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Setting a robust research agenda for geropsychiatric nursing science will encompass both short-term methodologic goals and longer term funding, knowledge development, and dissemination goals. This article identifies immediate needs in the areas of multidisciplinary training, collaborative research models, and selection of research designs appropriate to the types of studies that are the particular province of geropsychiatric nursing scientists, for example, prevention, translational, and effectiveness evaluation of different interventions for aging populations. Longer term goals include nurturance of productive research mentor-mentee relationships within the specialty and development of innovative means for disseminating the yield of nursing research.
Kolanowski and Piven (2006 [this issue]) presented a thorough review of advances in geropsychiatric nursing research, primarily over the past 5 years, and of persisting gaps in our knowledge base and research agenda. In this commentary, the authors’ explicit and implicit recommendations for future research are condensed into 10 global recommendations (see Table 1) focused on two key areas: methodologic issues that can be addressed in the near future and knowledge development and dissemination that represent longer term tasks.
Because aging is embedded in a cultural matrix, research must be attentive to cultural and racial differences among older adults; constructs that represent culturally specific mediators of treatment outcomes are needed. Commonly used concepts such as acculturation, culture, and ethnic identity need to be “unpacked” to reveal more essential components, and more relevant clinical constructs need to be identified and operationalized. Other methodologic needs include attention to treatment fidelity issues, the development of racially and culturally sensitive measurement instruments, and the development of multidisciplinary research teams to address longer term knowledge development goals.
Future geropsychiatric nursing research will focus on prevention, translation of findings from bench to bedside, large-scale intervention trials with meaningful outcome measures, and health services research. With the promise of the genomic era anchored to the realities of contemporary society and health care environments, the sociocultural context as well as emerging genetic considerations need to be represented in theoretical models that account for population differences in responses to behavioral and pharmacological treatments. Theory-driven measurement of the social context, which nursing is particularly well suited to address, remains sorely absent from much mental health and illness research. As nurse scientists develop treatment strategies, organize resources, and form partnerships, their research must be scientifically rigorous, service oriented, and outcome based.
Applying these perspectives, it becomes possible to envision a robust and achievable research agenda for geropsychiatric nursing science that capitalizes on the unique strengths of our specialty.
Preparing researchers in the cross-disciplinary integration of social, basic, behavioral, neuroscience, clinical, and services research will necessitate addressing the complex conceptual and methodological challenges of conducting research with culturally diverse older adults. The National Institute of Mental Health (NIMH)–funded Post-Doctoral and Junior Faculty Clinical Research Training Program in Geriatric Psychiatry (NIMH T32 and R25 training mechanisms, respectively; C. F. Reynolds, principal investigator [PI]) at the University of Pittsburgh School of Medicine provides a model for such training. This program has assisted young investigators to progress through the career pipeline to become successful investigators, senior leaders, and mentors.
Geropsychiatric nurse scientists should continue to participate in the Summer Research Institute in Geriatric Psychiatry, which is a national initiative sponsored by NIMH to enhance the skills of new investigators in the area of geriatric mental health and illness. The program includes a weeklong intensive and interactive workshop on research methods for 25 to 30 selected fellows and junior faculty followed by ongoing communication and intensive mentoring. It has successfully bridged and shortened the transition period from fellowship to first research funding. The National Institute of Nursing Research (NINR), through its Intramural Program Summer Genetics Institute and funding of Institutional Research Training (T32) in genetics, also contributes to building a cadre of nurse scientists to conduct research in genomics and health. With genomics as a central science, this NINR program encourages nurse scientists to identify research opportunities across the National Institutes of Health (NIH) and to examine the relevance of their interests to the research priorities of other institutes and funding agencies.
There is growing consensus that team science would be encouraged if more than one PI could be recognized on individual awards in place of the present paradigm of a single PI working with a small group of subordinates on an independent research project. The NIH has signaled intent to adopt a multiple-PI model that will complement but not replace the traditional single-PI (RO-1) model. Given growing emphasis in nursing research for multifactorial theory development, this offers a promising route to consider funding opportunities that will address the broad array of interests in geropsychiatric science.
