By Kenneth Miller
This article originally appeared in the Spring 2019 issue of Columbia Nursing Magazine and is Part II of the issue's Special Research Report.
In the late 1980s, Columbia University School of Nursing, whose emphasis had always been on preparing superb clinicians, set out to transform itself into a research powerhouse. First came the so-called Columbia Model, a groundbreaking approach to nursing education, which required all instructors to engage in research or scholarly practice. A part-time doctor of nursing science (DNSc) program was launched a few years later and had morphed into a full-time PhD program by 2008. Eminent nurse-scientists flocked to the school, as did students eager to follow in their footsteps.
Today, three decades after the initiative began, its success can be expressed in numbers. Columbia Nursing is one of the largest per-capita recipients among nursing schools of grants from the National Institutes of Health (NIH). Its doctoral program is among the top 10 percent of nursing school recipients nationwide of federal training grants for predoctoral and postdoctoral scholars. The school’s faculty members have more than 70 active research grants and publish dozens of articles each year in peer-reviewed journals.
Columbia Nursing’s research enterprise is organized around an array of programs, including two centers funded by the National Institute of Nursing Research (NINR). In all these settings, veteran investigators pursue their own ambitious projects, while mentoring those just starting their careers. Together, masters and novices focus on improving clinical effectiveness, health systems, and health policy, often wielding powerful new digital tools—mobile technologies, artificial intelligence, informatics—to track patients’ symptoms and behaviors, enhance their interactions with health care providers, and find meaningful patterns amid petabytes of data.
“No matter their area of study,” says Elaine Larson, PhD, RN, senior associate dean for research and the Anna C. Maxwell Professor of Nursing Research, “our nurse-scientists share the same basic goals: to better serve underserved populations, to reduce health disparities, and to improve care for all patients.” Read on for a sampling of their pioneering work.
Helping Patients Help Themselves
The NINR-funded Precision in Symptom Self-Management (PriSSM) Center strives to advance the science of symptom self-management for Latinos, considering variables such as genetics, environmental factors, health behaviors, and interpersonal relationships. PriSSM is directed by Suzanne Bakken, PhD, RN, a professor of biomedical informatics and the Alumni Professor of Nursing, and Arlene Smaldone ’03, PhD, RN, a professor of nursing. “Our research is informed by what’s known as the socio-ecological model, which starts with the individual and then broadens out to look at the family and the community,” Bakken explains. Every PriSSM pilot study captures a set of common data elements for each participant, including physical activity with a Fitbit-like wearable accelerometer and saliva samples that are tested
for DNA and other biomarkers.
One of those studies, led by Michelle Odlum, BSN, EdD, an assistant professor of nursing, is testing a fatigue self-management intervention for older Latinos with HIV/AIDS. Nearly half of the 1.1 million people living with HIV/AIDS in the United States are estimated to be over age 50, thanks to medications that have greatly extended survival in recent years. Studies suggest that up to 88 percent of this population suffers from fatigue—a symptom that can interfere with patients’ self-management (including adherence to their antiretroviral regimen) and their overall quality of life, yet one for which few therapies exist. And because low income and unemployment are among the risk factors for fatigue, Latinos with AIDS and HIV may be especially vulnerable.
“I really wanted to help these patients with their symptom management,” says Odlum, who’d previously worked with Bakken to develop a system enabling low-income individuals with AIDS and HIV to access their electronic health records online and to share them with caregivers and case managers. For the new intervention, Odlum and her team adapted a fatigue management curriculum designed for multiple sclerosis patients, the Energy Conservation Course, by working with focus groups of Latino AIDS and HIV patients to modify it for their needs. The customized course uses lectures, discussions, and practice exercises to teach energy-conserving skills, such as taking frequent rest breaks, paying attention to body mechanics and ergonomics, living a balanced lifestyle, and managing priorities.
