Transcript Interdisciplinary Research: Developing Strong Partnership

Interdisciplinary Research:
Developing Strong Partnerships
Kathleen A. Dracup, RN, DNSc, FAAN
Professor and Dean
University of California, San Francisco
School of Nursing
Interdisciplinary Research
• Everyone talks about it
• Many groups fund it
• Few people share what they
know about the process
Interdisciplinary Research
• Historical perspective
• Benefits
• Models
• Barriers
• Strategies
Collaboration - The Foundation of
Interdisciplinary Research?
• A research effort carried out by a team composed
of members from different disciplines
• Examples:
– Nursing
– Medicine
– Psychology
– Economics
– Social/behavioral
– Bench science
– Statistics
* Niles, JONA 2001;31:411
Collaboration: The
Alternative View
To cooperate with an
enemy invader of
one’s territory
Historical Perspective
Traditional Model
Physician
Registered Nurses
Ancillary Personnel
Patients
Historical 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 Wars
Collaboration
Turf
Inclusion
Exclusion
RN-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 RNs
Collaboration Landmarks
1970s IOM founded
NINR (Center)
1980s AHCPR (AHRQ)
2001 Crossing the Quality Chasm (IOM)
2003 Summit on Health Professions and
Education
BENEFITS
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K. Dracup
Why Do We Need
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
Interdisciplinary Research?
• Demographics
– aging population
– increase in prevalence of chronic
illness
– 50% of population has more than
one disease
Why Do We Need
Interdisciplinary Research?
• To bridge the gap between
– the behavioral and biological sciences
– clinical trials and application in
practice
– scientists and the community
Gaps
• Efficacy of
interventions
in trials
• Potential
• Intention
• Information
• Effectiveness of
interventions in
practice
• Reality
• Action
• Behavior
Hill, Circ. 1998;97:807-810
Example: NHANES
Trends in Awareness, Treatment, & Control of High
Blood Pressure in Adults: US, 1976-1994
1976-1980 1988-1991 1991-1994
Awareness
51%
73%
68%
Treatment
31%
55%
54%
Control
10%
29%
27%
Hill, Circ. 1998;97:807-810
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?
• 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:
• Healthcare providers and patients are influenced by
several factors, many beyond their control
• Physical and social environments, health care systems &
policies influence adoption of therapies
Hill, Circ. 1998;97:807-810
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 - 2001
BASIC SCIENCE
Genetics
Vascular
Cardiac pathology
Obesity
CV repair and remodeling
CLINICAL SCIENCE
Gene interaction, bioinfomatics
Translational/applied genomics
Proteomics
Misc
POPULATION SCIENCE
Lifestyle/Metabolic risk factors
Psychosocial
CV risk disparities
Genetics/Prevention
QOC
$826
500
167
65
20
74
$264
189
37
8
30
$51
22
2
9
11
7
72.4%
23.1%
4.5%
Interdisciplinary ResearchBenefits
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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 Research
• Jean Johnson
– Most widely cited nurse researcher
– Published in nursing, medical,
psychology journals
• http://isi2.isiknowledge.com
Increased 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
Interdisciplinary Research
MIND-BODY INTERACTIONS AND HEALTH:
Exploratory/Developmental Research Program
(R21)
– “A central goal of this program is to facilitate
interdisciplinary collaboration and innovation in mindbody 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 •http://grants.nih.gov/grants/guide/rfa-files/RFA-OB-03-005.html
administrative units.”
Participating Institutes
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Fogarty Center
NCI
NCCAM
NEI
NHLBI
NIAAA
NIAID
NIAMS
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NICHD
NIDCR
NIDDK
NIMH
NINDS
NIA
NIDA
Interdisciplinary Models
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K. Dracup
Interdisciplinary Groups
• Often begin opportunistically
• Depend on like-minded people
having related aspirations and
complementary skills
Interdisciplinary Research
Models Are Circular
Nurse scientists
Statisticians
Psychologists
Anthropologists
Dietitians
Sociologists
Economists
Patient care advocates
Physicians
Community leaders
Interdisciplinary Models
nursing
medicine
Interdisciplinary
nutrition
psychology
Intradisciplinary Models
Example:
Study of cognitive function
in elderly patients on
chemotherapy
Might include nurse scientists
in:
•Cancer
•Geriatrics
•Genetics
•Neurology
Intra-disciplinary
Models
Research Question
Answered by
Interdisciplinary Team
Models
Interdisciplinary
Team
Develops the
Research Question
Barriers
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K. Dracup
Interdisciplinary ResearchBarriers
• Historical
– competition
– territorialism
– traditions/stereotyping
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K. Dracup
Interdisciplinary ResearchBarriers
• Structural
– institutional organization
– lack of role models
– academic reward system that focuses
on independence
Interdisciplinary ResearchBarriers
• Interpersonal
– ineffective communication
– poor conflict management
– lack of collaboration etiquette
Strategies and SolutionsStructural & 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 SolutionsInterpersonal 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 Surgeons
(also apply to interdisciplinary research!)
•Ability
•Affability
•Availability
A Case Study in
Interdisciplinary Research
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K. Dracup
Exercise and Heart Failure:
Effects on the Autonomic Nervous
System, Immune Function, HealthRelated Quality of Life, Clinical and
Cost Outcomes
(funded by American Heart Association)
Purpose & 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
Inter/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
Survival Curves for All
Cause Mortality
100
90
80
70
60
50
40
30
20
10
0
Tarone-Ware p = 0.018
Log Rank p = 0.043
0
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Controls
Exercise
Breslow p = 0.010
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Conclusion
• 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 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