Nursing research in the u s research supported by the national institute of nursing research ninr
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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. School of Nursing www.ohsu.edu/son. http://www.ninr.nih.gov. School of Nursing www.ohsu.edu/son.

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

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Nursing research in the u s research supported by the national institute of nursing research ninr

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


Judith gedney baggs phd rn faan elizabeth n gray distinguished professor

School of Nursing

www.ohsu.edu/son


Http www ninr nih gov

http://www.ninr.nih.gov

School of Nursing

www.ohsu.edu/son


Purpose of talk

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


Who else funds nursing research in the us

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


Mission of ninr

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


Driving forces for funding priorities

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


Strategies guiding research program

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


Areas of research emphasis

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


Promoting health and preventing disease

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


Improving quality of life qol

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


Improving quality of life qol1

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


Improving quality of life qol2

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


Elimination of health disparities

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


End of life eol research

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


Ninr research emphasis areas

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


Examples of recent calls for proposals

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


Questions

Questions?

School of Nursing

www.ohsu.edu/son


Limitation of treatment decision making in the icu an ethnographic study ro1 nr04940

Limitation of TreatmentDecision Making in the ICU:An Ethnographic StudyRO1 NR04940

School of Nursing

www.ohsu.edu/son


End of life decision making in icus roles and relationships of key players r15 nr 012174

End-of-Life Decision MakingIn ICUs:Roles and Relationships of Key Players(R15 NR 012174)

School of Nursing

www.ohsu.edu/son


Patient family problems

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


Why study icus

Why study ICUs?

  • 20% of deaths in United States

School of Nursing

www.ohsu.edu/son


Problems with prior research

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


Study aims

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


Study purpose

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


Framework

Framework

  • Socio-cultural Domain Theory

  • Domain – Includes a range of social relations, customs, and norms

School of Nursing

www.ohsu.edu/son


Culture

Culture

Shared knowledge and customary actions that express, mark, and maintain social systems

School of Nursing

www.ohsu.edu/son


Roles rules relationships

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


Why ethnography

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


Data sources setting

Data Sources & Setting

  • Participant observation, field notes

  • 131 Semi-structured interviews

  • Family meetings

  • Cultural artifacts

School of Nursing

www.ohsu.edu/son


Study timing

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


Research team

Research Team

School of Nursing

www.ohsu.edu/son


Data analysis

Data Analysis

  • Prolonged analysis of texts

  • Comparisons within and across cases, units, and groups

  • Case


Interviews

Interviews

  • Families

  • Clinicians

    • Physicians

    • Nurses

    • Social workers

    • Ethicists

    • Chaplain

    • Pharmacist


Roles rules and relationships of icu physicians during eoldm

Roles, Rules, and Relationships of ICU Physicians During EOLDM


Physicians interviewed

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


Nurses interviewed

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


Physician roles

Physician Roles

  • Societal expectation

  • Types of roles in systems of care

  • Types of roles in the hospital

  • Roles specific to ICU


Rules and relationships

Rules and Relationships

  • Differing expectations for role enactment

  • Rules govern the relationships

  • Physician participation in EOLDM


Rules and relationships by icu

Rules and Relationships by ICU

  • Physician role configurations varied by ICU

  • Configurations influenced unit-specific culture


Complexity attending role

Complexity: Attending Role

Who is the attending?


Attending roles

Attending Roles

  • Hospital Rules

  • Frequently PCPs relinquish responsibility to ICU MDs

  • Service rules, “hand offs”


Who is attending for eoldm

Who is Attending for EOLDM?

  • MD responsible for care including EOLDM

  • A shifting target


Medicine vs surgery

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.’”


Varied attending roles by unit

Varied Attending Roles by Unit

  • MICU – Intensivists

  • SICU/BTICU – Admitting surgeon

  • CVICU – Varied by subgroup


Other md roles in eoldm

Other MD Roles in EOLDM

Consultants

  • Neurologist – brain death

  • Psychiatrist – capacity

  • Palliative Care - EOL


Varied interaction with nurses

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.”


Consequences for mds

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.”


Consequences for nurses

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.”


Consequences for families

Consequences for Families


Conclusions

Conclusions

  • Even in a single hospital, each ICU had a different culture.

  • Physicians were important in developing the culture for EOLDM in the ICU

    • As leaders

    • As care providers


Implications

Implications

  • Interventions

    • Tailor to each unit

    • Development involve key players

    • Address family confusion


Publications

Publications

  • Baggs, J. G., Norton, S. A., Schmitt, M., Dombeck, M., Sellers, C. R., Quinn, J. R. (2007). Intensive care unit cultures and end-of-life decision making. Journal of Critical Care, 22, 159-168.

  • Wiegand, D. L., Norton, S. A., & Baggs, J. (2008). Challenges in conducting end-of-life research in critical care. AACN Advanced Critical Care, 19(2), 170-177.

  • Baggs, J. G., Norton, S. A., Schmitt, M. H., & Sellers, C. R. (2004). The dying patient in the ICU: Role of the interdisciplinary team. Critical Care Clinics of North America, 20, 525-540.

  • Baggs, J. G. (2002). End-of-life care for older adults in ICUs. Annual Review of Nursing Research, 20, 181-229.


Questions1

QUESTIONS?

  • About my work or about NINR.


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