Odlum has completed the three-session curriculum with about 30 subjects and is now conducting follow-up research. A pleasant surprise has been the participants’ enthusiasm for the wearable accelerometers that the study uses to monitor patients’ sleep and activity patterns. “We’ll say, ‘You had 20 episodes in the middle of the night where you were tossing and turning. What was going on?’ They love it, because it helps them understand what’s affecting their energy levels and learn to manage their days.”
This data, along with clues found in participants’ saliva, is also helping the researchers pursue a deeper understanding of the dynamics of HIV-related fatigue. One question is whether genetic factors predispose some patients to this symptom. Odlum also plans to investigate whether her intervention affects participants’ levels of proinflammatory cytokines (signaling molecules linked to many chronic conditions) or the length of their telomeres (cap-like structures at the ends of chromosomes that tend to shorten with age or illness). “If we can establish these benchmarks, they could be applicable to people from other ethnic groups as well,” she explains.
But whatever scientific findings eventually emerge, the study is already producing encouraging results. “These patients are eager to know about their health, and eager to make changes,” Odlum says. “It’s a wonderful thing when we’re able to help.”
Making Research a Two-Way Street
Besides their biometric and sociological aspects, studies under the PriSSM umbrella have two other features in common: They were designed with help from people in the population being studied, and the results are being shared with the study participants as well as with professionals. In a recent project, for example—aimed at developing a family information management system for caregivers of people with dementia—assistant professor Adriana Arcia, PhD, RN, worked with community members to develop information visualizations that would help caregivers recognize their own health risks, including depression symptoms and caregiving burdens.
Arcia (the daughter of a Cuban refugee and a Nicaraguan immigrant, both social scientists) also led an intramurally funded study in which she consulted with Hispanic patients with asthma to create easily comprehensible infographics explaining their test results—including pulmonary function tests, which are typically not shared with patients because they’re considered too difficult to interpret. “Our graphic walks the patient through it,” she says. “Let’s say you blew out three liters in one second, and four would be normal for a woman your age, race, and height. We show that you blew out enough to fill one and a half two-liter bottles of soda, compared to two full bottles, to indicate that you have 75 percent of your lung function.” The illustrations are printed on a pamphlet, with space for a clinician to write instructions for the patient. “People don’t just want to understand their health status, they want to know ‘What do I do about it?’ Facilitating
that conversation is a critical piece of the process.”
Such participatory approaches to research are woven into predoctoral and postdoctoral training at Columbia Nursing. While studying for her bachelor’s in nursing, associate research scientist Samantha Stonbraker ’13 ’16, PhD, RN, spent a month as part of the school’s clinical integration program at Clínica de Familia La Romana, an outpatient clinic in the Dominican Republic that specializes in HIV prevention and treatment for adults and children. For her student project, she developed a patient-education talk and a brochure about mental health for adolescent mothers. Yet despite her fluent Spanish, she recalls, it struck her that “none of the moms had any idea of what I was talking about.”
Later, as a doctoral student, Stonbraker returned to the clinic to learn more about patient education in that context and the factors that influence it. With guidance from Larson, she conducted a retrospective chart review to characterize the HIV-positive patient population and then developed surveys to measure patients’ health literacy
and to explore how they sought and used health information. These studies were the focus of her doctoral dissertation. “It turned out that levels of literacy and understanding were very low,” Stonbraker says. “Even people who’d been coming to the clinic for six or seven years couldn’t tell you what a CD4 count or a viral load is.”
For her postdoctoral project, she worked with Bakken and Rebecca Schnall ’09, PhD, RN, the Mary Dickey Lindsay Associate Professor of Disease Prevention and Health Promotion, to develop a tool that would improve the way information is provided to patients at the Clínica de Familia. Stonbraker conducted more interviews with patients and staff, as well as a literature review, to determine what content was most vital to communicate; the answer proved to be information about medications and the importance of patients’ adherence to taking them. She then worked with both patients and providers—adapting participatory-design methods developed by Arcia—to create graphics for use as visual aids in patient-education sessions. These illustrations, bound into a small, laminated booklet, are currently being tested at the clinic.
