Judith Gedney Baggs, PhD, RN, FAAN Elizabeth N. Gray Distinguished Professor

1. Nursing Research in the U.S.: Research Supported by the National Institute of Nursing Research(NINR) Judith Gedney Baggs, PhD, RN, FAAN Elizabeth N. Gray Distinguished Professor

2. School of Nursing www.ohsu.edu/son

3. http://www.ninr.nih.gov School of Nursing www.ohsu.edu/son

4. Purpose of talk: To provide a picture of areas in which US nursing scientists are being funded to conducting research. Opportunity in China, National Natural Science Foundation. School of Nursing www.ohsu.edu/son

5. Who else funds nursing research in the US? Examples: • Sigma Theta Tau • Oncology Nursing Society • Hospice and Palliative Care Nurses Association • American Association of Critical-Care Nurses School of Nursing www.ohsu.edu/son

6. Mission of NINR • To promote and improve health • Funds clinical and basic research and research training • Health, illness, health promotion, disease prevention, quality of life, health disparities, end of life. School of Nursing www.ohsu.edu/son

7. Driving Forces for Funding Priorities • Aging population • Increased need for services • Increased use of technology • Translation of research to practice • Shortage of nurses and nursing faculty School of Nursing www.ohsu.edu/son

8. Strategies Guiding Research Program • Biobehavioral research • Adopting, adapting, generating new technologies • Improving methods for future scientific discoveries • Developing scientists School of Nursing www.ohsu.edu/son

9. Areas of Research Emphasis • Promoting Health and Preventing Disease • Biological and behavioral • Environmental and genetic factors • Socioeconomic factors • Interactions School of Nursing www.ohsu.edu/son

10. Promoting Health and Preventing Disease • Develop biomarkers for risk and response • Develop/improve biobehavioral methods, measures, interventions • Identify factors influencing decision making for behavioral changes • Develop individual/family interventions to sustain health promotion. • Community based interventions • Address consequences of prematurity School of Nursing www.ohsu.edu/son

11. Improving Quality of Life (QOL) • Self Management • Technologies for self-identify and report symptoms • Promote healthy lifestyle choices • Behavior supporting adherence • Factors for independence/self-care in long term care • Strategies for survivors and disabled School of Nursing www.ohsu.edu/son

12. Improving Quality of Life (QOL) • Symptom management • Causative mechanisms • Improve recognition of symptoms • Interventions improve response/adaptation • Strategies to improve management • Strategies for assess and intervene to improve QOL for person with chronic or life-threatening illnesses School of Nursing www.ohsu.edu/son

13. Improving Quality of Life (QOL) • Caregiving • Interventions to improve physiological and cognitive function of elderly • Interventions to improve caregiving • Factors to improve transition between settings • Models for first responders in emergencies School of Nursing www.ohsu.edu/son

14. Elimination of Health Disparities • Mechanisms underlying disparities and intervene to eliminate • Culturally appropriate interventions to communicate to at-risk populations • Apply research findings to decrease health disparities in children and adolescents • Reduce consequence of poor maternal/reproductive health • Increase scientists from underrepresented groups School of Nursing www.ohsu.edu/son

15. End-of-Life (EOL) Research • Identify and improve decision making and treatment strategies at EOL • Validate instruments and methods to study EOL • Interventions to improve palliative care and QOL for patient and family • Factors related to EOL among underrepresented • Informatics tools to manage data from EOL studies • Expand EOL research School of Nursing www.ohsu.edu/son

16. NINR Research Emphasis Areas • Promoting Health and Preventing Disease • Improving Quality of Life • Eliminating Health Disparities • Setting Directions for EOL Research School of Nursing www.ohsu.edu/son

17. Examples of Recent Calls for Proposals • Health promotion among racial and ethnic minority males • Integrating biobehavioral and sociocultural research to prevent HIV transmission • Clinical decision making in people with or at risk for life-threatening illness • Role of human-animal interactions in child health and development • Psychosocial stress and behavior: Integration of behavioral and social science research • Scientific meetings for creating interdisciplinary research teams in basic behavioral and social science research School of Nursing www.ohsu.edu/son

18. Questions? School of Nursing www.ohsu.edu/son

19. Limitation of TreatmentDecision Making in the ICU:An Ethnographic StudyRO1 NR04940 School of Nursing www.ohsu.edu/son

20. End-of-Life Decision MakingIn ICUs:Roles and Relationships of Key Players(R15 NR 012174) School of Nursing www.ohsu.edu/son

21. Patient/Family Problems • EOL Treatment not congruent with ICU patient preferences • Need research to understand end-of-life decision-making (EOLDM) process in ICU School of Nursing www.ohsu.edu/son

