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INVITED COMMENTARY The Past and Future of Nursing Research Margaret M. Heitkemper*, PhD, RN, FAAN Elizabeth Sterling Soule Chair in Nursing Professor, Department of Biobehavioral Nursing and Health Systems Director, Center for Womens Health and Gender Research School of Nursing, University of Washington, Seattle, WA, USA The past three decades have witnessed a remarkable growth in nursing science development. In both Korea and the United States, nurse scientists are poised to address important issues related to the prevention and management of significant health care problems. The need for greater nursing science development in the areas of self management, genetics, geriatrics, health promotion across the lifespan, technology, and mental health are briefly highlighted. Future research efforts will be enhanced by interdisciplinary collaboration and the creation of international nursing research centers. At the same time, we need to remain cognizant of the importance of mentoring future nurse scientists. [Asian Nursing Research 2007;1(1):4–10] Key Words health care research, nursing, nursing science Portions of this paper were derived from a keynote presentation at the Western Institute of Nursing in Portland, Oregon, April 2007, and published as proceedings in Communicating Nursing Research, Vol 40. Thank you for the opportunity to be part of the interventions,health informatics and evidence-based inaugural issue of this important Asian Nursing practice to name a few.Compared to other sciences, Research journal.Research and nursing science devel- nursing science is relatively young;however,we have opment have been at the forefront of Korean nurses’ made great strides and should be proud of these mission. This paper provides broad examples of accomplishments. what nurse scientists have accomplished as well as In the early years of nursing science development, some thoughts regarding priorities for future scien- the conduct of research was viewed as a prerequisite tific efforts. Both in Korea and the United States to full consideration as a profession.As Marge Batey (U.S.),nursing science as a discipline has retained an (1968) noted in the Preface of the first volume of emphasis on methodological precision, while apply- Communicating Nursing Research,“As nursing gropes ing that rigor to increasingly complex issues of for its maturity, it is coming to recognize its respon- patient health. Our science has progressed from sibility as a profession to search for and to build a early papers and conferences focused on how to do broader and a sounder knowledge base for its pro- research to substantive knowledge development in fessional practice.” No longer should nurses be seen key research areas of health promotion,disease pre- as only the focus or subjects of study from an anthro- vention,clinical therapeutics,family and community pological or sociological perspective, but should be *Correspondence to:Margaret M. Heitkemper, PhD, RN, FAAN,Department of Biobehavioral Nursing and Health Systems, School of Nursing, Box 357266, 1959 NE Pacific Street, T601, University of Washington, Seattle, WA 98195, USA. E-mail: heit@u.washington.edu 4 Asian Nursing Research ❖ June 2007 ❖ Vol 1 ❖ No 1 The Past and Future of Nursing Research seen as scientists conceiving and conducting the stud- While genetic information may help guide deci- ies needed to inform professional nursing practice. sion-making,it also brings with it ethical issues related In 2003,Donaldson urged nurse researchers to con- to confidentiality as well as the impact of disclosure sider issues of professionalism or the elevation of the of genetic risk in cases where there is no cure (Lea, status of nursing secondary to the development of Williams, & Donahue, 2005). Schutte and Holston science related to health. She wrote, “...in deciding (2006) wrote that we need to consider how ethnicity, future directions for nursing research and science, it culture, and health literacy influence the utility and better fits nursing’s societal mandate to have as the desirability of genetics information and technology. highest priority understanding and improving the Nurse scientists and nurse ethicists are providing health status of those whom we serve.” critical guidance as we move forward in our under- Based on the U.S. National Institutes of Health standing of genetic vulnerabilities (Frazier, Meninger, roadmap initiatives,I have attempted to reflect in this Lea,& Boerwinkle,2004). paper the contributions of nursing science to predic- Increasingly, our attention must be given to the tive, preemptive, personalized (or patient-centered), issues of mental health disorders because of their link and participatory health care. to physical health and quality of life. In 2006, the U.S. National Institutes of Mental Health Director Thomas Insel noted,“After six decades of progress, PREDICTIVE mental disorders remain unacceptably common, causing more disability in people under age 45 than Over the past two decades,we have seen a dramatic any other class of non-communicable medical illness.” increase in the inclusion of genetic markers into nurs- Basic science can provide information on genetic sus- ing research studies. Understanding disease risk and ceptibility to such disorders,neuroscience can inform vulnerability through genetic markers may be keys us about neuroanatomical alterations linked with not only to predicting disease development but also mental disorders,and neuroimaging can provide