“I can’t speak highly enough about the mentoring I’ve received at Columbia,” says Stonbraker, who completed her postdoc in August 2018 and is continuing her research thanks to a career development award from the NINR. “My advisors have struck the perfect balance between letting me be independent and being available if I needed help. Whenever I come up with a new idea, they take a deep breath, think about it for a second, and say, ‘Yeah! Let’s figure out how to make this work.’”
Postdoctoral fellow Maichou Lor, PhD, RN, is pursuing a similar line of inquiry with a very different patient population. The daughter of ethnic Hmong parents who fled Laos during the Vietnam War, Lor was born in a Thai refugee camp and immigrated with her family to Madison, Wisconsin, at age 6; by her teens, she was serving as the interpreter when her parents or other relatives went to medical appointments. As a nursing student at the University of Wisconsin–Madison, she began to see that the challenges her family members faced in navigating the health care system reflected larger policy issues. “I realized that populations who don’t speak English aren’t a part of the conversation in a lot of the research we do,” she explains. That led her to become the first Hmong-American nurse to earn a PhD in the United States—after which she came to Columbia Nursing for a postdoc.
With Bakken as her adviser, Lor is conducting a study among Hmong patients in Wisconsin, investigating how they describe pain and how that affects their interactions with providers. She’s also working on a study with providers to determine what kinds of information tools might help them better communicate with Hmong patients who are in pain. The goal of both projects is to use visualization methods to develop a culturally and linguistically appropriate pain-assessment tool that serves the needs of patients and clinicians alike. “Although I’m focusing on Hmong patients now,” Lor explains, “I hope that the work I’m doing will have applications for other immigrant groups, particularly those that have low literacy and English proficiency and aren’t used to the American system of practicing health.”
Shaping Policy to Improve Care
The Center for Health Policy (CHP), directed by Patricia Stone, PhD, RN, the Centennial Professor of Health Policy, is dedicated to educating nurses in health policy methods as well as developing and disseminating knowledge that informs policymakers at the local, state, and national levels. Faculty members also work with interdisciplinary partners to develop and evaluate policies aimed at improving public health. Although the center focuses primarily on policies related to infection prevention in health care systems and nursing homes, its mission extends to topics ranging from reducing antibiotic overuse to improving end-of-life care. “As nurses, we know that health policy informs our practice,” says Stone. “So it’s crucial that nursing best practices inform health policy.”
In 2018, the CHP secured more than $8 million in federal and foundation funding. The largest award was a $2.7 million grant from the NINR to fund the new Center for Improving Palliative Care for Vulnerable Adults with MCC (CIPC), co-directed by Stone and associate professor Jingjing Shang, PhD, RN. The prevalence of multiple chronic conditions (MCCs) in older adults represents one of the nation’s most daunting—and fastest-growing—health care challenges. Patients with MCCs represent 93 percent of Medicare spending, with 75 percent going to the one-third of beneficiaries who have four or more chronic conditions. Elderly patients with MCCs are likely to have more complications and longer hospital stays than other patients their age and to experience end-of-life crises that lead to high use of health care resources without significant increases in their quality of life or survival.
In partnership with the Visiting Nurse Service of New York, the CIPC provides support and guidance to nurse-scientists researching better ways to care for these so-called superutilizers. (Columbia Nursing researcher Maxim Topaz, PhD, RN, the Elizabeth Standish Gill Associate Professor of Nursing, serves as the Visiting Nurse Service’s site principal investigator.) “We want to understand what patients with MCCs actually need as they face the end of life,” Shang explains, “and to find methods that meet those needs while reducing burdensome treatments and transitions.”
Two CIPC pilot studies are currently underway. One, led by assistant professor Eileen Carter ’14, PhD, RN, is exploring the risks and benefits associated with antibiotic use from the perspective of nursing home residents and their families. “In the last six months of life, over half of nursing home patients receive an antibiotic, but about 40 percent of prescribed antibiotics in nursing homes are thought to be unnecessary,” Carter points out. “Although antibiotics can save lives, overuse can fuel the rise of antibiotic-resistant microbes. It also needlessly exposes patients to the risks of adverse drug reactions, such as nausea and diarrhea, as well as painful and potentially fatal opportunistic infections, such as Clostridium difficile. Yet no study has looked at whether antibiotic use actually serves the wishes of these patients and their loved ones.”
