30th Anniversary Scientific Symposium: “Advancing Science, Improving Lives: A Window to the Future”

[music playing] >> Patricia Grady: So nursing
science plays a critical role in the health
of the research enterprise, bridges the gaps
between the bench, the research clinic,
and the community, and also important
in translating the findings to clinical care. Rather than focusing on any
particular disease or condition, nursing science addresses the needs of individual
patients through family and patient- centered care with a goal of improving health and quality of life. At NINR this approach
is manifested through a concentration
on four broad areas of investigation: symptoms science, wellness,
self-management, and end-of-life
palliative care. Symptom science,
nursing science provides a unique perspective
into the biological and clinical features
of symptoms. New advances in genomics and other fields
have allowed nurse scientists to better understand the debilitating symptoms
of chronic illness, such as pain, fatigue,
disordered sleep. In addition, nursing research is evaluating
the influence of behavioral, environmental,
and social factors in the manifestation of symptoms and their resolution.
Through out its history, NINR has supported
research to develop improved personalized
strategies to ease and prevent the adverse symptoms of illness across
diverse populations and settings
that will facilitate clinical management of illness and lead to more
productive lives. I am pleased
that symptom science will be discussed
further this afternoon in the two science panels. The first will concern
sleep research followed by omics research and its impact
on precession health. These are examples
of cutting edge nursing research that resonate with this year’s
[unintelligible] State of the Science
Meeting Determinants of Health. With regard to wellness, research into wellness
has yielded demonstrable health improvements
in the American population. The nursing profession
and nursing science have had tremendous impact in identifying and testing
evidence-based approaches and encouraging
their adoption by individuals, families,
clinicians, and communities. NINR has supported research
to understand the physical, behavioral,
and environmental causes of illness
across health conditions, settings, and the lifespan
in minority and underserved populations
in particular. NINR supported research
has also identified healthy lifestyle choices and explored many
of the barriers to wellness. And facilitated prevention
strategies as well as developing evidence-based interventions
that promote wellness in the context
of environmental factors and cultural diversity. With regard to
self-management, increased life expectancy
and advances in life-sustaining
treatments have resulted in greater numbers of people
living with chronic conditions. Self-management has become more
central to chronic conditions as long-term care
responsibilities are shifting
from healthcare providers to the individuals,
their families, and the communities. NINR supported research has helped support individuals
from diverse backgrounds and their families to live
with chronic illness by developing effective approaches
to self-management that can improve
the quality of life while reducing the burdens
of care on caregivers and also their families
and the community as well. Not to mention
in more recent years the healthcare system. With end-of-life
and palliative care, facing serious
advanced illness, living with progressive
disabling function, and diminishing independence, addressing the continuum
of end-of-life care from early palliative care
to later hospice and bereavement support demands a seamless comprehensive and integrated system
that reaches all communities, all cultures,
and all practices. NINR has been deeply
involved in fostering the national dialogue
to address this important and highly personal issue and all of the areas surrounding
end-of-life care. As the lead institute at NIH
for end-of-life research, NINR has supported research
to assist individuals, families, and healthcare professionals,
in managing the symptoms of life-limiting conditions
and planning for end-of-life decisions. In addition to the four areas
just mentioned, supporting advances
in technology and training play a key role
in advancing NINR’s efforts to expand the impact
of nursing science. Nursing science can
foster the development of novel culturally sensitive
interventions and technology that will deliver tailored care
and real-time health information to patients,
families, clinicians, and communities. In the area of training, the development of a strong
cadre of nurse scientists has been a primary goal of NINR since its establishment
30 years ago. To continue
to leverage advancements in nursing science
and improvements in health, it’s essential that
the scientific work force of the future be dynamic, interdisciplinary, and diverse.
Advancing science, Improving Lives: A Window to the Future That’s our motto for approaching the next 30 years. The innovative
questions initiative, or IQ, was part of NINR’s view
to the future. Launched at the end of 2013, it was designed
to develop creative and results-oriented
research questions that could assist us in guiding
the future directions for research in nursing science. The goal of this initiative was to engage
our community and provide you,
your colleagues, and the public,
with an opportunity to help shape the future
of nursing science. Out of this initiative as well as other input grew
our new NINR strategic plan. These questions were
the springboard for the plan, and I’m happy to announce,
proud to announce, and relived to announce, that its release occurs today,
at today’s event. So as you leave today, you will have in your hands
the new strategic plan. We believe that this plan
will have a significant impact on the health
of the American people. Now just briefly highlighting a couple of things
in the new plan, we are committed
to the major areas that I’ve spoken of just
a few minutes earlier. But in looking at them
over the next five years and looking at symptom science and continuing to advance
the importance of this area, we will support basic clinical and biobehavioral research
to promote personalized health strategies
for symptom management. In this context, there will be
particular focus on symptoms in multiple
chronic conditions, integration of biomarkers
with phenotypic indicators, and utilization of Omic science.
In the area of wellness, we will continue to
support research to elucidate the causes of illness,
determinants of health, and assessment of behaviors that lead to healthy
lifestyle choices, with a goal of developing
innovative approaches to advance health and wellness. Findings from these studies
can inform health promotion and disease
prevention activities, strengthening
the scientific foundation for their ongoing efforts to improve health outcomes
and health services and to reduce the burden of illness on patients
and families. In the area of self-management, our commitment to this science
of self-management focuses on enhancing healthy behaviors and adherence
to treatment, promoting functional status
across conditions, and improving health outcomes, and maintaining quality of life. NINR will also continue
supporting research to guide individuals
from diverse, multicultural backgrounds and their families
in personalizing self-management skills
and tools. End-of-life
and palliative care will continue to be
an important area for us. And we will continue
to support research on the management
of advanced symptoms of serious
life-limiting illness. Also optimization of individuals
and caregivers health and well being
and facilitating decision making about end-of-life preferences at this difficult time. Other priorities include
the development of strategies to align care
with individual and family centered goals
and preferences throughout the trajectory
of advanced illness. Lastly, NINR will maintain
its support of the two cross cutting areas
of technology and development
of the innovative and growing under
scientist workforce. With regard to technology, we will support
research programs that are developing
and refining technologies to improve symptom
risk assessment and to identify
potential interventions. The accelerating
availability and accessibility of cutting-edge technologies
provide nursing science with an ideal opportunity
for improving health and preventing illness
in diverse and underserved populations
across the lifespan. Training, again,
we will reinforce the foundational commitment to supporting
a diverse, dynamic, and innovative workforce
with the goal of keeping — of developing the next
generation of investigators and enhancing the overall
research capacity in strategically important
areas of research. These efforts will continue
to encourage earlier entry into research careers, expand the interdisciplinary
backgrounds of new investigators, and enhance the abilities
of mid-career investigators, to improve
the quality of life as these individuals advance nursing science
over the coming decades. The perspectives described in this strategic plan
provide a framework for more detailed planning as well as for evaluation of current research
and future initiatives. NINR envisions this plan
as a living document that will continue to inform
our strategic planning and all of our activities
as we move forward. We recognize that today is a time
of extraordinary opportunity in the health research health
enterprise as a whole. We are entering an era
of precision health in which we will be
able to tailor treatments to individuals
based on their genes, the environment,
their lifestyle. The field of data science
will change the way that scientists collect, store, and analyze large data sets, which could revolutionize
the way in which we conduct
clinical research and clinical trials and how we explore
adverse symptoms. The scientists supported by NINR are poised to lead
interdisciplinary teams that will unlock the potential
of precision health and data science and fuel the next generation
of advances in the health sciences. This is a time
of incredible transformation in the health sciences
and in healthcare, it’s a time
of formidable challenge and exceptional opportunity. And we look forward to meeting
these challenges with you. Thank you very much. [applause] It’s now my pleasure
to introduce Dr. Afaf Meleis who will serve as the Director of Ceremonies
for today’s event. We are delighted that
she could be with us today. I know she supposedly
is retired, but it appears
she’s even busier now than she was
when she was “working.” Anyway, Dr. Meleis is
a Professor of Nursing and Sociology
at the University of Pennsylvania where she served
as Dean of the School of Nursing
from 2002 to 2014 proceeded
by faculty positions at the University of California,
Los Angeles, and the University
of California, San Francisco. Her leadership continues
through participation in multiple high-profile
boards and committees, and she is very
much in demand for her unique expertise
nationally and globally. She’s a member of the National
Academy of Medicine and co-chaired its global
forum on Innovation and Health Professional
Education. Her research scholarship
is focused on global health, women’s health,
culturally competent practice, and interprofessional education. Dr. Meleis joins
us today from — I’ve forgotten what
geographical location — but is also in joining us bringing her
many honors with her. She is the recipient
of a number of honors, and I can’t name them all,
but I will just highlight. She most recently received
the American Academy of Nursing
Living Legend Award — [applause] — the Sigma Theta Tau
International Nell J. Watts Lifetime Achievement
in Nursing Award. [applause] And became an honorary fellow in the National League
for Nursling’s Academy of Nursing Education. We are pleased to have her
at the podium. Please join me
in welcoming Dr. Meleis. [applause] >> Alaf Meleis: [unintelligible] [laughter]
Not yet. Thank you, Dr. Grady, for this overview
on NINR’s strategic goals, which I believe, and I believe many
of us here believe, they are really visionary,
they are futuristic, and they are — most importantly
they’re responsive to the urgent needs,