22. Why study ICUs? • 20% of deaths in United States School of Nursing www.ohsu.edu/son

23. Problems with Prior Research • Researchers have aggregated data, treated all ICUs as similar • Most researchers target one group • Most research retrospective School of Nursing www.ohsu.edu/son

24. Study Aims • R01: Facilitators and Barriers • Understanding of the Process of EOLDM • R15: Roles of the key participants in EOLDM in ICUs: family, physicians, nurses, and patients. • Inter-relationships. • Identify the expressions of and interactions among these roles and relationships in family meetings. School of Nursing www.ohsu.edu/son

25. Study Purpose • RO1 To describe similarities and differences in the cultures of several ICUs and the influence of culture on EOLMD • R15 To focus on the roles of the key persons in EOLDM in ICUs (family members, physicians, nurses) and inter-relationships. To help support interventions respectful of the perspectives of all participants in EOLDM. School of Nursing www.ohsu.edu/son

26. Framework • Socio-cultural Domain Theory • Domain – Includes a range of social relations, customs, and norms School of Nursing www.ohsu.edu/son

27. Culture Shared knowledge and customary actions that express, mark, and maintain social systems School of Nursing www.ohsu.edu/son

28. Roles, Rules, Relationships • Culture is embedded in social relationships, social identities or roles, and both formal and informal rules School of Nursing www.ohsu.edu/son

29. Why Ethnography? • Dis-aggregate cultures in different ICUs • See cultural influences • Take place in real time • Consider multiple perspectives • For R15 use Qualitative Description School of Nursing www.ohsu.edu/son

30. Data Sources & Setting • Participant observation, field notes • 131 Semi-structured interviews • Family meetings • Cultural artifacts School of Nursing www.ohsu.edu/son

31. Study Timing Prolonged engagement – 3 years, 7 months on each of 4 adult ICUs (MICA, SICU, Burn-Trauma ICU, and CVICU) in an academic teaching hospital School of Nursing www.ohsu.edu/son

32. Research Team School of Nursing www.ohsu.edu/son

33. Data Analysis • Prolonged analysis of texts • Comparisons within and across cases, units, and groups • Case

34. Interviews • Families • Clinicians • Physicians • Nurses • Social workers • Ethicists • Chaplain • Pharmacist

35. Roles, Rules, and Relationships of ICU Physicians During EOLDM

36. Physicians Interviewed 44 Interviews with 29 physicians • 9 intensivists (3 unit medical doctors) • 1 non-intensivist unit director (cardiologist) • 5 attending surgeons • 1 attending neurologist • 4 consultants (2 cardiologists, 2 palliative care) • Trainees: 9 residents and 1 fellow

37. Nurses Interviewed 57 Interviews with 51 nurses: • 28 staff nurses • 8 nurse practitioners • 5 nurse leaders • 4 nurse managers • 3 care coordinators • 1 nurse researcher

38. Physician Roles • Societal expectation • Types of roles in systems of care • Types of roles in the hospital • Roles specific to ICU

39. Rules and Relationships • Differing expectations for role enactment • Rules govern the relationships • Physician participation in EOLDM

40. Rules and Relationships by ICU • Physician role configurations varied by ICU • Configurations influenced unit-specific culture

41. Complexity: Attending Role Who is the attending?

42. Attending Roles • Hospital Rules • Frequently PCPs relinquish responsibility to ICU MDs • Service rules, “hand offs”

43. Who is Attending for EOLDM? • MD responsible for care including EOLDM • A shifting target

44. Medicine vs. Surgery • “[Surgeons] might say, ‘The vast majority are going to not do well, but there is a small percentage that will surprise us. . .’ That’s one way to present it…I [the intensivist] might say, ‘There are very, very few people that do well.’”

45. Varied Attending Roles by Unit • MICU – Intensivists • SICU/BTICU – Admitting surgeon • CVICU – Varied by subgroup

46. Other MD Roles in EOLDM Consultants • Neurologist – brain death • Psychiatrist – capacity • Palliative Care - EOL

47. Varied Interaction with Nurses • MICU or Medical patients in CVICU • SICU/BTICU/Surgical patients in CVICU • “No one would ever, if a surgeon said, ‘No, you’re not talking with the family,’ they wouldn’t call palliative care. But we still do curbside palliative care help.”

48. Consequences for MDs • Physicians versed in nuances of physician roles by discipline and by unit “The relationship that critical care physicians have with specific doctors is rule number one. We know that Dr. So and So wants us to do everything. We also know that Dr. B. doesn’t want everything.”

49. Consequences for Nurses • Nuances of roles varied for other team members and for families. “It seems funny to have 2 attendings, and they are both talking to the family, and they’re not talking to each other.”

50. Consequences for Families