Carter and her team will follow approximately 120 nursing home patients in New York City over a six-month period. One aim of the study is to assess the quantitative relationship between antibiotic use and the symptom burden in this cohort, to better understand why and how often these medications are being administered. Patients and family members will also be surveyed to determine the degree to which antibiotic use conforms to or conflicts with their goals for palliative care. “We want to know how engaged they were in decisions to administer the drugs and how aware they are of the risks,” Carter explains.
The second CIPC pilot study, led by associate research scientist Carolyn Sun ’15, PhD, RN, is exploring the symptoms experienced by and the amelioration strategies used by Chinese-Americans with endstage renal disease. Her goal is to develop culturally appropriate, evidence-based care strategies. Sun, whose doctorate is in global health, has done extensive research on nursing practices in Africa and the Middle East. Her current project grew in part from her experience when her husband’s Chinese-born grandfather was dying of cancer; the family declined to place him in hospice care, believing that it would be perceived as giving up on him and therefore disrespectful. Later, Sun learned that Asian-Americans are less likely than members of other ethnic groups to use hospice or palliative care, for reasons that include different cultural expectations at the end of life, as well as language barriers.
For patients with end-stage renal disease, however, palliative care can help avoid months of suffering—and the prevalence of the condition is about 1.5 times higher in Asian-Americans than in Caucasians. (Most such patients have other chronic conditions as well, making them candidates for a CIPC study.) Sun and her colleagues are working to develop a palliative care model incorporating elements from traditional Chinese medicine—such as acupuncture, cupping, and herbal remedies—as well as other methods that might make such care more acceptable to this cohort of patients and their families. The interdisciplinary team will recruit more than 30 elderly Chinese Americans with end-stage renal disease who receive care from the Visiting Nurse Service, collecting data on their symptoms and existing care strategies and enlisting them in focus groups to help develop the new approach. “Many things that Asian-Americans do for their health, like tai chi and yoga, have crossed over into Western medicine,” Sun notes. “As we become a more global society, I think both sides will increasingly learn from each other.”
Getting More Bang for the Health Care Buck
Another NINR grant to the CHP funds a five-year-old program known as Comparative and Cost-Effectiveness Research Training for Nurse Scientists (CER). The U.S. spends far more on health care than any other country, yet studies consistently show that our outcomes are poorer than those of our peer nations. Comparative and cost-effectiveness research is a set of methodologies that generate patient-centered evidence to determine which interventions achieve the best care for the least cost. The CER program provides six trainee nurse-scientists with research support, didactic courses, networking opportunities, and financial assistance to build their skills in this vital discipline. Each fellow is matched with two faculty mentors—one within nursing and one from another field—to advise them as they pursue original research projects using these techniques.
CER postdoctoral fellow Laura Starbird, PhD, RN, was first drawn to health care policy research while studying for her master’s in nursing at the University of California, San Francisco, where she grew frustrated with the obstacles that prevented her patients who were both HIV- and hepatitis C-positive from getting the full array of support they needed. During her doctoral studies at Johns Hopkins, she came to realize that it takes more than a great idea to change policy in the real world. “When you walk into a room with policymakers,” she says, “their question is always going to be, ‘Okay, what does this cost and how does it compare to what we’re already doing?’”
Now, as a postdoc at Columbia Nursing, Starbird is learning how to find the answers. She’s using her CER fellowship to research two different interventions for people living with HIV and hepatitis C— patient navigators to link individuals to care, and practice coaches to help substance-abuse clinics implement HIV and hepatitis C testing for their clients. “Rather than just focusing on individual patients’ behavior,” she says, “it seems more feasible and sustainable to make our health systems work better. A well-run organization makes it easier for patients to make healthy choices and prevents them from falling through the cracks.”
