By Kenneth Miller
As a rookie nurse in 1968, Elaine Larson, PhD, RN, associate dean for research, had an experience that left her shattered. One of her patients was a woman in her early 30s with rheumatic heart disease. “She called me into her room and said she was having a little trouble breathing,” Larson recalls. “I listened to her heart and took her pulse. Everything seemed fine, so I just propped her up with a pillow. But when I came back five minutes later, she was in acute distress.” Within half an hour, the young woman was dead of acute pulmonary edema.
“Afterward, I thought that if I’d known more about this patient’s condition, I could have taken appropriate action,” Larson says. She also realized that other nurses might find themselves in a similar position. So she threw herself into the literature, wrote up a case study, and submitted it to the American Journal of Nursing. When it was published, she knew she’d found her calling: “In addition to taking care of patients, I wanted to help find solutions about how to take care of them.” That revelation spurred Larson to pursue a master’s degree in nursing and microbiology and a PhD in epidemiology—and, eventually, to join the faculty of Columbia University School of Nursing, where finding better ways to care for patients is a defining mission.
When Larson arrived in 1998, the school was just beginning its transformation into a premier center for nursing research. Today, it is one of the largest per-capita recipients among nursing schools of grants from the National Institutes of Health. “In terms of both the quality of our research and of the faculty that lead it,” says Larson, “we’re among the top-10 schools in the nation.”
Even though Florence Nightingale pioneered evidence-based nursing care and statistical analysis in the 1850s, the medical establishment long dismissed the notion that nurses could be key drivers of health care research. It would be more than a century after Florence Nightingale established the role of evidence as critical to nursing that research related to the prac- tice of nursing would first enter the literature. In the 1950s and ’60s, practice was still the focus. Then, in the 1970s, as more university-affiliated schools of nursing began to engage in research, themes around nursing theory, patient outcomes, and the engagement of nurses in independent research emerged. The process of discovery gained strength during the 1980s, with Columbia University School of Nursing gaining prominence as a leader in scholarship and research.
The school attracted a growing number of highly credentialed scholars, who launched groundbreaking studies on topics that included care of the frail elderly, case management of diabetics, AIDS care, and suicide prevention among adolescents. In time, the school was awarded major grants, starting with a million-dollar award from the Kellogg Foundation to devise a new approach for academic medical centers— piloted at Columbia-Presbyterian—serving medically underserved inner-city communities. Talented and ambitious students flocked to the doctor of nursing science (DNSc) program, established in 1994, and to the PhD program that succeeded it in 2008.
Being part of a major academic medical center, Columbia Nurs- ing is able to pursue interdisciplinary studies across a variety of health care fields. The school’s distinguished faculty of nurse-scientists is deeply engaged in discovering best practices in clinical care and pub- lic health. Larson, an internationally recognized authority on infection prevention and control, is a pioneer in the study of hand sanitation; her ongoing research has led to the development of new hygiene proto- cols that significantly improve patient care and outcomes. Among her many projects, she is co-principal investigator—with Jennifer Dohrn ’85 ’05, DNP, director of the Office of Global Initiatives and its WHO Collaborative Health Center for Advanced Practice Nursing—for the school’s Global Nursing Research Development Initiative, establishing networks of nurse researchers as part of interdisciplinary collabora- tive teams between Columbia Nursing and initiatives in southern and eastern Africa and the eastern Mediterranean regions.
“Worldwide, nurses make up the largest proportion of health care professionals, and serve as the backbone of health care systems,” Larson explains. “To improve global health and primary care delivery, and address global health disparities, it’s crucial to understand current nursing care needs, practices, and outcomes.” The initiative culminated in one summit meeting in Nairobi, Kenya, in 2015, and a second in Amman, Jordan, in 2016, to define priorities for research and formulate strategies for moving forward. This project brought together nurse and midwifery researchers and leaders in both regions to define clinical nursing research priorities.
Harnessing big data, informatics technology, and the principles of precision medicine in order to develop digital health care tools for under-served populations in this country—particularly Latinos—is another research area central to the school. “Our focus is on reducing health disparities by designing and testing symptom self-management interventions,” explains Suzanne Bakken, PhD, RN, professor of bio- medical informatics and Alumni Professor at Columbia Nursing and director of the Precision in Symptom Self-Management (PriSSM) Center, an interdisciplinary research center. “We’re working on projects such as tailoring interventions based on genetic, environmental, and lifestyle factors, and designing infographics to help people understand their risk of various conditions—such as hypercholesterolemia.”