healthcare needs in society. But I also find them
right on target in terms of growing
our nursing knowledge and our nursing science. So that’s what really nursing — this is what our domain
of nursing is about. But more than that, Dr. Grady, I want to thank you on behalf of thought leaders in this country
in nursing and their collaborators and the many patients
who benefit from the wonderful science that’s translated into
evidence-based practice. I want to thank you
for your foresight, for your vision,
for your leadership, for the incredible work you have done on this campus to bring NINR in part of — to its eminent position right now among 27
other centers — NIH centers [unintelligible]. Let’s give her
a round of applause. Thank you, Dr. Grady. [applause] So I have been
called many names but never Director
of Ceremonies before. So what is a Director
of Ceremonies? This is what I’m told
I’m supposed to be doing. Very briefly talk a little bit about NINR’s accomplishments and including those, of course, of Dr. Grady, but I won’t do much
of that because of time. I’m going to introduce
the two moderators and the two panels. And the moderators themselves
will introduce the panel members and make sure that we have time
for questions and answers. Then I will provide
some closing comments coming from my own background as a global health scientist. So we are celebrating 30 years, 30 years of NINR’s
many accomplishments. [applause] Yes, 30 years,
absolutely incredible. So congratulations
to you at NINR, but really congratulations
to all of us in nursing, not only in this country
but around the world. Because the impact
of what’s going on here is influencing
everywhere in the world. So anniversaries
usually give us an opportunity to reflect, and I know NINR team
members have been reflecting about
accomplishments, and I would like
to highlight a few which from my point of view, I’m not a sleep scientist
so don’t worry I’m not going to say
anything about sleep. In fact, when my assistant heard that I’m coming
to sleep she said, “But you are the one
who does not like sleep. Why did they invite you
to be in sleep?” [laughter] But I will as a scholar
in women’s health and global health, I will select
some of the pioneering findings that I’m really
excited about, about women, gender, and cultural differences
in health and wellbeing. And in some of the interventions that have been developed
by support from NINR and by investigators who are associated
with this great institute. So NINR investigators
compared men and women’s experience responses and demonstrated that they respond differently. So we have the evidence
for that. But one landmark finding
is that they also respond differently to medications, to the same medications. And this research
highlighted the importance of continuing
to study gender and sex differences. So lest we forget that. A couple of other
major findings for women and their health demonstrated that while obesity is good actually as a predictor of lower risk for falling for peri- and pre-menopausal women, but that risk,
that lower risk, does not hold if the women
have type two diabetes or if they have
an inflammation. So that lower risk is gone. Lest you think
you should become obese. [laughter] Another major finding
that has resulted from NINR support is related to something we have
always thought about, multiple roles effect
women’s health. But we really did not
have the evidence in the past to look
at those multiple roles. Well, this group
of investigators looked at Korean immigrant women
and found out that they tend to give much
higher priorities in their lives to their household and
caregiving responsibilities. And therefore,
they are not able to manage their own diabetes. And, you know, we do blame
immigrants many times because they are not
managing whatever it is that we’re telling them
to manage, but the reasons for that
are the importance of the other roles
and familiar roles. So we have some evidence
for that now. Also NINR supported research
resulted in the development and testing, as Dr. Grady said, of gender appropriate and culturally
sensitive interventions. Particularly, and I’m really
interested in the girl child. The girl child
has been neglected, the adolescents,
we call them adolescents here, but they are the girl child
in the rest of the world. So this research that
has gender sensitive and culturally
sensitive intervention actually helped the much hard to reach this girl
child, adolescent, to use risk
reduction methods for sexual — use of sexual risk
reduction methods in this because those interventions were really precisely
geared toward them. Another group
of NINR researchers found that by using a very innovative and really culturally
appropriate and culturally
relevant intervention, which is based in
different cultures on Kin Keeper model
of community and family. So more community-based
bringing people together. This model helped
increasing cancer knowledge and more importantly
to actually increase the screening responses. They went for screening, and that is in minorities such as African American,
Latina, and Arab women. These are underserved women, so the research focused
on underserved women and increased their knowledge but also increased
their going for screenings. So also as Dr. Grady mentioned, end-of-life research is
a strong priority for NINR. Because families of minority patients such
as African Americans, Hispanics, and Asians, have significantly
lower quality of death and dying experience
and also responses, then minority families, that’s regardless of their
education, so we know that. Well, those NINR group
of investigators developed and tested effective tools for better ways by us to have productive discussions for end-of-life
and palliative care. That means a lot
to us particularly at the University
of Pennsylvania where we have
the Life Program, and it has been a really
major issue in reaching them. So using that research
very much helps. So also Dr. Grady said that
besides growing the science, which is a priority, there is another
priority for NINR, and that’s growing
the scientists and training the scientists. So, Dr. Grady and her team
developed something that I’m really excited about and lots of people
are excited about, and that’s a very strong
intermural program which resulted in developing superb research experiences for pre-doctoral
and postdoctoral students. So by having
pre-doctoral students coming from our universities and spending time
in any lab on the campus, what you have created
is a scientifically well-groomed pipeline of biologically and genetically oriented
nursing scientists. And that is for the pre-doc, and then they go
and finish their dissertations on their own campus. But it has also created this great intermural program for postdoc students to work with very well established researchers and scientists in biological and genetically
oriented sciences. I think this has been
an outstanding investment in scientists. And I really do believe
it’s a game changer too for the science they produce, and not for the science
we produce for nursing, but it’s really for the science
produced in all fields. But it also by doing that, it was nurturing
and investing and fostering interdisciplinary connections and partnerships
between the scientists. Which definitely had an impact on the quality
of nursing science and general science and particularly
in symptom science, which we’re going to
hear more about today and we will see
in this symposium. So moving forward, as we heard about
the futurist strategic plans and we will hear specifically
about sleep today, more support will be devoted to innovative scientists and those who will advance nursing science by using, incorporating data science, or big data, and omics,
which includes protonics, metabolomics, and microbiomes. So an exciting
30 years building to where we are right now, so much more work to do, so many new worlds to discover, to add in, scientific worlds
to discover. And there is such
a bright future for integrated science which is really the future
of science, this integrated — the development of integrated knowledge
and integrated science, and that will happen through
interdisciplinary change of professionalism and so on. And this epitomizes,
this symposium today that you’re about to witness
when I get off the podium, it epitomizes and reflects that progress
and defines the future of science. And with that,
I add my voice to Dr. Grady
by welcoming all of you, this room looks fantastic, so much power in this room. And thank you for coming
and joining us for this beautiful
celebratory symposium. And we promise you a very
intellectually stimulating and inspiring symposium which demonstrates achievements in nursing science
and clinical research. And the reason I can promise that or we can promise that is because of the highly
-accomplished leaders in sleep science
who are here, sitting right here
to be with us today. And they very definitely
helped put on the map that sleep is vital
for all aspects of our lives, as well as not
only individuals, but as you are going
to hear, populations, but it’s also the health and well-being of our nation. And it is so important
from the fundamental growth and development
of infants and children to the ability to be functional and be productive
on a daily basis. And your influence as scientists
has been so fantastic that one of our sons — I have six grandchildren now — one of our sons,
with every baby they have, they get a sleep consultant.
[laughter] I asked him,
what’s wrong with nurses? [laughter] But it is because
of what we have heard about the importance of sleep. We have two panels
this morning — this afternoon,
the Symptom panel and the Omic science panel. And we will start with
the Symptom Science panel which will be moderated by one
of my dear colleagues from Penn,
Dr. Dinges, and I will take the privilege of being at the podium
to introduce him, and he will introduce his panel. And I would like to say
a few things on him. I know that you have
a page about him, but, as I said,
I am at the podium and I do want to introduce him. [laughter]
He is a professor and chief of the Division
of Sleep and Chronobiology; he’s the Director of the Unit
of Experimental Psychiatry, a Vice Chair for Faculty Affairs and Professional Development
in the Department of Psychiatry, and all that at the University
of Pennsylvania School of Medicine
which is now called the Perelman School of Medicine. As you will see
and as you have read, he is an internationally
recognized expert on sleep physiology and chronobiology
in relationship to human health
and their safety. Something really dear
to our hearts, the safety of people. His primary research focus
is on identifying how sleep needs and circadian biology interact together
to influence wakefulness and neural behavioral
cognitive effective and physiology functions. It’s a really big order,
very important. His research has had
extensive public policy impact relative
to work hours and safety sensitive occupations
and, of course, nursing is a safety
sensitive occupation. He has more than 350
scholarly publications; he served on NINR
advisory council, on numerous NINR committees. He has been an editor
and chief of Sleep, president of the World
Sleep Federation, President of the U.S.
Sleep Research Sleep Society, and on the on the board
of directors of the American
Academy of Sleep Medicine and National Sleep Foundation. He holds a Masters and a PhD in physiological psychology
from Saint Louis University, and he has so many awards, I won’t mention any of them, only the last one, 2016 award because now he’s not only
getting awards about this earth, it is a Space
Biomedical Community award. And so, please, we are delighted he accepted to be the moderator
for this panel. Please help me welcome him
and his panel. [applause] >> David Dinges:
Thank you, Dr. Meleis. And I want to thank the NINR for inviting me to this meeting. You can tell I picked up a little dysphonia
in the last 12 hours. And I’m medicating it with gum, can you believe it, mastication increases
saliva which helps. But it does mean
that my voice will squeak so I’m going to try
to hold it down and let the acoustics
people dial it up so you can hear it.