Predoctoral scholar Aluem Tark ’16, MSN, RN, is focusing her CER studies on variations in implementing Physician Orders for Life Sustaining Treatment (POLST) across the country. Like Starbird, Tark came to her topic from personal experience: working as a pediatric oncology nurse at a New York City hospital, where she often found herself caring for young patients at the end of life. “For me, the main question was ‘If I can’t add to the quantity of this kid’s life, how can I improve its quality?’” she recalls. “I went into research because I wanted to find ways to do that not just for individual patients, but for the health care system as a whole—and to be surrounded by other people with the same goal.”
At Columbia Nursing, Tark is examining policy issues around palliative care in nursing homes, particularly advance directives such as POLST forms. What she finds most valuable about CER2 is the opportunity to learn from researchers in a wide variety of fields. “We work with epidemiologists, economists, public health researchers,” she explains. “Every week, we have a conference where we share our perspectives. That’s priceless.” After earning her PhD, Tark aims to become an independent researcher, eventually bringing her expertise to her native South Korea, where palliative care remains an unfamiliar concept. “I want to be a bridge,” she says, “so that this kind of care can be implemented effectively everywhere.”
Improving Care for the LGBT Community
The mission of the Program for the Study of LGBT Health—a collaboration between Columbia University School of Nursing, Columbia University Department of Psychiatry, and the New York State Psychiatric Institute—is to promote the health and wellness of LGBT people in the U.S. and abroad. Led by Walter Bockting, PhD, and Anke Ehrhardt, PhD, both professors of medical psychology, the program focuses on five basic areas: youth and families, aging, lesbian and bisexual women’s health, transgender health, and the neuroscience of gender.
Tonda Hughes, PhD, RN, a professor of nursing and of psychiatry and the director of global health research at Columbia Nursing, is working with the program on a number of major studies. For the past 20 years, she has led the NIH-funded Chicago Health and Life Experiences of Women (CHLEW) study, the longest-running study of sexual minority women’s health currently in existence. Hughes is also conducting a series of scoping reviews (surveys of existing research) of LGBT health studies around the world, a crucial step in determining the knowledge gaps that need to be filled. And she recently completed a study on the experiences of lesbian and bisexual women in Rwanda. “Although the country lacks the legal sanctions on homosexuality found elsewhere in Africa, the stigma remains huge,” Hughes explains. “Several of the women we interviewed had been raped by a family member or someone brought in by the family to try to change their sexual orientation. Many of their parents had stopped paying their school fees, and they were living in poverty. In a country known for its tolerance, we found lingering, deep-seated negative attitudes.”
Before Hughes joined Columbia Nursing in 2017, research psychologist Cindy Veldhuis, PhD, was one of her trainees at the University of Illinois at Chicago. After earning her doctorate in psychology, Veldhuis followed her mentor to her new academic home. Now a postdoctoral fellow at Columbia Nursing, she is studying how stress and stigma affect LGBT women, particularly in the areas of relationships and health behaviors.
Veldhuis gained national attention for a study she led on worries over violence and discrimination among LGBT women and gender minorities in the wake of the 2016 presidential election; in an online survey of more than 1,000 people, nearly 70 percent reported having higher concerns about their safety than before the election. More recently, she completed data collection for a project titled the Study of Queer Intimate Relationships (SOQIR pronounced “so queer”), which examines stress and health behaviors among women in same-sex/ gender couples. In interviews with eight couples and online surveys of over 500, Veldhuis and her team explored the impacts of race/ ethnicity and sexual identity on relationship dynamics and behaviors such as drinking, marijuana use, and other forms of avoidant coping, such as binge-watching television. Veldhuis is also studying lesbian and bisexual women’s relationships and risky alcohol use on a Ruth L. Kirschstein Postdoctoral Research Fellowship from the NIH, the first such grant awarded at the school. “In previous studies, we’ve found that women in same-sex couples are at higher risk of hazardous alcohol use if they have multiple marginalized identities— that is, if they’re a racial/ethnic minority as well as a sexual minority,” she explains. “We’re analyzing the results of SOQIR to examine the effects of the stress that comes from multiple marginalized identities within couples.”