Informing and advancing policies aimed at improving the availability, affordability, safety, and effectiveness of health care nationwide is a critical area of study. Patricia W. Stone, PhD, RN, the Centennial Professor of Health Policy and director of the school’s Center for Health Policy, focuses primarily on health care-associated infections in nursing homes and health care systems. Her work involves collaborating with health care institutions and organizations, including the Centers for Disease Control and Prevention (CDC) and multiple state departments of health, to investigate the prevention of health care-associated infections, especially among elderly patients in hospitals and nursing homes.
Although her research deals with big-picture topics, Stone—like many of her colleagues at Columbia Nursing—is driven by concerns that are deeply personal and inextricably tied to her experiences as a nurse. A few years ago, when her mother was dying in a California hospital, Stone noticed that the nursing unit appeared unusually chaotic. The state was grappling with a severe nursing shortage at the time, forcing the hospital to use traveling nurses as staff. “The nurses were good, but I could see they weren’t functioning as a team,” she recalls. “At one point, when I asked where my mom was, the nurse on duty didn’t know. She said, ‘I’m sorry, I’m a traveler.’” That episode eventually led Stone to conduct a study of hospital staffing, which showed that longer nurse tenure on a unit is linked to fewer problems such as infections, falls, and pressure ulcers, and thus shorter length of stay for patients.
A hallmark of Columbia Nursing’s commitment to research includes cultivating the next generation of nurse-scientists. The school offers pre- and postdoctoral fellowship support that ranges from tuition stipends to workshops in proposal and manuscript writing. But the most critical resource is one-to-one interaction with the faculty. “We pride ourselves on providing doctoral students with the opportunity for experiential learning,” says Arlene Smaldone ’03, PhD, RN, assistant dean for scholarship and research. “To do that, you need mentoring from scientists who actually live the life. The majority of our faculty are sup- ported by at least one externally funded grant. That’s important.”
With such professors and role models, a young nurse researcher can accomplish extraordinary things. Rebecca Schnall ’09, PhD, RN, for example, studied under Bakken, receiving her doctorate in nursing informatics in 2009. Schnall became an associate research scientist at the school, with a focus on translating evidence-based approaches for patient self-management into mobile applications, a promising new field called mHealth. In 2016, she and her team were awarded a $7.9 million grant from the National Institutes of Health to develop a mobile health app geared to young men at high risk for HIV. Her project, a five-year study conducted at sites in New York City, Chicago, Seattle, and Birmingham, Alabama, will adapt and test an intervention covering a range of topics—including correct condom use, dealing with stigma, and communicating effectively about safer sex—among 700 racially and ethnically diverse adolescents who have sex with other men. The app will feature games, videos, and interactive scenarios.
“Our aim is to provide this population with information to make better health decisions,” says Schnall. “There is much evidence that mobile technology is a great way to connect with this generation. By meeting them where they are, we’re hopeful about the intervention’s potential to decrease infections.”
The school is also reaching beyond the traditional boundaries of academia to help clinical nurses make scientific contributions of their own. A new program called Linking to Improve Nursing Care and Knowledge (LINK) connects hospital-based registered nurses from NewYork-Presbyterian with nurse researchers at Columbia Nursing to carry out specialized research for nurses in clinical settings who have identified recurring problems in patient care. The LINK team provides conceptual, statistical, and logistical support, including assistance in determining feasibility and pursuing funding. More than a dozen projects are currently in the pipeline.
“As nurses, we bring a special perspective to research on patient care,” notes Larson, who is a member of the LINK team. “Physicians tend to say, ‘to control your disease, take this medication three times a day.’ A nurse is more likely to ask, ‘Do you have anybody at home who can help you with your pills?’ Many of the biggest issues in health care are behavioral: how to support patients in managing their illness; how to motivate clinicians to clean their hands. Nurses understand that the key to improving outcomes isn’t just developing new therapies; it’s getting people to do the right thing.”
*This article originally appeared in the Spring 2017 issue of Columbia Nursing magazine.