Good afternoon. Let me lend my voice
to saying good afternoon and welcome to
the Symptom Science panel, the Science of Sleep. The first one of two panels. I want to thank Dr. Grady and her extraordinary team
at NINR and congratulate them
on 30 incredible years of pioneering nursing science. And, of course,
thank you for asking me to this incredible event. I wouldn’t have missed it. Before I introduce
our esteemed panelists, I want to remind us
of some things that both Dr. Grady touched on and that Dr. Meleis touched on. Since the inception of the NINR, and, in fact,
it contributed to this, since that inception,
there have been many, many revolutions in the way
we understand health. But the two that most impress me are that we finally
came to grips with the fact that human behavior
can and often is the vector by which health can be
promoted or degraded. I made a list the other day
of all the things that when I was a boy were thought to be completely safe
and effective. They included smoking
and all kinds of stuff. Now we know those
are the road to death. Those are the road to
debilitative low quality lifestyle. And you only have
to think about these when you think about
excessive calorie intake, I already mentioned smoking
and tobacco products, chronic unprotected exposure
to the sun and skin cancer, chronic exposure to asbestos, repeated exposure
to head injury. Who knew that those head
traumas were in fact cumulative and could produce significant
neurological damage? So we continue
to see now the fact that what we do in our lives and if we do that repeatedly and it’s not health promoting but health damaging results
in a cumulative burden on the individual, a cumulative manifestation
of symptom, and a cumulative
cost to society. So I think the dynamics
of behavior and understanding how to intervene
to make people healthier, function better,
and live longer, is an essential part
of what healthcare is about. And NINR stands very much
at the center of that. Now today we’re going
to turn our focus on sleep in this particular panel
and sleep disorders. And we know that they’re just
like these other things. If you go chronically without
sleep or to little sleep, you get cumulative — the experiments that
have been funded by NINR, the seminal studies show you get a cumulative
build up of deficit. And it’s not just in the brain. It’s in behavior and physiology,
metabolic effects. Suddenly you start
gaining weight, suddenly the brain
wants to eat fast burning calories, fat calories. So these are published studies, they came out of NINR support, and they show that it has
a direct effect on adequate sleep on a whole range
of functions. Inflammation,
metabolic functions, cardiovascular functions,
et cetera. So the challenge
is to figure out how we understand
sleep disorders and reduced amounts of sleep from the standpoint
of preventing, first identifying the symptoms
that would indicate that and then preventing that
from escalating over time. And part of the barrier
has been a question that I always get from people, “Well, if you’re so smart,
how much sleep do we need?” And, of course, I say,
“Well, it depends,” and they say,
“No, none of that ‘it depends.’ How much sleep do we need?” Well, I’m very pleased to say that the frustration
over that question, which has escalated to the
highest level of government — [laughter] It has. CDC, NIH, et cetera. Has resulted
in largescale evaluations of the scientific literature
by consensus panels, using Rand criteria
and Oxford criteria, for determining
what the threshold is for reducing sleep time that will produce diseases
of all sorts and problems. And those papers
came out last year, and seven hours is the limit. You should not be
sleeping less than seven hours. Now that’s for the population. There are individual
differences in people, but when both the epidemiologic
and laboratory studies, and there were 1,200
of these studies, looked at, published, when the thresholds start
to get below, several problems emerge. Many people are in the six
to seven zone now, and the problems will
start to emerge there. But once you get
below six hours, there is a lot of illness,
disease burden, and risk associated with it. Now the exceptions, again, are the genetically
short sleepers. But they’re actually
a tiny minority of all the people
sleeping with less. A lot of this by the way
has to do with our environment. Going to bed
with televisions on, with lights on. I have a colleague
who’s studying remotely the impact
of airport noise on sleep in people. And he comes from Europe where they care about that,
so I had to bring him over because didn’t have anybody
in America who cared. [laughter]
But he’s discovering to his horror that when they record
the bedroom at night that nearly a quarter
of all people are sleeping with the television blaring and the screen on. This is absolutely horrific. I can’t imagine what would
prompt someone to do that and disturb
their sleep like that. Anyway, today we do have an answer
of at least a threshold, but we want to talk
about this now from this standpoint
of two research lines by two esteemed colleagues, Dr. Nancy Redeker
and Dr. Terri Weaver. They are internationally recognized scientists
on the panel. And they are going
to discuss the causes and consequences
of both disturbed and insufficient sleep. I want to pause a second
and introduce Dr. Nancy Redeker. She is the Beatrice
Renfield Term Professor of Nursing and Director
of the Biobehavioral Laboratory at Yale School of Nursing. She holds an appointment in the
Department of Internal Medicine, Division of Pulmonary Care
and Sleep Medicine. And I must say, Nancy,
that’s impressive. Internal medicine at Yale
School of Medicine. She is a principal investigator of the NIH NINR-funded Yale center
for Sleep Disturbance in Acute and Chronic Conditions. She has a sustained program
of research for 25 years and has addressed
the role of sleep and sleep disorders
among patients with acute and chronic conditions and the effects of behavioral
sleep or motion interventions. Behavioral promotion
interventions are an extremely
important area for improving
on healthcare in America and sleep in particular,
as you’ll hear. She is currently
conducting studies funded by NINR focused on the sustained effects
of cognitive behavioral therapy for insomnia among patients with stable heart failure. And community partnerships
to promote sleep among families living with economic adversity. And, again, I commend you
for that, Nancy, that’s an important
underserved community. Her ongoing work also
addresses sleep promotion in the acute care
environment. She serves on
the National Advisory Council for Nursing Research,
she’s an ambassador for the Friends of the NINR, she is editor along
with Jeffery Phillips McEnany of the text Sleep Disorders and Sleep Promotion
in Nursing Practice, the first textbook focused on the integration
of scientific evidence about sleep
in nursing practice. She’s garnered
the American Journal of Nursing Book
of the Year award. She’s also editor-in-chief
of Heart and Lung, the journal of acute
and critical care. She holds a PhD
from New York University and a Masters and BSN
from Seton Hall University. And another bachelor’s degree
in sociology from Rutgers in New Jersey.
Excuse me. Our second esteemed panelist is Dr. Terri Weaver. Dr. Weaver is Professor and Dean of the University of Illinois at Chicago’s
College of Nursing. She is nationally
and internationally recognized for her research on the effect
of daytime sleepiness on daily behaviors and the assessment
of treatment outcomes. Her program of research centers
on treatment adherence, a very important area for NINR and for healthcare in general, analysis for treatment efficacy
for obstructive sleep apnea, a widespread disease. The mechanisms and outcomes
of daytime sleepiness which is very common these days. She has expertise in issues related to functional status,
quality of life, treatment adherence,
instrument development, and randomized
clinical trials. Dr. Weaver
is recognized nationally and internationally
for her research on the effect
of daytime sleepiness on daily behaviors and assessment
of treatment outcomes. She has produced two
notable disease-specific functional status measures that are used worldwide,
one on the chronic — one for chronic
pulmonary disorders and their functional effects, and the other
for sleep disorders and sleepiness —
excuse me — which is the gold standard
for evaluation of the impact of treatment
for sleep disorders relative
to quality of life. Dr. Weaver has 107
scholarly publications, her research has been
supported by NIH for more than 20 years, NINR, and the National Heart Lung
Blood Institute. She currently serves
on the board of directors of the American
Academy of Sleep Medicine, the American Board
of Sleep Medicine. She has also served
on the executive committee and Training
Education Chair for the World Federation of Sleep Research
and Sleep Medicine. She received her BSN from
the University of Pittsburgh and her Masters and PhD from the University
of Pennsylvania. She is the recipient of numerous
awards and honors, most notably she
received the Avis Henshaw Award from the Friends of the National Institute
of Nursing Research, and she is a fellow of
the American Academy of Nursing. So we have two
outstanding people here, and they’re going
to get a chance now to answer a few questions that I want to ask them and that the NINR would like
to hear them talk about. And I’m going to say, first of all,
welcome to both of you. Thanks for putting yourselves
out like that to come up here and answer these. We’d like to get started
by asking Dr. Redeker, if you don’t mind,
let me begin with you, and just first ask you
to give us five minutes on what your science is about, what you’ve been doing,
where you’ve been, and where you’re headed. >> Nancy Redeker: Thank you
this is very exciting today. I wanted to say
I sort of fell into sleep and I won’t tell you
my life story, but a lot of things
happened by serendipity. When I work
with doctoral students, we talk about
having a very direct, you know, sort of a very linear but well planned
program of research. And while that’s important,
I think a lot times you need to take advantage of things
as they come along. And it my not exactly be where you thought you were
headed when you started out. So you have to be selective, but I think my program
of research has done that and whether that’s the right way
or not, I don’t know. But I like it where it is. But I do want
to say David mentioned that I have a couple
of what might appear to be sort of disparate areas of interest going
on at least right now. One is about self-management of insomnia in people
with heart failure and the other
is at the other end sort of the
developmental spectrum looking at young children
with sleep. And I have to say
both of those emerge from my life
and my clinical experiences. But I first wanted
to sort of give a little grounding for this, and this is also
sort of the model for our NINR funded center. So, you know,
I started my career as a cardiac critical care nurse and observed that
patients had — obviously, patients
had symptoms in those days, and it was the 1980s,
so I won’t — you can guess how old I am. But, you know, we sort of
in the acute care environment didn’t think about what happened to the patients
after they went home. And then I went on
and got my PhD and I was looking
at cardiac surgery patients and collected some symptom data, and nobody was really
talking about sleep in this population then, but, oh, by the way, these patients had
sleep disorders and we — it wasn’t the major point
of the dissertation but we found out
they had some complaints. And, oh, by the way,
there’s this new technology called wrist actigraphy. And so both of those things
sort of set me on the trajectory
of looking at sleep and ultimately a K Award
where I realized I needed to learn
more about polysomnography and those sorts of things. But I wanted to
sort of ground this because I think this sort of — in the field of sleep, you know,
sleep effects everybody, but my sort of model for that and what sort of links my work is really the trajectory
model of chronic illness. So the idea that over the course
of a chronic illness, you have remissions
and exacerbations, there’s an end stage, acute care for most people is part of a longer term trajectory
of chronic conditions. And when we think about sleep and we think about
the experience for patients, we need to think
about how it changes over that trajectory. For example,
my first work was with following cardiacs. And we really did circadian
rhythms of activity, rest, and also sleep. And looking at how
those patients recovered their sleep
over the course of recovery and then how it stabilized
longer term. And now I’m looking at a more, well, you could say
they’re not so stable over time but heart failure patients, which is a more
chronic population. So there’s two things.
