Imagine a patient lying unconscious in the bed, overcome by the Ebola virus. He’s quarantined, and health care providers are wary of coming too close. If Duke University School of Nursing (DUSON) and Pratt School of Engineering researchers have their way, in the not too distant future the nurses can send in a robot.
Visually similar to the early-generation artificial intelligence machines from the Terminator movies, the robot rolls to the contagious patient’s bedside and provides necessary care without fear of infection. This scenario might not be a reality yet, but it is currently being studied at DUSON and is exactly the kind of advanced interdisciplinary work the newly-revamped Center for Nursing Research (CNR) wants to nourish and cultivate.
“The purpose of nursing research is to make an impact on the lives of individual families and communities,” said Dean Marion Broome, PhD, RN, FAAN. “The Center for Nursing Research is an infrastructure — a place to access critical resources that can help you think through projects and prepare cutting-edge grants for external funding. Regardless of whether topics change, we’re focused on adapting interventions to help chronically ill people as well as promote health of individuals, families and communities.”
Continuing the Nursing Research Tradition
While the CNR revitalization is new, DUSON has a long history of externally-funded research across a wide variety of topics. As part of that tradition, faculty have worked hard to maintain steady funding to support their investigations. In 2015, DUSON ranked ninth nationwide among schools of nursing in National Institutes of Health-funded research.
But the funding climate has changed. Dollars have been diminishing and competition is heating up. At the same time, DUSON’s faculty is getting younger — roughly 50 percent of faculty arrived within the last five years. These young assistant professors are still mastering the tripartite research, teaching and service mission, making it harder for them to successfully navigate the research arena alone.
That’s why the changes to the CNR are so vital, Broome said. It gives these burgeoning researchers the support needed to effectively design proposals and interventions that will win financial backing from outside sources.
“There’s a lot of pressure on the faculty o seek and maintain funding for their research. Research costs money,” she said. “And we want to assist them as they work toward new, innovative ideas and hone their research skill sets.”
In an effort to push nursing science forward and increase its opportunities for translation, the CNR has five goals:
- Develop a supportive infrastructure that will position DUSON as a leader in nursing science and its translation.
- Recruit and retain outstanding research faculty, staff, students and trainees.
- Focus on targeted research clusters of excellence for growth and investment.
- Promote and accelerate DUSON research, innovation and accomplishment.
- Diversify the research portfolio and funding sources.
To meet these goals, DUSON leaders plan to focus on faculty mentorship, engage Duke University Health System (DUHS) nurses in collaborative research projects and strengthen infrastructure with human capital, space and technology. They also intend to recruit and cultivate world-leading research faculty and promote student scholarship.
According to Judy Prewitt, DNP, RN, ANP, associate chief nursing officer of practice, DUHS, bolstering the partnerships between DUSON and DUHS nurses has been a natural outgrowth. Shared interests, goals and ambitions are helping push evidence-based practice and nursing-led research to the forefront of health care.
“The cross-pollination of teams has strengthened both DUSON’s Center for Nursing Research and the DUHS Nursing Research Council,” she said. “The collaboration, while still in the early stages, has already accomplished some early goals as we plan for the future of Duke Nursing and the profession of nursing. It really does seem like the sky is the limit.”
According to CNR Strategic Planning Research Working Group co-convener Sharron L. Docherty, PhD, PNP-BC, FAAN, associate professor, transforming the Center gives the School and its faculty the opportunity to examine its strengths and opportunities.
“The CNR needed to transform in order to meet the needs of our scholars as they continue to make great strides in accelerating nursing science,” said the ADAPT Center for Cognitive/Affective Symptom Science director. “In looking over the work done by the Research Working Group, the promise that this plan holds for our School to play a major role in improving health care delivery and patient outcomes is readily apparent.”
Renewing the CNR
As with many current changes within DUSON, relaunching the CNR aligns with the new strategic plan while strengthening the School’s research infrastructure and augmenting its ability to recruit and retain high-quality nurse researchers.
Redesigning the Center, though, was a School-wide feat, said Marilyn Hockenberry, PhD, RN, PPCNP-BC, FAAN, the Bessie Baker Professor of Nursing and associate dean for research affairs.
“We looked at our mission of leading and accelerating nursing science and translation into clinical practice. We looked at our infrastructure to see how we could provide better support for the faculty as they lead nursing science around the globe,” she said. “Then, we focused on targeted research clusters — areas where we wanted to invest and grow.”