ear- to predicting who might benefit from a particular lier diagnosis. However, research is critically needed therapeutic strategy. The sequencing of the human to examine environmental influences particularly genome has taken us from understanding single gene during early development, behavioral risk factors, disorders (e.g., Huntington’s disease, cystic fibrosis) compliance with therapy, behavioral therapies, and to having the basic knowledge to examine more com- family support.Because of nurse scientists’ expertise plex, multifactorial (multiple gene) disorders such in both qualitative and quantitative measurements as heart disease, diabetes, pancreatic cancer, and as well as behavioral therapy, we are well poised to alcohol abuse. As an example, in our laboratory we contribute to this research agenda. have examined alleles of the serotonin reuptake trans- Research regarding stress and depression and anx- porter protein as an approach to understanding the iety suggests that stress may serve as a trigger of not link between depression and symptom experiences only physiological responses but also of mental illness in women with functional bowel complaints (Jarrett in genetically susceptible individuals. For example, et al., in press). Such results are intriguing and may set exposure to stress during critical periods of develop- the stage for selecting tailored or personalized ther- ment may lead to subsequent mental health problems apeutic options for patients based on their genetic later in adolescence or adulthood. Stress and post- profile. In future, we may be using genetic markers traumatic stress disorder are linked to a number of with critical care patients to determine therapeutic functional disorders such as irritable bowel syndrome, strategies for those patients with acute respiratory fibromyalgia, insomnia, migraine headaches, chronic distress syndrome or multiorgan failure. The next fatigue syndrome, interstitial cystitis, and chronic step will be proteomics as we examine not only the pelvic pain. Stress and depression are also linked to genetic susceptibility but the expression of genes. heart disease as well as other medical disorders. Asian Nursing Research ❖ June 2007 ❖ Vol 1 ❖ No 1 5 M.M.Heitkemper One example from the Korean nursing community is The last 25 years has shown us the impact of the work of Son (2007) who described a positive rela- globalization on health, particularly in the area of tionship between hostility and serum homocysteine infectious disease. HIV, hepatitis, tuberculosis, bird levels in patients with coronary artery disease.We are flu, and SARS are but a few examples of infections challenged to consider “what is the physiologic link that spread across geographic boundaries. At the between stress and physical ailments?” and “what is public health level, there are monthly alerts about the interaction among stress, genetic predisposition, the potential for devastation due to avian flu. Clini- personality, gender, culture, and environmental influ- cians within our health care institutions are very ences and disease expression and outcomes?” concerned about methicillin-resistant Staphylococ- Understanding genetic risks and disease prediction cus aureus, vancomycin-resistant Enterococcus,and will increase the average lifespan as well as enhance Clostridium difficile, which are pervasive and pose the quality of life of individuals living longer. An grave risks for vulnerable clients.The work of Elaine examination of the demographic trends from Korea Larson (Kretzer & Larson, 1998) has informed us and the U.S.as well as other industrialized countries about the challenges of instituting and maintaining makes it evident that the percentage of individuals routine procedures such as hand-washing and the use over the age of 65 is rapidly increasing. This antici- of antimicrobial products.Several investigators have pated increase in the number of older adults makes examined the impact of routine nursing practices it imperative that there is greater understanding of (e.g., catheter care) on infections in hospitalized how to improve the quality of life of older individuals. patients. Recent work has demonstrated that moni- For example, efforts are needed to reduce disability toring systems can reduce the incidence of catheter- due to chronic illness,test health promotion strategies related infections (Saint, Kaufman, Thompson, to reduce chronic illness, and develop strategies to Rogers,& Chenoweth,2005).However,much work reduce caregiver strain. Nurse researchers have made remains to be done in terms of preventing ventilator- profound contributions to the understanding of aging associated pneumonia and C. difficile. Even less is in a number of important areas including the clinical known about the long-term sequelae of these infec- management of dementia,urinary incontinence,heart tions acquired in acute care settings. failure, as well as coronary artery disease and stroke At the individual level,we have challenges related prevention.Centers of excellence focused on research to identification and treatment of chronic infectious and education related to aging are needed.It is essen- disorders including HIV,hepatitis B virus (HBV),and tial that these centers be collaborative and interdis- hepatitis C virus (HCV).At this time,it is estimated ciplinary. Interventions to reduce caregiver stress that 10% of the Korean population is chronically have been developed and tested but await broader infected with HBV;1.25 million Americans are chron- implementation. ically