One is in order to manage sleep we have to understand where they are
on the trajectory, but we also have to,
from research point of view, think about when
we’re measuring it because sleep, even in
exacerbated heart patients, looks very different
than it looks in stable heart failure patients. And how we target
our interventions in our research needs
to take that into account. The other thing
I wanted to point out, and we know this
increasingly from our work, that sleep contributes to the development
of chronic conditions. Things like obesity,
things like heart disease, sleep disordered breathing
for example, short sleep,
contribute to those things. So it’s not always something that we need to deal
with across that trajectory, but it’s an issue
around prevention. So the idea of, you know,
doing health promotion, doing prevention to address
sleep in the same way that David described it in order to prevent that
trajectory of chronic conditions which I think is very near
and dear to us as nurses but also to the NINR. The other thing that’s really
important is the notion that sleep contributes
to many, many, outcomes. And we don’t think about them
all all the time. So it’s not only development; it’s the pathophysiology
associated with disease, but it’s associated
with quality of life, it’s associated with function,
safety, obesity, and many, many, other things. And so my model
for this is very broad. But the other
important piece to that, and I have to say speaking about experiences,
I mean, I was triggered — my initial entrée
into this field was through my clinical
experiences as a nurse. But it’s been informed
by other things I do. So, for example,
about eight years ago I went to Yale
where we had a strong — and I got involved in our
self-management center. So my work now
has evolved to look at self-management of sleep. So self-management of sleep
across this trajectory and what you need to self-manage at different times
really matters. And so I wanted to end there,
but, you know — so it sounds — and then, of course, we’re doing
this work with young families. Well, that’s a health
promotion piece, and the idea is to prevent
long-term negative consequences by intervening early. And we’re talking about
infants and toddlers in this new study. So I’m very excited about this, and I’ll stop there,
and it’s Terri’s turn. >> David Dinges: So,
Dr. Weaver, what — give us some introductory
remarks on sort of, you know, where
your scientific work has been and how you see
where it’s headed. >> Terri Weaver: First I want
to say it’s very challenging to be up here
at this time in the afternoon
on a very comfortable couch. [laughter] Talking
about daytime sleepiness, here we are
in that circadian dip. I do want to thank NINR, particularly Dr. Grady
and her team, for the invitation to be here. And also, a long overdue
thank you for funding my F31 that got me here and launched my interest
in daily functioning and how chronic illness
affects daily functioning. As David said,
sleepiness is pervasive, or sleep debt and its influence on behavior is pervasive. And that’s always intrigued me, is in situations where there
is daytime sleepiness, how does it affect
everyday functioning, and then what do
we do about it. And if the intervention works, how do we capture that, and then also I was interested
in if it doesn’t work, why that is the case. And so that’s actually
been my program of research. I actually first started working
with David many years ago when I was at the University
of Pennsylvania, and he started a great study that really looked at adherence to CPAP treatment and found that although the field claimed a high level of adherence,
that, in fact, when it was objectively
covertly monitored, that was not quite
the case at all. And so I initially
asked the question, well, then do they
make this decision to not adhere to this treatment? And we did the analysis
of those data and found that it was indeed
the first week of treatment. Which greatly surprised me because patients usually
persevere for a while before they give up. But this indicated
it actually happened prior to probably even
getting the treatment. From there it was
then how do we capture then the impact
of the treatment on behavior, and that led me after
having developed a tool for measuring functional status
in pulmonary disease, which is my specialty, to developing a Functional
Outcomes of Sleep questionnaire that is now used
internationally to measure the impact of sleepiness
on daily functioning. The question then was whether or not the treatment
was effective. And moved to clinical trial work in a population
that hadn’t been well studied which was those who had
more mild disease known as the CATNAP Trial, that was done multi site studies throughout the United States
and in Canada, and actually showed
with a number of outcomes, including moods,
psychomotor vigilance, inattention, functional status, and just quality of health, that CPAC did work in those
with more mild disease. But interestingly,
when we — the question was, what should be
the dose of the CPAP? We know it should be used
every day, but for how long? Two hours, four hours? And that led me
to look at that in a large multisite study and found that
in people who had — that were impaired
both objectively and subjectively in sleepiness that it really depended
on the metric you used to some extent whether or not they improved in their degree
of sleepiness. So that four hours was fine
is someone would — really you were interested
in self-reported sleepiness, but that objectively
measuring it or looking at daily functioning, they needed actually greater
than six hours of use. But more interesting and intriguing
to me was the fact that not only did we describe
the dose needed for specific outcomes such as self-reported
or objective sleepiness and managing occupational
sensitive areas, but it also showed
that there was individuals that used it greater
than seven and a half hours. And in fact, were still sleepy. So what in the heck
is what that? They’re adherent to treatment,
and they’re still sleepy. So I’ve just finished a study, we’re very excited,
it’s in press. It will be coming out
in the Magnetic Journal of Residence Imaging —
whoever thought? But, we found that
in those people who were high users of CPAP and adherent
to treatment that in fact they did have a problem
in their white matter with compromised myelin and problems
with radial diffusivity, and although patients with sleep apnea
have problems with — some have deficits
in their white matter, we’re finding that this is true for those who are still
sleepy compared to those who are not. So now the question
that I next have to answer is we know that there are
pharmaceutical agents that improve this sleepiness. Does it affect those
neuronal deficits? So that’s where
I’m going next. >> David Dinges: That’s exciting. Thank you both. I want to jump back over
to you, Dr. Redeker, and give you a few minutes to — tell us what you think
have been the key advances in sleep science
in the past three years. That’s a tough chore. And then in what ways
has sleep research been used to improve health. I’m assuming that
the key advances will likely be related
to the health improvement, but what do you think? >> Nancy Redeker: Well,
so I think one of the points is the one you raised about
we’re getting better about refining how much sleep people
actually need and that’s — you know,
that’s across the lifespan. So I think
the second piece of that — I think we’re beginning
to understand we have a lot
of epidemiologic work, we have a lot of large
population studies looking at the role
of sleepiness, the role of sleep relative
to obesity and all that. So there’s a lot of that, and I think what that’s done is served to raise
the awareness. And I’m going to save
where we think we need to go. But I think the other point is I think we’re
beginning to realize that sleep isn’t
just a problem. And this is at the clinical
and policy level, as well as — I think the research
has made us realize that sleep isn’t something that sleep disorder specialists
need to deal with. All of us in the healthcare
field need to deal with it. And I think some of the recent
epidemiologic findings, I think some of
our clinical trials have all sort of led us
in that direction. And it’s not just
sleep duration, it’s the quality of sleep
that’s important. Sleep efficiency,
you know, insomnia. People may sleep or think
they sleep a certain amount but if they have insomnia
it’s still a negative outcome. So I think the important thing is looking at what the outcomes
of sleep have been and that’s three
and more years ago. But I think it’s just
really coming to the fore, and I think the public are
starting to realize it as well. >> David Dinges: And what ways
do you think sleep research has been
used to improve health? >> Nancy Redeker: So I think
we’re getting much better at our interventions. I think that we are
much more aware — I mean, we’re doing
cognitive behavioral therapy for insomnia in our work. I think it’s becoming
more accessible. I think we’re aware — and Terri talked about
the challenges of CPAP, but we know that it works
if people use it. I mean, so I think we have a lot
of effective treatments now and that’s really emerging. I think we’re seeing
increasing understanding of the omics and so forth. And so, I think —
when I think about the — it’s been exponential, I think,
in the last several years. >> David Dinges: Thank you. Terri, let me turn those
same questions to you. What have been the key advances
in sleep science in the past 30 years? And in what ways do you think
sleep research has been used to improve health? >> Terri Weaver: Well,
building on what Nancy said, I think the field has been — it’s great watching it develop. Initially really concentrated
on syndrome definitions and definitions of chronic
sleep disorders because we knew they existed, a lot of that coming out
of original basic psychology and other areas. But we really
didn’t define it. We defined sleep apnea,
what a hypopnea was, what an apnea event was, and then moved further
to identify measures that were helpful such as
your psychomotor vigilance task to be able to look