To identify the appropriate research clusters — called Research Areas of Excellence (RAE) — the Research Working Group, with guidance from consulting firm AMC Strategies, LLC, surveyed the faculty to determine where they devote their investigational energies. From this faculty input, four similarly-focused research efforts were identified.
- Precision Health: Evidence-based, customized approaches to health that incorporate genomics, environment and lifestyle.
- Population Health and Chronic Illness: Improving health outcomes of a group of individuals, families and/ or communities; and reducing health disparities within groups with chronic illness, co-morbidity and mortality, including racial and ethnic minority, LGBT and rural residents.
- Clinical Innovation: Advancing approaches using ideas, processes, products or procedures to benefit the health of individuals, groups and populations.
- Methods and Analytics: Optimizing the use of cutting edge and underutilized approaches to study design and analytics.
These clusters have the potential for new research synergies. For example, Hockenberry said that faculty members who study infants and older patients, respectively, might once have been in different investigational groups because they study different age populations. But now, if they were researching the same biomarkers, they would both be included in Precision Health.
And understanding the differences between the RAEs is important, Hockenberry said, because it affects how and with whom faculty collaborate, both internally and externally.
"As we develop towards this conceptual model, we’ll be able to provide a platform to better know each other across the School and the University,” Hockenberry said. “We’re trying to get people to stretch their minds, to think outside the box.”
Dean Broome and Hockenberry have already initiated such collaborations and pilot programs with the Duke Institute for Health Innovations (DIHI). According to Suresh Balu, director, Strategy and Innovation for the DIHI, “Extending the multidisciplinary team science research paradigm to health innovation will be critical to the success of our innovation agenda. Our strong partnership with DUSON will help us to develop novel care models and technology solutions that bring pragmatic value to clinical care.”
Strengths and Differences
By dividing faculty research activities into conceptual areas of research excellence, the CNR showcases the way DUSON is unique among its peers.
Most schools of nursing do not have research programs in precision health. However, this RAE includes faculty research into biomarkers, omics approaches to health care, clinical implementation and utility and phenotypic and genotypic health characterizations. The scope is fairly broad, Hockenberry said, because it includes investigations that are predictive, preventive, personalized and participatory in nature while concentrating on improving health outcomes and reducing health disparities.
“Precision health offers opportunities for the implementation of genomics and other precision health tools in multiple areas of health care to improve patient- and population-level outcomes,” said Allison A. Vorderstrasse, DNSc, APRN, CNE, FAAN, associate professor at the School of Nursing. "The current and future collaborative nature of precision health across the Duke medical center and campus make this the perfect environment for us to do this work. In fact, it positions the School to be a leader in this area,” she said.
Geoffrey S. Ginsburg, MD, PhD, professor of medicine in the Duke Institute for Genome Sciences and Policy, agrees. “The opportunity for Duke in precision health is enormous. DUSON will bring talented nursing faculty and students together to address an important strategic research and clinical agenda,” he said. “There is no question that this group, in partnership with the Duke Center for Applied Genomics and Precision Medicine, will enhance Duke’s prominent role in what is now a national agenda.”
Population Health and Chronic Illness
Creating this RAE allowed DUSON to build upon its existing expertise in studying diverse populations across lifespans. This work focuses on disease within populations, including HIV, sickle cell and cancer, as well as disease by age group — neonatal, children and adolescents and older adults. The overall goal is to improve group outcomes, identify health patterns and pinpoint policies and interventions that link those outcomes and patterns.
“The growth of research as a priority for DUSON is great for Duke Health. I look forward to increasing collaboration with nursing school faculty and students, particularly in the areas involving clinical data and biological sample collection, “said Mark Stacy, MD, professor of neurology and vice dean for clinical research, Duke University School of Medicine. “We can be leaders in the precision health and population health sectors of clinical research."
There are numerous potential interdisciplinary partnership opportunities available internally with organizations such as the Duke Center for Population Health and Aging, the Duke University Population Research Institute and the Duke Cancer Institute.
This RAE gives faculty the chance to build upon the School’s existing expertise in patient-centered care and simulation models, mHealth, eHealth, wearable technology and virtual environments. It brings the schools of medicine, engineering and computer science together with DUSON to work with outside industries to create new technologies and care models for improving health care quality and efficiency.
“This area has great potential for the School of Nursing to provide national leadership through its interdisciplinary work,” said Constance M. Johnson, PhD, RN, FAAN, associate professor and senior research faculty member. “Interdisciplinary research is key to solving health care problems since it brings together teams of individuals from different disciplines with diverse perspectives, theories and specialized knowledge to solve specific problems. Together they have greater strength than a single discipline.”
