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