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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 4/5/03 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 • • • • • • 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 • • • • • • • • Fogarty Center NCI NCCAM NEI NHLBI NIAAA NIAID NIAMS • • • • • • • NICHD NIDCR NIDDK NIMH NINDS NIA NIDA Interdisciplinary Models 4/5/03 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 4/5/03 K. Dracup Interdisciplinary ResearchBarriers • Historical – competition – territorialism – traditions/stereotyping 4/5/03 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 4/5/03 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 4/5/03 Controls Exercise Breslow p = 0.010 1 2 3 4 5 6 7 8 K. Dracup 9 10 11 12 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