While working as a cardiovascular surgery nurse and studying for his MSN, postdoc Billy Caceres, PhD, RN, noticed that LGBT patients often had multiple risk factors for heart disease that went untreated, leading to repeated readmissions. He began wondering whether stress related to sexual or gender identity might itself be a risk factor, and, if so, whether nurses could play a role in mitigating that risk. By the time he finished his PhD, he’d decided to focus his research on sexual minority women—an interest that led him to Columbia Nursing for a postdoctoral research fellowship supervised by Hughes.
Caceres recently applied for a grant from the National Heart, Lung, and Blood Institute (NHLBI) to recruit women from the CHLEW study and their heterosexual sisters to investigate the impact of adverse life experiences and familial factors on the risk of cardiovascular disease. To gain a broader range of insights, he’s also a trainee in Columbia Nursing’s CER program and is leading a pilot study funded through PriSSM on symptoms of post traumatic stress disorder and cardiovascular disease in Latinas. Last year, he led a preliminary study of 547 lesbian and bisexual women from the CHLEW study, showing that trauma in childhood or adulthood—including sexual abuse and intimate partner violence—is associated with higher cardiovascular risk. (Co-authored by Hughes, Veldhuis, and Kathleen Hickey, EdD, RN, a professor of nursing, the study won the Cardiovascular and Stroke Nursing Best Abstract Award from the American Heart Association.) “All my work is centered on the idea that different people are exposed to different stressors, so different interventions may be necessary to help reduce the associated risks,” he explains. “But we’ve only started scratching the surface of how these factors impact health.”
Postdoctoral research fellow Kasey Jackman ’05 ’10 ’17, PhD, RN, is leading a PriSSM pilot study investigating the associations between discrimination based on gender identity or ethnicity and sleep disturbance and fatigue outcomes in Latinx transgender people. Jackman is also a member of the research staff at Project AFFIRM, a multiyear study led by Bockting that follows more than 300 transgender and gender-nonconforming people in New York, San Francisco, and Atlanta, assessing the dynamics that influence their vulnerability, risk, and resilience. Jackman previously led a sub-study that investigated the role these dynamics play in non-suicidal self-injury.
In two recently published papers, Jackman’s team reported that non-suicidal self-injury was more closely associated with felt stigma (individuals’ perceived or anticipated rejection on the basis of their transgender identity) than with active stigma (such as discrimination or harassment). They also found that trans people were less likely to self-injure when they felt that their appearance represented their gender identity—whether or not that involved gender-affirming interventions, such as hormones or surgery. In a separate study, researchers led by Jackman found to their surprise that older trans women reported lower levels of internalized transnegativity and psychological distress compared to a younger group. “We think that, over time, people may learn to cope with the challenges they’re facing and become more accepting of their own identity,” Jackman explains. “We still have very high rates of suicidality in the trans community, but this research suggests that trans people develop resilience over time.”
Kodiak Soled, MSN, RN, a first-year PhD student, is researching family-building desires and experiences in transgender and genderexpansive people. Soled’s path began in Boulder, Colorado, where she spent several years as a therapeutic chef, clinical herbalist, maternity wellness coach, and postpartum doula; she also founded a parenting support group for LGBT people. Eventually, she landed in the graduate nursing program at Johns Hopkins, where she researched provider knowledge gaps regarding transgender health as a barrier to care.
After earning her master’s degree, she decided to pursue her doctorate at Columbia Nursing because of the mentoring and sense of community for which the Program for the Study of LGBT Health is known. “It was hard to find another top-tier school with such a mutually supportive group of people,” she says. With Bockting as her adviser, Soled is focusing on reducing the challenges that face gendernonconforming people who choose to have children. “My goal is to help providers learn more about the gestational experience in this population, so that care is delivered in a more competent and sensitive manner,” she adds. “In a small way, I’m out to change the world.”