at sustained attention, the Epworth Sleepiness Scale,
the Berlin Questionnaire. So we realized
that it’s not enough to just say this is the illness. We have to take a look
at how to measure it, which was increasingly
important. I think the other thing
is the appreciation that sleepiness,
as Nancy said, is really something that’s a consequence
of so many other disorders. So the link, then, not only
with sleep disorders to chronic disease, but by in of itself the impact of chronic disease on sleep such as cancer,
fatigue, renal disease, and just the temperature
of the dialysate and how that affects
quality of sleep after individuals
who have dialysis. And the ability then to look
at GERD and other things. So I think it’s a great
opportunity for nurses to look at chronic
disease management. Also, I think
it’s the appreciation for how sleepiness
affects self-management. If, in fact,
sleepiness has an effect, or the impact of these
chronic illnesses, on sleep, on the ability
to cognitively process and be able to respond
from a neural behavioral point of view, can they self-manage? And the role of that — of that in self
-management planning. I think we always think about how to manage
chronic disease, but we forget to include
the sleep part. Also, the treatments
that we utilize, I think we are
starting to — as Nancy said —
look at their effectiveness, which we haven’t in the past. And you’re seeing more
and more placebo controls. And finally, I think
the other area has been
in specific populations. We looked at children and sleep, I think a great advance was the appreciation
for the fact that there is changes
in the delayed sleep phase syndrome and those who were adolescents
and these school start times. And we’re seeing more
and more school districts finally getting it. That having those in middle and high school
get up an ungodly hour and have 7:30 class start times is really unreasonable and their brain doesn’t work
for the first three periods. I think also we appreciate that maybe some of
the cognitive decline in older individuals may be related
to problems with sleep. What is the relationship
with Alzheimer’s? It’s been recently funded
by NINR and explored, and I think that that’s
critically important. We know that community
dwelling elders who are not getting outside,
who are limited, don’t have enough
light entrainment, and that has affected
their quality of sleep. As Nancy’s work
and others in ICU and just the environment
of the hospital and how that
is affecting individuals and their sleep
and ability to heal, I think is critically
important as well. >> David Dinges: Thank you. I must say listening
to both of you, I recall back when I first
started out in my career as a junior faculty member
in the school of medicine, I was struck by the predominant
model of some of my good and esteemed
physician colleagues was acute treatment
and that’s good enough. And what I hear
from both of you is bodies of work and thoughtfulness about this. Just because the patient
leaves the office with a treatment one time
doesn’t mean that this is done and that really this is about how the patient uses
that treatment, what happens over time, what other treatments
can you bring to bear, what are their
functional limitations relative to their treatments — I think that’s a silent
revolution that has occurred. NINR, I think,
has helped pioneer that and both of you and others have made that happen
inside medical disorders, internal medicine,
heart, lung, blood, et cetera. >> Terri Weaver: I think
also just appreciation that some of the lack
of response may be genetically
based on a phenotype that we haven’t
yet identified. And that’s a great intro
for the next session. >> David Dinges: Yeah, we’re going
to hear more about that. >> Terri Weaver: But —
and I think also that so many of these treatments now can be nurse led with looking at such interventions
such as chronic behavioral therapy which has proven not only
to be effective in adherence but also in insomnia. As effective as medication,
which I think is enormous. And many nurses — >> Terri Weaver: More effective — >> David Dinges: [unintelligible] >> Terri Weaver: And more
are engaged in that, and then maybe in other areas
where this can be applied — in cancer, in COPD, in asthma — to promote sleep as well as motivational interviewing and all of the apps
that are developed to help with adherent
to treatment. >> David Dinges: So,
60-second wrap-up. Where should sleep science
go in the future? Nancy? >> Nancy Redeker: So, I think
Terri hit the nail on the head. So we mentioned there’s been
a lot of epidemiology. So we know sleep — bad sleep
is bad for your health, and that’s not a very
scientific way to say it. But, I think we need
to move towards understanding more about the biology —
not only the biology, but the cultural
environmental influences. So we have some very large
epidemiologic studies, but we don’t always
understand the biology. And part of the complexity
of that is sleep is complex. It has behavioral components,
it has biological components. There’s — I mean,
I won’t go on. I have a big slide that lists
all how these hang together. It’s a circadian phenomenon. And so, we don’t really know which part of sleep
always affects which outcome. And then, we don’t understand the mechanics of
how that happens. So I think we need to go there
and that sort of leads us to personalized
health interventions. I think the other key piece,
though, is that, what I said before is we have
a cadre of sleep specialists. And Terri and I, in some way,
have sort of bridged that field. But sleep — all of you
in nursing practice should be working with sleep in your patient populations. And so, there’s two
sort of levels of how do we look at sleep. But I think we do have
very efficacious interventions. The problem is we’re not always getting those interventions to the right people
at the right time. Things like CPAP
for sleep disorder, breathing. Things like behavioral
interventions for insomnia. And, so I think what we
really need to move toward is more implementation
and science and effectiveness work. Because in many cases,
these treatments work. We’re just not always
sure how to get — for example,
we try to do some work looking at cognitive
behavioral therapy and getting it out
through nurse practitioners into primary care settings. Well, you have a 10-
or 15-minute encounter with a patient, how the heck are you
going to do that? And yet, 30 percent of people who present in primary
care have insomnia. So I think we need implementation science
and effectiveness. I think we need better
work even for the science we already have into getting
that out into policy and into the public sphere. Terri talked about school
start times in Connecticut. Now we have several communities that are changing
the school start times. Well, that’s the further
translation end of it, but it’s really important. In the transportation
industry, it’s really, you know —
David’s work with sleepiness. And so, it’s not only
the sort of basic science, it’s getting
the science out there. And so that’s where I think should be an important priority. >> David Dinges: Terri, where
should sleep science be going? >> Terri Weaver: Well,
Nancy covered most of where I think it is heading. And I do think it’s that
nexus of understanding who should get what treatment and when and who boasts benefits
by those treatments. Because, again,
personalized medicine or health as I’d like to say, is really built
upon understanding that and it’s
a number of factors. It’s socioeconomic —
for example, we know certain zip codes where people
are more disadvantaged aren’t sleeping as well. There’s a racial
component in sleepiness and in sleep apnea
that we do not understand that needs to be
further explored. We have — don’t have
a lot of data, I don’t think, in sleep
regarding health equity. And I think that
that is something that really needs to be done. Are responses to treatment
the same across racial and ethnic lines as well as other
specific populations? And that may not be
the case as it is, for example,
in treatment in asthma. And I think we really need
to explore that. And then the interventions
with the ability now to use digital telehealth — others — what is
the response to that? Does it work for everyone? Are there individuals — maybe the older
individuals — who respond to that quite well but maybe not enough? >> Nancy Redeker: Is there
an app for that? >> Terri Weaver: Is there
an app for that? >> Nancy Redeker: So,
the other thing we need to do so you’re all — how many
of you either remember wearing a Fit Bit or a Jawbone,
or blah blah blah? Well, so we’re not quite sure what they all actually measure. I don’t want to pick on — but the other place
we need to go is validating some of these personal devices that people are wearing. And I know technology’s part
of the NINR program as well. >> David Dinges: Well, we’re
getting to the end here only in time. Do we have time for a few
questions from the audience or? Do we? >> David Dinges: We have
microphones throughout the room. If anybody has a question
for our panelists, please come up. >> Gail Melkus: Hi,
Gail Melkus from NYU. Thank you for a very
interesting panel. My question really
gets at policy. From what I’m hearing is that in the context
of chronic conditions there are effective treatments. But then I’m also
hearing that bad sleep is bad for our health. And so from a disease prevention health promotion aspect, we should — you know, assess for sleep and we should just
promote sleep. But then as Nancy mentioned, there’s only few towns
in Connecticut that have a later
start time for kids. We know that we’re a society
that never unplugs, and so the kids
go to school later, but they stay later. So they have team sports,
they’re getting home at 6:30, 7:30. They’re up
till midnight, 1:00 a.m. People are working long. So is it that we don’t
have enough evidence yet such that
it’s affected policy so that the insurance
companies and employers and schools, et cetera, are paying attention
to the importance of sleep? Because I believe
that there is the evidence, and everything that
you’ve said is true. But we’re not believing it. Like your
European colleague — they get it. They’re unplugged.