In fact, DUSON’S multidisciplinary partners already see the value of working with the new CNR.
“It has been unbelievably valuable to work with the nursing school since we get to see how nurses might use the products of our research. Too often, engineers develop technology in a vacuum without thinking about how their products will be used by everyday people,” said Kris Hauser, PhD, the principal investigator on the Ebola robotics project from the Pratt School of Engineering. “Collaborating with DUSON has given us eye-opening information about both the promise and limitations of human-operated robots outside of a controlled lab environment.”
Methods and Analytics
Few schools of nursing have tackled research in ways that focus on score analysis, SMART design, data visualization or mixed-method observational studies. DUSON’s nationally-recognized faculty routinely use these approaches to develop and apply cutting-edge methodologies, models and analytics for research. This thinking brings big data to nursing research and fosters interdisciplinary partnerships.
“As a university-wide center for health policy evidence generation, innovation and implementation, the Margolis Center seeks a close connection to thought leaders, faculty and trainees in nursing at Duke. In the work of health care delivery reform, nursing leaders and nurses are on the front line,” said Mark McClellan, MD, PhD, Robert J. Margolis Professor of Business, Medicine and Policy and director of the Duke-Margolis Center for Health Policy. “Nursing research generates some of the best ideas for improving care and reducing costs — both central to the Margolis mission. One promising area of policy impact will be through collaboration with DUSON in real-time, real-world evaluation and implementation of alternative models of care.”
The Four Cores
As another major part of the CNR redesign, DUSON crafted and bolstered four main areas of service that support research faculty. Each core — faculty science, research design and statistics, pre-award liaison services and research oversight and compliance — is intended to give faculty the strongest possible foundation with the largest range of support services from which to choose.
The Faculty Science Core mentors research faculty, helping them develop the skill sets needed for successful protocol design and investigations. At any point, faculty have access to resources that can strengthen the design and quality of their research efforts. Not only does this core offer senior research faculty mentorship; it also provides brain storming sessions, mock reviews and final editorial reviews. Interested faculty can also participate in the grant writing club and the design and methods think tank. This core also houses the ADAPT Center and DUSON’s International Research Program.
Research Design and Statistics
Nursing research oftentimes requires statistical expertise — a skill set that not all nurses possess. Consequently, faculty conducting methodological studies on social, behavioral and health care research can benefit from outside help when analyzing the data they collect, and they find it in this core. Faculty can receive statistical support through collaboration and consultation with other faculty, postdocs and graduate students. In addition, the DUSON Statistics Laboratory with PhD- and master’s-prepared statisticians is housed here. Faculty can also take advantage of graduate-level courses in research methods and statistics.
Pre-Award Liaison Services
Before faculty can put their research skills to work, they must first receive approval for their concepts. Pre-Award Liaison Services provides pre-award grant specialists who oversee grant preparation and submission. They assist faculty with budget planning and help investigators gather needed School and Institutional review and approvals.
Research Oversight and Compliance
Working in tandem with Pre-Award Liaison Services, the Research Oversight and Compliance Core is responsible for reviewing new protocols and research data security plans. It supports faculty through Institutional Review Board (IRB) processes and provides educational support and grant-supported research staff.
Staff facilitate required contracts and agreements that underscore research protocols with other departments. Through the core’s IRB Preparation Laboratory, research practice specialists and grant-supported research personnel help faculty with study implementation and compliance education.
“We have restructured to provide a ‘concierge’ feel so that those with research needs can receive the best continual, most individualized support with their work as possible,” said Phyllis Kennel, MS, RD, LDN, Research Oversight and Compliance Core director. “Our hope is that we can provide operational research expertise and assistance to the growing research areas of excellence and allow for more fluid operations.”
Individually, the CNR redesign and the creation of four core areas are both enough to change the way DUSON faculty conduct their research activities. Paired together, however, they offer faculty, staff and students an unparalleled research experience that opens more interdisciplinary doors and paves the way for nursing research to impact and shape health care decisions and actions at all levels.
“Physician scientists are very interested in looking at how we diagnose particular conditions — or better yet, how we prevent or cure them,” Broome said. “Nurses study quality-of-life issues to gain knowledge about patients and how they negotiate illness. Nurses know how to design interventions to help patients and their families, to promote health and manage illness.”