The establishment of John A. Hartford Foundation–funded Centers of Geriatric Nursing Excellence and the associated predoctoral and postdoctoral research training (see www.gerontologicalnursing.info/ and www.hartfordign.org) programs have been instrumental in ensuring a “pipeline” of well-prepared investigators who can conduct research and educate the next generation of geropsychiatric nurse leaders. Leaders in the specialty should seek funding for a Center of Geropsychiatric Nursing Excellence.
Nurses are uniquely positioned to conduct intervention-based research (e.g., nurses can obtain biological samples such as blood while implementing psychotherapeutically based behavioral interventions), yet intervention research in geropsychiatric nursing is sparse. It will be increasingly important to think in terms of research questions embedded in the existing literature and then decide exactly what methodologic approaches will best answer them. Although randomized controlled trials are desirable, in many situations randomized controlled trials based on strict criteria are unlikely to be carried out owing to the lack of trained investigators, funding constraints, and inadequate research infrastructure. Also, in some cases, existing cultural and social practices do not lend themselves to such studies. Alternatives include other types of experimental and quasi-experimental designs and secondary analyses of data from existing clinical trials. In addition, we need to acknowledge the role of qualitative and community-based participatory research, not only in developing sociocultural constructs but also in developing and testing new interventions tailored to specific sociocultural contexts. Combining mental health prevention programs with public health promotion strategies in future studies, for example, not only will reduce stigma but may prove to be cost-effective while providing multiple positive outcomes.
Collaboration between diverse mental health disciplines requires a common definition of problems. Multidisciplinary research teams should use terminology endorsed by the appropriate governing bodies and recognized by all mental health disciplines. Nursing scholars have not been consistent in their use of terminology to describe psychopathology such as delirium (e.g., delirium, acute confusion, acute confusional state), nor have they used language endorsed by the Institute of Medicine, the World Health Organization, or NIH when it comes to prevention science. Historically, public health concepts of primary, secondary, or tertiary prevention—focused on preventing the disease itself, the severity of the disease, or the associated disability, respectively—have worked well for medical disorders with a known etiology. The progression of mental disorders from the asymptomatic to the symptomatic state may be insidious, however, and a person may be dysfunctional without meeting diagnostic criteria. Gordon (1987) identified three categories of prevention that are based on a risk-benefit point of view (i.e., the risk to an individual of getting a disease against the cost, risk, and discomfort of the preventive strategy). These are universal prevention (targeting the general public or an entire population group), selective prevention (targeting individuals or subgroups of the population whose risk of developing a mental disorder is significantly higher than that of the rest of the population), and indicated prevention (targeting persons at high risk for mental disorders). These categories are endorsed by both NIMH and the World Health Organization and should be used in the development of geropsychiatric nursing science.
The ability of the field to address the complex conceptual and methodological goals identified by Kolanowski and Piven will largely depend on continued success in attracting new investigators and supporting their growth into interdisciplinary scientists and leaders. As noted previously, participating in programs that prepare researchers in cross-disciplinary integration will be necessary to meet this goal.
In an effort to reauthorize NIH for the first time since 1993, House Energy and Commerce Committee Chair Joe Barton (R-Texas) has proposed consolidating institutes and centers into one division focused on specific diseases or organs, another on basic research, and a third division to coordinate and enhance research that overlaps. The proposal would recast NINR from a mission-focused institute (e.g., National Cancer Institute; National Heart, Lung, and Blood Institute; NIMH) to a science-enhancing group (e.g., complementary medicine, office of women’s health, office of minority health). If NIH were to consolidate thusly, and if NINR were to become a science-enhancing group, geropsychiatric nurse researchers would be forced to seek funding from other NIH entities. Interestingly, the NINR declined to send a representative to discussions regarding this proposal.