But we’re not. So where do we go with this? >> Terri Weaver: I think
that we are challenged with the school start time issue because those times
are connected towards jobs and sports and parental schedules
and it’s so entrenched. But I do see the tide turning and I’m on the board of the American
Academy of Sleep Medicine and we’re looking
at all of these things from a policy perspective and working with our legislators
here in D.C. to really try to change that. I think that also leads
to traffic safety and those issues
related to drivers being sleepy. I call sleep the toss necessity because I don’t think society — it’s getting there. It’s getting —
it’s really made progress but not quite to the point that appreciates that sleep — just like nutrition —
is vital to health. And until we get
people to accept that as well as exercise. And often we’ve said,
you have to go and exercise. And individuals do that, but then they cut
short their sleep. So we have to figure out how to create those balances and also how to unplug. I know — I think parents
are starting to see, you know, that the devices
get locked away and then kids go to bed. But it’s going
to take some time, I think, till that
message gets out there. And continually conduct
research that underscores — and David’s doing that
and we’re doing that — underscores the impact
of lack of sleep and sleepiness
on all aspects of life. I mean, really, you have Viagra. Sleepiness affects sex so you’d think
that there would — that there would be
that ah-ha moment that sleep is important
for everything. [laughter] >> Nancy Redeker: So I think —
so I think the other piece is we tend to treat
everything separately, right? So we deal with
obesity over here and we deal with
sleep over here, we deal with nutrition
over here. It all needs to be
a part of the package, and here’s an example. So, I understand the American
Academy of Pediatrics has come out and said
we should reduce or — I have young grandchildren,
so that’s how I knew this — that we should reduce screen
time in very young children. Well, I think that came out because of obesity
and inactivity when you had too
much screen time. Well, it turns out screen time is one of the leading reasons
why children sleep 30 — an hour less than
they did 30 years ago. And so screen time —
looking at that screen at night — and I do it myself,
so that’s why I have insomnia, looking at that iPad. Or even the Kindle. So screen time
is bad for your sleep. So why don’t we sort of bundle
these things together and maybe we need some research
about how to bundle it together. And we have
a young faculty member who has a K Award
at our school, who is looking at obesity and she’s linking diet,
exercise, and sleep all
in the same package. It’s not a separate thing. >> David Dinges: A question
over here? >> Jinjiao Jasmine Wang:
Hi, [unintelligible] for your wonderful
presentation — for the wonderful symposium. My name is Jinjiao Jasmine Wang. I’m from Vanderbilt University. Before I ask the question,
I just want to be clear that sleep research
is not my area, so my question might seem
a little whimsical to some of you. But I just have this idea that we’ve all been
talking about sleep as an outcome itself and we’re talking about designing interventions
to improve sleep. But do you think maybe
many years down the road that we can probably use sleep as an intervention by itself? Or as a container for some
other interventions especially when it comes to mental health. Just a thought,
and thank you again for great talks. >> Terri Weaver: Absolutely. When we’re
talking about response to illness, I think promoting
sleep may help that. I mean, we know Delta sleep has an effect on
growth hormone for example. We know that there’s
a tie to inflammation and that would affect
healing in other ways and cardiovascular disease. So, I absolutely agree that sleep
is not only an outcome, but it is an intervention. But we don’t think
of it that way and we should think
of it that way. And across the care provision — the continuum — from prevention all the way through to in hospital
to home care. Because I don’t think
it’s a thread that exists now when we think about
treating patients. But we should, absolutely.
And it should begin — and I know there’s
some work with — I know Nancy’s done others with,
for example, in acute care. Making sure we’ve got
eye masks and earplugs and things to promote sleep. Cutting out those darn 7:00 a.m. whatever — bed, bath,
you know, tests, and often the reason for that is that the physician
wants it that time. So we really have
to be advocates for the patients
in that sense. Absolutely. >> Nancy Redeker: So we published
a study in 2004 which was — all we did was we looked —
in those days, nurses were still doing
flow sheets, right? Across the —
all we did was look at what was done
with patients from 7:00 p.m. to 7:00 a.m. And what we found is that some huge percentage of patients
were getting bathed — these were ICUs —
and that patients were getting bathed
in the middle of the night. So that was probably
my least rigorous, most straightforward,
easy study. That paper got picked up
by USA Today. The public is really
interested in this. So, anyway. >> David Dinges: I would add
they’re building a new hospital at the University
of Pennsylvania. A new hospital at the University
of Pennsylvania. And the architects
reached out to us, to my colleague Mathias Basner, who’s an expert
on noise and sleep. They want to design this
so patients can sleep all night and are not disturbed at all. And they’re serious about it. And, which means
it’s going to have an impact on operations,
nursing schedules. But I do think
we have to be brave and do down that path
to try and to do what both of our speakers
have talked about. We have time for I think
just one or two quick questions. Right here. >> Nancy Allen: Hi, Nancy Allen
from the University of Utah. So, I work
in a cognitive disorders clinic. My research is in diabetes
and dementia. So, as you can imagine, sleep is a reversible
cause of dementia when people are not
getting enough. So it is very much
a part of my practice. However, in primary care, what’s reimbursed — and that’s the reality —
drugs. Drugs are reimbursed for treating
sleep disorders, right? So when we talk about, you know, the treatment of insomnia and some of these
other disorders and we’re coming up
with these great behavioral interventions, I’m going to push you
to think about ways that you can integrate
your behavioral interventions into the electronic
health record to make them feasible
for people to carry out within that short
clinic appointment. You know, the IOM
is taking over — you know, it used to be
meaningful use, we’re now — that’s what this conference
is going to be about. The social determinants
of health — and it’s going to be
really important that we get these tools into
the electronic health record so that it’s bam, bam, bam. It’s part of your treatment plan and part of your order set. We’ve done that in our clinic. And I’m just going
to encourage researchers to not stop with just the intervention but put it into
the electronic health record as part of that plan of care. >> Nancy Redeker: So I would
completely agree with you. I think the other point is
to have scalable interventions. So Colin Espie, in Insomnia
a number of years ago, talked about step care. So there are people
who may be helped just by a brief
bibliotherapy, right? Or an app.
Or — so you don’t always need
an eight-week face to face or group session of,
you know, so — but what we haven’t really done
is really do head to head testing
of all the levels — at least in insomnia —
of these different kinds. And so, using technology — I mean, it may not all happen
within the confines of a primary care interaction. It may be something
like referring people to the Internet
or using an app. But I don’t — I think
that’s another place for some research —
is to find out — personalizing it,
who benefits at what level from how deep an intervention. And I suspect that’s true with sleep duration
and other components of sleep. >> Terri Weaver: And I think
we all should know the components of sleep hygiene. They’re simple, they’re basic,
they’re logical. We should teach our patients,
we should teach our students. And I think that’s go a long way and it’s easy
to deliver and practice. >> David Dinges:
We’re really at the end. If it’s a very quick
question, go ahead. >> Jessica Castner: Certainly,
my name is Jessica Castner. I thank you for your leadership an inspiration
in sleep research. This is a conceptual question
about the chicken and the egg. As an emergency nurse
in my background, dyspnea, that disrupts sleep at 4:00 a.m. is much different than
experiencing dyspnea at 4:00 p.m. And with their chronobiology, how do you think nurses
can lead the way with symptoms that disrupt sleep? You know, we have this expertise in sleep hygiene
and managing it, but what about chronic disease with symptoms
that disrupt sleep? And how can we
as symptom scientists really push that forward. >> Terri Weaver: Well, we’re —
actually, that research is going on now
and funding by NINR using such things as CBT and other interventions to really look
at sleep quality and dyspnea, as I said, in asthma
and other illnesses. And how promoting
sleep by breaking that cycle of
the symptom interfering and the worry about that
affecting a patient’s sleep. So I do think that that
work is going on now and it needs to continue
in a major way. >> David Dinges: I want to thank
everyone for those thoughtful questions and our panelists for their insightful answers. It was a delight
to chair this session. We’re going to turn it
back over to Dr. Meleis. >> Female Speaker: Thank you. >> Afaf Meleis: The success
of a panel is when it raises more questions
for us for the future, and certainly this panel — this distinguished panel — let’s give them
a round of applause. [applause] Fantastic progress in science, but we know we have a lot more
to do in the future. So, thank you all also for asking the questions
and contributing. And I looked at the audience, and there hasn’t been a moment of sleepiness in the audience. So I think we are
doing really well. Now I’d like to — we’d like to give you
a short break, and it really is a short break. Ten minutes exactly. We’re going to really start it
for the next panel. Don’t go too far. You can talk with each other right out there
or stretch for a minute. Back in 10 minutes, please. [music playing] So I was going to ask
the previous panel — as you’re sitting down
I’ll tell you my question — is there such thing
as oversleeping? And are there outcomes
of oversleeping? Or are we only talking
about deficiency in sleeping? All right, now that
I have your attention. [laughter] It’s absolutely my pleasure
to introduce this — our next science panel,
Precision Health. Precision Nursing,
Precision Health: From Omics to Data Science. The moderator of our Omics panel is Dr. Yvette Conley and everybody
is seated here. And I want to say a few things
about Dr. Conley. It’s never enough to say
all the things that those moderators and members of the panels
have done. They’re just really
all very distinguished. She is a professor of nursing and human genetics
at the University of Pittsburgh School
of Nursing where she also directs
a fully equipped molecular genetics laboratory. And I might add, she is the first geneticist to hold a primary academic position
in a school of nursing and we’re very proud of it. [applause] Dr. Conley earned her master’s degree
in genetic counseling and her PhD in human genetics from the School of Public Health at the University
of Pittsburgh Graduate School of Public Health. Her research focus is
on omics approaches to understanding
the biological underpinnings of variability in patient
outcomes and development — patient outcomes
and development of symptoms after a neurological insult. She authored more
than 110 publications and she is highly connected and committed to NIH/NINR. She’s a Director
of an NINR-funded T32 training program that trains nurses in genomics. She has been a PI
for six NIH projects and co-investigator
for another 12. She serves on NIH study section, she is an appointed member
of the NINR genomic nursing science
blueprint work group and is co-chair
of the National Human Genome Research Institute, NINR genome research
consortium work group. I said she’s really
highly connected to NINR. She’s doing a lot for NINR. She’s a recipient, if course,
of many awards. Among the innovative rewards that she got from
University of Pittsburgh and a chancellor’s award and an International Society of Nurses and Genetics
President’s aware. But the — most recently, she has just been inducted as an honorary fellow to the American
Academy of Nursing, an honor reserved
for very few people. [applause] She actually hasn’t
been inducted yet. It has been announced, but she’s going to be
inducted next month I think, with a great, beautiful dress. [laughter] And, so we are just so pleased that she accepted
to moderate this panel of omics science for the omics science
discussion. So, please join me
in welcoming Dr. Conley and the panelists