Strengthening the Nursing Workforce
In 2010, the U.S. Institute of Medicine called for a rapid expansion of the nurse practitioner (NP) workforce in primary care to meet the needs of an aging population. The number of NPs has been booming ever since; today, they constitute about 20 percent of all primary care providers. Yet many barriers hinder their ability to deliver optimal care. Associate professor Lusine Poghosyan, PhD, RN, focuses her research on identifying those obstacles and finding ways to remove them.
Born in a small village in Armenia, Poghosyan followed her mother into nursing and immigrated to America in 2004; she joined Columbia Nursing’s faculty in 2011, after earning her PhD, and quickly gained recognition as one of the country’s leading experts on nursing workforce development. “Most of my papers are about increasing awareness about who NPs are, what they’re capable of doing, and what kind of support they need to do their jobs well,” she explains. “Often, health care organizations have no idea what to do with them.”
Although multiple studies have shown that patients treated by NPs have outcomes equal or superior to those of patients treated by physicians alone, she notes that regulations in 29 states require NPs to have physician oversight for their delivery of care. Poghosyan’s research has shown that in many practice environments, relations with administrators and access to resources are poor. Fewer than 40 percent of NPs have their own patient panel to whom they deliver continuous care. In a 2018 study, she and her team found that quality of care for patients with chronic illnesses improves when NPs work in practices with favorable environments—but that such practices remain in the minority. “Physicians sometimes get two exam rooms, while NPs get only one, even though they see the same number of patients,” she says. “That’s just not realistic or productive.”
Poghosyan has developed a tool called the Nurse Practitioner Primary Care Organizational Climate Questionnaire to help health care systems gauge their use of NPs. She is also partnering with researchers around the country and abroad to identify better practices and policies and is mentoring a handful of investigators who share her professional passion.
Associate research scientist Allison Norful ’17, PhD, RN, for example, changed her career course from medicine to nursing after being hospitalized for a cardiac condition when she was a premed. The experience made her realize that, as she puts it, “nurses are the glue that hold health care together.” After she became a cardiology nurse, her gift for creative organizational problem-solving propelled her up the administrative ladder. She returned to school for an MSN and NP certification, then worked for several more years in managerial positions, where she became increasingly convinced that nursing workforce fixes could improve patient outcomes. She recalls that the organization’s leaders “kept saying, ‘Show me the evidence.’ Finally, I said, ‘I’m going to go build the evidence.” She chose Columbia Nursing for her doctorate, largely so that she could work with nursing policy experts like Poghosyan.
For her doctoral and postdoctoral research, funded through Columbia Nursing’s Center for Health Policy and later the National Center for Advancing Translational Sciences, Norful focused on the role of interprofessional teams within primary and acute care settings— particularly on provider co-management, a process involving representatives of two different disciplines working together to manage the same patients. She went on to develop the first instrument to gauge the quality of such collaborations, the Provider Co-Management Index, which she’s now testing with 3,000 primary care providers in New York State. “This tool measures dimensions of a practice environment that are crucial to effective co-management,” she explains, “like effective communication, mutual respect and trust, and a shared philosophy of care."
Another of Poghosyan’s advisees is predoctoral scholar Cilgy Abraham, BS, RN—who is also receiving mentorship from Norful. (Graduate students at the school often receive guidance from both senior and junior faculty, before going on to become mentors themselves.) Abraham, the recipient of a Future of Nursing Scholarship from the Robert Wood Johnson Foundation and a Margaret E. Mahoney Fellowship from the New York Academy of Medicine, is researching topics such as the cost-effectiveness of using NPs in managing patients with chronic illness and predictors of burnout among primary care providers. “In my mind, all of this connects,” she says. “The relationship between costs, work environment, and staffing is key to patient outcomes.”
Harnessing the Power of Mobile Tech
One of the biggest obstacles to improving health care for underserved populations is that such populations can be difficult for caregivers to reach. In recent years, for example, one in four new HIV infections have been in youth aged 13 to 24, mostly young men who have sex with men. Yet few evidence-based HIV-prevention interventions exist for this cohort, and they are often reluctant to attend the group sessions that are typically required. Rebecca Schnall ’09, PhD, RN, the Mary Dickey Lindsay Associate Professor of Disease Prevention and Health Promotion, has developed a potential solution—an app called MyPEEPS Mobile.