infected with HBV—the majority of whom are of Asian descent (Hepatitis B Foundation,2007). At the same time,4.1 million (1.6%) Americans have PREEMPTIVE been infected with HCV, of whom 3.2 million are chronically infected.With drug therapy seroconver- Preemptive therapies are those directed at a time sion rates less than ideal, liver transplantation is before the symptoms and damage occur such as in the increasingly used. Enhancing self care and ultimately case of osteoporosis, heart disease, and type 2 diabetes. quality of life for these vulnerable individuals remain We now realize that many diseases such as osteoporo- a high priority. We are beginning to understand the sis and cardiovascular disease seen in adults actually linkages between infections and other disorders have their origins in childhood.As such,interventions include gastric cancer, cervical cancer, hepatocellular directed earlier may avert or postpone problems cancer, and autoimmune disorders. Vaccines when later in life. available have substantially reduced the risk of 6 Asian Nursing Research ❖ June 2007 ❖ Vol 1 ❖ No 1 The Past and Future of Nursing Research chronic HBV. Longitudinal studies are needed to the number of bariatric procedures is rapidly rising as determine the impact of vaccination on the rates of well (Lee & Wang, 2004). While nurse researchers HBV-associated hepatocellular cancer. However, have been engaged in obesity research at a number access to vaccines is not universal. of levels including genetic predisposition, metabolic While basic scientists rush to develop vaccines syndrome,and exercise adherence,even greater atten- and better antibiotics, there is still the challenge of tion is warranted. The results of studies need to be developing safe interventions to enhance prevention disseminated and used to form the basis for public and compliance. Investigators remain concerned policy changes such as mandatory physical exercise about disparate health literacy levels among our pop- in grade schools, healthy food choices in vending ulations and its impact on health promotion as well machines,foods in school cafeterias,and health pro- as self management.For example,the recently devel- motion activities in the work place. oped human papillomavirus vaccine will necessitate understanding of how persons from a variety of sociocultural backgrounds make decisions related to PERSONALIZED prevention and health behaviors. Prevention infers changes in health-related behav- Given the growing database related to genetic predis- iors. Nurse scientists have explored strategies to position,disease pathogenesis and behavioral factors enhance smoking cessation,reduce alcohol consump- that predict successful outcomes,individualized inter- tion, and increase weight loss as important routes to ventions can now be designed and tested. One area decreasing disability. Globalization has made obe- for which tested interventions are clearly lacking is end sity a growing worldwide problem in industrialized of life (EOL) care. The bulk of the science to date nations. Recently, while in Seoul, Korea, I noted 3 is derived from patients in the last stages of cancer. Starbucks, 3 Dunkin Donuts, 1 Krispy Kreme, 1 Despite the substantial number of deaths due to car- Burger King, 1 MacDonalds, and 3 Outback Steak- diovascular, respiratory, and neurological disorders houses within walking distance from my hotel.The and injuries,there is a dearth of data-based literature associated increased risk of cancer, arthritis, sleep available to guide EOL practice for patient groups.In disturbances, diabetes and its complications, and December 2004,the U.S.National Institutes of Health cardiovascular disease have resulted in concerns about convened a conference to review the scientific evi- the overall negative impact of obesity on the average dence related to EOL care.This state-of-the-science lifespan. conference brought together researchers from a vari- The rising rates of obesity, metabolic syndrome, ety of disciplines (nursing,medicine,social work,psy- and type 2 diabetes are multi-component problems. chology,public health).Nurse investigators presented Decreasing levels of physical activity beginning early on diverse topics including EOL care for pediatric in life and increasing access to high fat foods con- patients, family support during palliative and EOL tribute to expanding waistlines of many individuals care, symptom management, and interprofessional living in industrialized countries. From a women’s communication challenges.Research priorities were health perspective, there are vulnerable periods identified including strategies to enhance communi- (puberty,pregnancy,menopause) when weight gain is cation among patients, family members, and health more likely. There are clear gender-related differences care professionals,symptom management,and care- in where weight is gained as well as the metabolic giver burden. consequences of that gain.At the same time,there are By the 1990s, chronic disease had superseded discouraging data about the efficacy of diet therapy communicable diseases as the leading cause of death and exercise adherence. In the U.S., the number of in all parts of the world except sub-Saharan Africa bariatric procedures has increased from 11,111/year and the Middle East.In all likelihood,chronic diseases in 1996–1998 to 106,242/year in 2002–2004.In Asia, will be the predominant global source of morbidity, Asian Nursing Research ❖ June 2007 ❖ Vol 1 ❖ No 1 7
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