for our scientific discussion on omics and precision health. [applause] >> Yvette Conley:
Thank you, Dr. Meleis. Good afternoon, everyone,
and welcome to the omics panel
on precision health. I thought I would get us started
by putting a little bit of the past 30 years
into perspective. If we go back 30 years
and think about, you know, scientists at that
point were saying, you know, most cancers are probably due to
a genetic abnormality. Today, we know that all cancers
have genetic abnormalities and we’re using
that information about a cancer’s
genetic abnormality to inform individualized therapy for our cancer patients. Thirty years ago, there was
no Human Genome Project. Today we have databases stuffed with vast amount of information about the structure
and the function and the variability
of the human genome. And these databases
are available for us to use. Technology has changed amazingly
over the last 30 years from an omics and data science
point of view. And, you know, if you think
about the fact that the first human genome took almost 10 years to sequence
and billions of dollars. And today it’s possible
to sequence the human genome in a couple of days for $1,000. So when you think
about the advancements that have happened
over the last 30 years, a lot of that has been driven
by, you know, the collection
of vast amounts of data that’s available
to us and technology. The other thing that’s changed
a lot of the past 30 years and really feeds into how
we’re doing in omics today is our omics toolbox
has changed amazingly. Thirty years ago, it was common
to look at one gene and one gene at a time
and look to see, well, what role does this gene play in a particular condition? Today, we have the ability to look at all genes
at one time. We can look at
the genetic variability of every gene in the genome. Genomics — we can look at — instead of looking
at one protein in a sample, we can look
at all of the proteins in a sample at the same time. Instead of one metabolite,
all of the metabolites. So, you know, and we’re not just
interested in humans anymore. We’re interested
in what microorganisms humans are housing. So we’re using omics approaches to characterize the genomes
of those microorganisms that are impacting our health. So our omics toolbox has changed
over this last 30 years. And I have to say
that I believe that NINR has embraced this omics toolbox
to its full extent. And we’ll — you know,
as we heard today, continue to do so. But, I believe that a lot
of the reason why folks are interested
in omics who may not have been
interested in the past is that omics toolbox
has expanded. We have a lot
more utility to it. And we’ve gone
from looking at one gene in a condition
to looking at, you know, many genes,
gene-gene interactions, how the environment
interacts with our genome. How our lifestyle
and our behaviors play a role in conjunction with our omics. And how that plays
out in healthcare. So, I think
the other thing is that, you know, when you think
about the fact that we’ve gone from
looking at single genes to more common complex
phenotypes like symptoms, it’s easy to see how
we’ve moved into an area where the applicability
of omics is now there. And if we think about how NINR has embraced
this omics toolbox — for example, their symptoms
science portfolio — part of that portfolio is,
you know, folks are using omics
to understand the biological underpinnings
of symptoms with the idea that if
we can figure out what those biological
underpinnings are that we can apply that
to understand variability and who gets symptoms
and why. Who gets a severe symptom? To also think about
the biology around why some symptoms co-occur and then to also think
about that data that’s being collected as a way to move interventions forward, but in an evidence based manner. So when we think
about precision healthcare, we need to be thinking about, you know, what are those
biological underpinnings and then taking that information and applying it towards evidence based interventions. And I — that is a big part of the NINR’s symptom
science portfolio. And, when you think
about the fact that 30 years ago NINR did not have a division
of intramural research and today they have a very productive,
impactful program. And part of that program is to move forward
symptom science. And they are making strides in moving symptom
science forward, but also thinking
about how to make those precision interventions that are going
to reduce symptom burden and increase quality
of life for Americans. NINR developed the genomic
nursing science blueprint to give us
all a framework to think about how we could
incorporate genomics into our research trajectories. NINR has funded
centers of excellence that focuses on symptom science and self-management. And if we think about the fact
that a lot of these centers are using omics
and data science to move the science
of symptoms forward and to think about how folks
self-manage their symptoms. And to think about
how behavior impacts how folks self-manage and that omics can be brought
in at all of those levels. And then I don’t think
we can say enough today about NINR’s dedication
to education and training
of nursing scientists extramurally and intramurally including the Summer Genetics Institute and the boot camps that NINR supports
every summer to help us stay on top of symptoms and the methodologies
that we should be thinking about when we’re thinking about
moving symptom science forward. So I think certainly NINR
is building a legacy that includes
omics and data science. And so now I would like to introduce my other
two panel members, and we’ll continue
this conversation. So our panelists
for this session are Dr. Bernice Coleman, Dr. Jessica Gill. Dr. Coleman
is a research scientist and board certified
acute care nurse practitioner working
in the heart transplantation and ventricular assist programs at Cedar Sinai Medical Center. She is also
an assistant professor in biomedical sciences
and translational medicine. She has 32 years
of advanced practice nursing experience. Her research has focused
on translating bench science to understanding
ethnic disparity and heart transplant outcomes. She is currently
collaborating on a project to study the impact of
the Precision Medicine Institute on the African
American community. Dr. Coleman was a panelist on the 2015
National Academies of Science, Engineering,
and Medicine workshop applying
an implementation science approach to genomic medicine where she provided
a clinical perspective on issues translating genomics
into practice. Results of this workshop
were published in 2016. She’s also a member on
the U.S. Department of Health and Human Services Advisory Committee on Organ
Transplantation. She holds s PhD from UCLA
School of Nursing and an MSN from Yale
School of Nursing. She is a fellow of the American
Academy of Nursing. Our other omics science panelist
is Dr. Jessica Gill. Dr. Gill is a tenure
track investigator and Lasker Clinical
Research Scholar at the National Institute
of Nursing Research. Dr. Gill completed
a postdoctoral fellowship at NINR to better understand the biological mechanisms of
posttraumatic stress disorder, or PTSD, and depression. The line of research led her to become
a clinical investigator in the Center for Neuroscience
and Regenerative Medicine, a collaborative
intramural program involving the U.S. Department
of Defense as well as the NIH. At the Center for Neuroscience
and Regenerative Medicine, Dr. Gill’s program of research and clinical practice examined the biological mechanisms
of PTSD and traumatic brain injury. Dr. Gill returned to NINR as a Lasker Clinical
Research Scholar to develop a program
of research that aims to determine the clinical and biological risks
to predict PTSD onset and neurological compromise following a
traumatic brain injury. Dr. Gill holds a PhD from Johns Hopkins University
School of Nursing, MS from Oregon Health
and Science University and Psychiatric Nursing, and a BSN
from Lynnfield College. So I’d like to welcome Dr. Coleman
and Dr. Gill. We’re going to start
with Dr. Gill, and if you would like
to get us started with a little bit of information from your perspective. >> Jessica Gill: Absolutely,
thank you so much, Yvette. So, I just want to
welcome everybody here and say that I’m very happy
to be here and part of this panel today. I wanted to talk a little bit
about how we’re using biomarkers
in my field of research, which is traumatic
brain injuries or TBIs. So there are three main
causes or categories that we’re looking
at these biomarkers. First, we’re looking
at biomarkers that provide some
diagnostic ability. We see about
a million Americans come into acute care every year. These individuals say
that they’ve had a TBI and believe that they’ve had it. But often when we interview them
and we look at neuronal imaging, we find that
there’s actually not a neuronal damage related
to this brain injury. So it becomes
very imperative for us to be able to identify
those patients who’ve had this neuronal damage and to be able to follow
these individuals over time. But one of the key features that we see in TBI patients is often they have
memory deficits as well as confusion. So this makes it very difficult
to phenotype these individuals when they come
into acute care. So what we really need
are diagnostic biomarkers that identify these individuals that we need to
follow over time who had these types
of TBI injuries. The other types of biomarkers we’re looking for are one
is being prognostic. And we know that about 80-90
percent of individuals who sustain
a TBI will go ahead and recover within
the next couple of months. So we really need to be able
to provide the education and training
to those individuals who will not have
any neuronal compromise so that way when they leave
the emergency room they know they’re going to have
an optimal recovery. But really what’s more important
is looking at those individuals that will go on to have
those chronic symptoms. How can we monitor them
over time and provide preventative interventions
to optimize their health. Lastly, within these categories
we’re looking for biomarkers that give us pharmacodynamic indications
of therapeutic targets. Currently, although
we have high volumes of patients coming into
acute care settings, we do not have any FDA
approved medications to either prevent the onset of
neurological symptoms and deficits in those
individuals at risk. Nor do we have
any types of treatments including interventions
that are non-pharmacological as well as FDA
approved medications to treat these symptoms
if they do become chronic. So this is a major unmet clinical need of patients coming into acute care
settings leading me and others to try
and identify biomarkers to guide the development
of monitoring technology as well as medications
and interventions to mitigate
these risks. So what we do in my group
here at NINR in the intramural program
is look at a variety of different biomarkers ranging from that of genomics
to proteomics. And where we’re
looking at genomics, we look at anything
from genetic predisposition to the function of a gene to epigenetic modifications
trying to understand how these genomic
markers influences great individual variability
in response to a TBI. Again, that we’re
seeing many individuals recovering
where others do not. So we want to understand why
this variability is occurring and how can we encapsulate
that in a biomarker that then we can use to approximate
the risk for recovery. Then we look at these
genetic biomarkers and how they influence
proteomic activity and then result
in different phenotypes. So how can we understand this very complex biological cascade
to then understand how we can monitor
these patients, provide more indicators of which patients are at risk for these long-term consequences as well as inform
some of the ways that we can treat them? And so I’m really excited
to be part of this panel because I think nurses
are really at the critical infrastructure
to develop this type of research. We’re the people who are
seeing these patients. We see this unmet
clinical need. And we also can take this very
complex biological information and translate
that to educate the patients as well as to change the way that these patients are treated. So that way we can really
foster neuronal recovery following TBIs, because what we see
in these individuals once they develop
chronic symptoms is often they’re irreversible. So really, we’ve
got an opportunity when we see these
patients in acute care to provide education as well as monitor them and those individuals at a risk and then provide interventions
to mitigate these risks. So that’s kind of
what we’re doing and where we are
in TBI research. And although
that’s specific to TBI, I think a lot of kind
of the platform that we’re using also
could be used in other clinical settings as well as other clinical issues to really guide developing optimal treatments
and optimal monitoring for these individuals
who are at risk to have non-optimal recovery. >> Yvette Conley: Excellent. Dr. Coleman,
what would you like to add? >> Bernice Coleman: Sure.
