strategic plan that addresses current and future health care challenges. NINR is the primary funder of basic and clinical research in nursing. Research at NINR is focused on four broad areas: symptom science, which is providing a foundation for personalized health strategies; wellness, which is identifying strategies to promote health and prevent illness; self-management, which is enhancing quality of life in persons with chronic illness; and end-of-life and palliative care, which is enhancing the quality of life at the end of life for patients and their families. There are also two crosscutting areas of innovation promotion and technology that improve health (Grady & Gough, 2015).
Nurse scientists are especially qualified to lead and conduct clinical and basic research studies that are translated to policy for a number of reasons, and we explore four of those reasons here. First, nurses are trained in a caring profession that puts at the center the patient/client who is embedded within a network of a larger family and community. Therefore, nurse scientists use a clinical lens when developing all parts of the research process, from the research question to the interpretation of findings. For nurse scientists, research questions typically originate in practice emanating from clinical problems that they have encountered, regardless of where they practice (e.g., community, hospital settings). Although research questions vary depending on the individual nurse scientist’s interest, they usually have the common goal of improving clinical outcomes for patients and their families.
Second, today’s science is best conducted within teams where each team member brings a unique skill set to the table. Nurses are especially well suited to work in a team; they understand team dynamics and are known to be successful at building, leading, and functioning effectively within teams. We have found this to be particularly true today because many research teams are interdisciplinary, and in addition to nurses often include a wide range of people from other disciplines, such as bioinformaticians, biomedical engineers, neuropsychologists, dietitians, and physicians. Nurses have vast experience with working in multidisciplinary teams, and have been successful team leaders. Over time, nurse scientists have continued to gain confidence in their ability to serve as leaders of large interdisciplinary research teams engaged in multisite studies.
Third, a PhD in nursing is thought of by some as a PhD in clinical research because of the type of courses offered and the amount of time and focus on clinical research. In doctoral nursing programs, the focus is most commonly on clinical research. All nurse scientists should have a PhD as well as a nursing degree. With the PhD comes a significant knowledge of research design and methods that those with only a clinical degree would not have. Prior to the availability of doctoral nursing programs, nurse scientists typically had a master’s degree in nursing and PhD preparation in another field such as physiology, psychology, anthropology, or education. As a result, nurse scientists gained knowledge of theory, research design, and methods from other fields and used these methods in early nursing research. Since the establishment of PhD programs in nursing, however, research preparation in nursing has had a strong clinical focus.
Last, not only do nurse scientists use a clinical lens for identifying important research questions, they also use that clinical lens, which is patient-centered and takes into consideration the context of the family and larger community, for interpretation of data and in the implementation of findings into clinical practice. Whether or not the nurse scientist is conducting a clinical study within a hospital setting or using an animal model in a laboratory, for many nurse scientists there is a clear and distinct link to improved patient outcomes. Understanding and discussing the findings of a study within the framework of the patient’s condition can help move the study findings more quickly to changes in clinical recommendations and ultimately policy changes. Many doctoral-prepared individuals have the skill to design a study and collect data, but it is the understanding of what the data mean and the relevance of the data to people and their health that is the challenge for all health care researchers. For example, a psychologist might have in-depth knowledge about how perceptions affect behaviors, but not particularly interpret findings to be relevant for the influence of illness perceptions on behaviors related to self-management of a chronic illness.
GROWTH OF NURSE SCIENTISTS CONDUCTING CLINICAL AND BASIC SCIENCE RESEARCH
We have had a shift in the types of research conducted by nurse scientists, with one trend being for nurse scientists to incorporate more biological measures and themes into their research. Recently, the Council for the Advancement of Nursing Science Idea Festival identified seven science emerging areas, one of which was omics and the microbiome (Wyman & Henly, 2015). Increasing the number of doctoral programs that include content on omics was identified as a priority (Conley et al., 2015) because currently few doctoral programs include content in this area (Wyman & Henly, 2015). Nursing research on omics is considered critical to increasing our understanding of biological mechanisms that help explain how and why nursing interventions lead to desired outcomes (Henly et al., 2015).
The commitment of NINR to basic and clinical research as well as the increased emphasis on investigating biological mechanisms are also reflected in recommendations for future research as a result of the Innovative Question Initiative that NINR initiated in 2013. The goal of the initiative was for leading scientists in the field to identify important scientific research questions in symptom science, wellness, self-management, end-of-life and palliative care, and the cross-cutting area of technology (Grady, 2014). More than half of the final innovative questions in the areas of symptom science, wellness, and self-management will have to be addressed by nurse scientists who conduct basic and clinical research. In addition, an indication of the importance of biological variables in furthering important work in nursing science was the frequency with which biological variables were identified in two emphasis areas. Specifically, references to biological variables were mentioned in six of the 11 final innovative questions in symptom science and in three of the eight in wellness.
Nurse scientists from several institutes at the NIH, including NINR, have been actively involved in discussions, which led to recommendations for tailored research topics that would use basic and clinical research to build the evidence base to inform integration of genomics into nursing practice and regulation. This led to the publication of “A Blueprint for Genomic Nursing Science” (Calzone et al., 2013), which has been widely used to drive basic and clinical research questions posed by nurse scientists. Because these research topics were developed by nurse scientists, findings from these studies and others have the potential to be moved into clinical practice in a timelier manner than what is currently experienced.
While nurse scientists are conducting clinical and basic science research in various ways, from genomic to animal models to protein measures, the example used in this section comes from genomic research initiatives by nurse scientists. Figure 2.1