Schnall’s focus on HIV grows out of her experience as a pediatric nurse and AIDS educator; she learned to leverage mobile technology while studying for her doctorate in nursing informatics under Bakken. For MyPEEPS, she adapted an existing HIV intervention, designed for racially and ethnically diverse young men who have sex with men, by working with potential users aged 13 to 24 to hone the app’s design. The six-module curriculum covers social and personal factors, including knowledge (for example, the correct way to use a condom), self-efficacy for safer sex, and communication skills.
Schnall is currently leading a five-year, randomized trial of the app—with 700 participants in New York, Seattle, Chicago, and Birmingham, Alabama—funded by a $7.9 million grant from the NIH, the largest in Columbia Nursing’s history. She’s also working on several other federally funded studies to develop and test other mHealth tools (as mobile health apps are known), including an applinked pillbox to boost medication adherence in HIV patients and an app that helps patients interpret and act on their HIV test results. “My vision for health care is to give patients resources to take better care of themselves,” she says. “I want them to have information at their fingertips, so that they can make better decisions.”
Arlene Smaldone ’03, PhD, RN assistant dean for scholarship and research, directs the PhD program at Columbia Nursing and also pursues investigative projects of her own—most of them centering on youth and adult self-management of chronic health conditions. She’s currently co-principal investigator, with Columbia pediatrician Nancy Green, MD, of a study in which mobile technology is used to help adolescents with sickle-cell anemia remember to take their medication—hydroxyurea—which prevents the buildup of abnormal hemoglobin in their blood cells, which in turn causes the painful and potentially lethal crises associated with the disease.
“Because symptoms seldom follow immediately after a dose is skipped,” Smaldone explains, “patients often forget to take it— especially in adolescence, when responsibility for adherence transitions from parent to child.” In the intervention that she and her team developed, a community health worker consults with parents and their kids (aged 10 to 18) to turn medication-taking into a habit by tying it to other daily routines. Once such a routine is identified, the family begins receiving automated text messages—written by the participants themselves—reminding them to perform their parts. A parent’s task might be to put the vial on the nightstand before bedtime; the child’s might be to reach over and take the pill.
The Hydroxyurea Adherence for Personal Best in Sickle Cell Disease (HABIT) study began in 2016 with a feasibility trial that suggested the intervention improved adherence. In the phase now underway—a randomized, controlled, multisite trial that will follow about 200 participants from four clinical sites in New York City and Philadelphia for a year—the text messages will end after six months, to determine whether the habit sticks. The researchers will also investigate whether the protocol reduces sickle-cell crises. “In interventions for chronic diseases, one size doesn’t fit all,” says Smaldone. “What’s exciting about mobile technologies is that they give us a bigger toolbox.”
As a recent graduate student, Meghan Reading ’18, PhD, RN, explored that toolbox in another way. Reading (who was an NINR Ruth L. Kirschstein Predoctoral Fellow and a Jonas Nurse Leader Scholar) entered the PhD program after several years as a staff nurse on a cardiac unit, where she saw how chronic disease disproportionately impacts the most vulnerable members of society. “I was attracted to Columbia Nursing because of how intimately they were working with the community in which they were situated and how involved they were in returning research data to the people who provided it,” she says.
Supervised by Hickey and professor of nursing informatics Jacqueline Merrill ’98 ’06, PhD, RN, Reading did her dissertation research on factors that influence how patients with atrial fibrillation engage with mobile apps that allow them to monitor their own heart rates. Her investigation required her to develop skills bridging two disparate fields—electrophysiology and informatics—and to collaborate closely with researchers at Columbia University Irving Medical Center’s Vagelos College of Physicians and Surgeons and Department of Biomedical Informatics. “My mentors not only supported my work, but they served as role models for this kind of interdisciplinary investigation,” says Reading, who’s now a postdoc at Weill Cornell Medical Center. “They gave me a blueprint for the rest of my career.”