NIMH supports the education and training of mental health researchers through a variety of well-established mechanisms, including early research training (e.g., predoctoral fellowships, postdoctoral fellowships, institutional training programs, mentored academic career awards, and midlevel career awards). The institute also maintains a mechanism for supporting short-term research education programs (e.g., the Summer Research Institute in Geriatric Psychiatry). NIMH supports an array of programs for special populations to increase the diversity of investigators in mental health and, importantly, has made a substantial commitment to NIH’s student loan-forgiveness programs. Finally, NIMH supports several types of small or specialized grants for newly independent researchers (e.g., B/START, small grants, Academic Research Enhancement Award grants). An analysis of these training and career development programs suggests that mental health and aging researchers are receiving a disproportionately small number of awards, given the magnitude of the public health concerns and opportunities for scientific advancement.
Research conducted by nurses was the focus of the Kolanowski and Piven review. Although geropsychiatric nurses have not, themselves, yet conducted much research involving older adults with schizophrenia, substance abuse, anxiety disorders, or medical comorbidities, others in the field of geriatric mental health have done so. To address gaps in the knowledge base, it will be important to summarize extant late-life mental health research without directing attention to the PI’s disciplinary background. Once this is done, it will be possible to make concise research recommendations to address gaps in our understanding of geriatric mental health and illness.
Geropsychiatric nurses would also benefit from joining the American Association of Geriatric Psychiatry and attending its annual scientific meeting to keep abreast of research our colleagues in medicine are conducting.
The National Academy of Sciences (Bruce, 2003) has explicitly identified attrition of developing investigators in clinical research as a looming crisis facing the NIH. At critical junctures in young investigators’ career paths, mentors can be invaluable. Mentoring occurs when the mentor (a senior person in terms of experience) undertakes to provide information, advice, and emotional support to the mentee (a junior person) in a relationship over an extended period of time and marked by substantial commitment by both parties. Usually, the mentor uses both formal and informal forms of influence to further the career of the protégé. A directory of formal mentors in geropsychiatric nursing research could be invaluable in linking potential mentees and mentors and could serve as a source list of professional organizations; publications such as journals, abstracts, proceedings, and newsletters; and conferences, seminars, and workshops.
For intervention studies to be helpful to practitioners and other researchers, it is important to publish details regarding the framework, process, and goals of an intervention and to specify which components of the intervention account for changes in patient outcomes. Yet space constraints in professional journals often preclude such detail. It is essential for geropsychiatric nurse researchers to describe and deconstruct interventions in detail and to explore novel opportunities for disseminating this information. Given and Given (2004) have suggested, for example, that nursing journals could dedicate a section to studies germane to geriatric mental health and illness, and their Web sites could provide links to full descriptions of the research. Other nursing professional journals might devote Web site space for a well-maintained repository for geropsychiatric nursing research findings.
Geropsychiatric nurses have particular interest and expertise in the impact of health behaviors and social circumstances on health, longevity, and the onset and course of illnesses, with special attention to the basic mechanisms linking stress, coping, and health outcomes among aging populations, as well as the effectiveness of different intervention approaches for maintaining health and preventing disease or disability. The value of knowledge the specialty generates in these areas underscores the need for a clearinghouse to collect and disseminate findings. Organizations such as the American Psychiatric Nursing Association, the National Gerontological Nursing Association, the American Academy of Nurses, the John A. Hartford Foundation, and possibly even the American Association of Geriatric Psychiatry could contribute to developing this resource.
At advanced age, serious physical and psychiatric illnesses frequently coalesce, blurring the boundaries of psychiatric and geriatric nursing. Over the next 10 years, geropsychiatric nursing must establish coalitions with organizations and investigators within and outside of nursing to create the collaborative energy necessary to fully realize the promise of modern biomedical and biobehavioral research to further our understanding of geriatric mental health and illness.