Again, thank you for the opportunity
to participate on this prestigious panel
with my buddies. Most notably,
thank you, Dr. Grady, for inviting me and of course
Yvette is a mentor. So, like Jessica, what got me started
in my particular area — and while I’ll be
going to talking a little bit
about transplantation, I think I definitely typify
what you just said, which is —
excuse me — which is that when we’re talking
specifically in these areas, they’re very transferrable. So as a clinician
managing patients as a nurse practitioner,
it was very curious to me that at our Christmas party
where everybody’s all dressed up and they look gorgeous
in beautiful dresses, et cetera, next year someone
won’t be at that party and more than likely it will be an African American patient. Now, I just didn’t
understand why, because I was —
I’m on the treatment team. I understand
what we do for them. I know these patients.
I manage these patients. And, that sort of led me
into the lab. And that, again,
was serendipity. I got a call from my mentor
who was an immunologist who was on my PhD panel
that said, “Bernie, you come
into this 12:00 with me. Ann Hutchins is talking.” I’m like, I didn’t know
who that was. So we went to the talk.
At the end of the talk he said, “Walk with me,
I got to go to lunch.” And I’m like, “Okay, fine.” And he goes,
“You’re going to do a postdoc and you’re going to do it
in Dolly’s lab and you’re going to look
at these SNPs.” And I said, “I am?”
And he said, “Yeah, you are. So what I want you to do
is go see Dolly.” So I’m like, “Who is Dolly?” So I went to see Dolly. What did she say to me?
Everybody said, “Are you actually
going to go see Dolly? Because we’re afraid of her.” I’m like, “Yeah,
Stan said I had to do it.” I went to see Dolly,
she asked me, “What do you like to do
for relaxation?” I just finished a PhD. I don’t know what
you’re talking about. Relaxation? The goal was
to get out of school.” [laughter] So, sewing was one of
the things I loved to do. She goes, “Great,
you’ll be a good pipettor.” I’m like, “Okay.” So, I made it through that and through that small study discovered that there
were some SNPs — inflammatory gene
SNPs of TNF-alpha in IL-6. This is early in 2000, that seemed to be
associated with death, and I’m like, ah-ha!
This is interesting. I didn’t have enough time
to breathe before somebody said, “Guess where you’re going next?”
“Where would that be?” I said.
And they said, “You’re going to
Summer Genetic Institute.” “I am?” “Uh-huh.” Because you don’t understand
what you just did. [laughs] So, thank you again, Dr. Grady. So, there I went off
to the Summer Genetic Institute, and I met my good friend Yvette. And we finished that work. And most recently, the work
where I am right now is — I have actually put together a genetic risk score
for transplant patients. And in this risk score, what I notice is that
if you’re African American — my two populations are
African American and Caucasian. If you’re African American
and you’re in the high-risk — actually, if you’re
African American and you’re in the low genetic
risk score, your outcome at 10 years
is exactly the same as your Caucasian counterparts. But if you’re in
the high-risk score, your — the Kaplan-Meier
precipitously drops. So, we’re moving on
a multi-center study, but how does that get to me
the community and PHI? Because my passion
around genetics and genomics pushed me and the International Society — because we are
the International Society of Heart/Lung Transplant. And in that database, they have probably
160,000 patients in it. And I thought, great.
I’m going to go study that patient population, because these are transplants, to see if I can find
what I’m looking for. And you will be surprised. There is not a variable
on ethnicity or race. So, I just got on a bandwagon and passionately got them
to understand that. And we — it took us
about a year to get a paper published, but we actually
came out last month with the lead paper
on health disparities and gaps in ethnic populations, so — which is great. But how do I get
to the community? I get to the community
because clinically, I know that prevention
really is the key. And the movement now with PHI
is very, very important. And I’m actually collaborating
with some of the researchers who are busy right now, going across the country,
getting information, doing studios — community engagement studios
around the country. And so, in L.A., we provided three populations of African Americans, Filipinos, and Hispanics. And that was a very interesting
way to really find out — to have the community
inform the direction of where this Precision
Health Institute’s going. Being mindful of time. Back to you, Chair. >> Yvette Conley: Well,
thank you. So, I think what
we would like to do that is have a discussion
amongst the three of us about omics and data science. And, you know, one of
the first questions that I wanted to throw out
there for us was, you know,
where do we think omics and data science
go in the future? To inform nursing science
and precision healthcare. So, what ideas should we
throw out there about, you know, the future?
What are we thinking about? >> Jessica Gill: I can start.
So, in TDI research, we’ve been really focused on smaller studies
of cohorts of 50. But more recently, there has
been larger cohort studies that are nationwide,
with multiple sites, allowing us to look at thousands or twenty thousand patients
to get a lot of questions that we weren’t able
to address before, like health disparities. And how do we understand
genetic risk factors? And how can we generate
this big data, but also consume it, and use it to
develop hypotheses? And so, that’s kind of where
we’re going with this research, and it really opens
more doors to us because we can look at questions and address questions, and not have to
repeat studies over and over to really address
the critical issues that we have about
TBI research. So, how can we identify
those patients again that are going to have
that non-optimal recovery, and look at demographics, as well as combine
this with proteomics and genomics to really address
these critical questions. So, that way, we’re not still
at the starting phase. So, I think it’s really exciting as these big consortiums
come together. And nurses are really
at the forefront of that, and really can help
that data both get generated, as well as use that data
as we have these big consortiums
coming together. >> Bernice Coleman: And I think
we need interdisciplinary teams working together. That’s really the — >> Bernice Coleman: —
critical piece of this. We have to organize
teams together. We have to go
after populations that, traditionally,
we haven’t — that haven’t informed
our research. Because as we move forward —
because we clearly are — this train has left
the station, as it relates
to developing interventions and really understanding what individual
populational needs are. We are going to have
to query community populations. Population science
is a critical — implementation science
is important, but importantly, we’re going to have
to get into communities. And I believe that nurses leading these interdisciplinary
teams are critical because we have those
clinical questions that really require us to tap into other professionals
in order to get the work done. I think the other piece of this, which hasn’t been brought up yet is that the mito DNA — the magical gift that everybody’s
mom gave them, plays a major role
in this omics toolbox because there’s
a lot interaction between the nuclear
and the mitochondria, in terms of what transcription
is going to come out of those genes that have been up regulating. So, I think the future is also going to pull
in the impactive mito, and also the issue
of making sure that, you know, stepping back
from the heavy science piece, but making sure that
we have populations — that we understand populations, and the specifics
of populations — the biological underpinnings. >> Yvette Conley: Yeah. You bring up the
mitochondrial aspects that we sometimes — gets overlooked
in our omics toolbox. But you know, there’s data supporting
that estrogen draws a lot of the biosynthesis
of the mitochondrial genome. So, you know, there’s a lot of, you know, sex-based data
that could be looked at, within the context of nuclear
and mitochondrial genetics. >> Bernice Coleman: And a lot
of the epigenetic changes are often mediated what’s happening
in the mitochondria. So, it’s sort of an area that doesn’t get spoken about much — >> Bernice Coleman: —
which is interesting, but it’s a powerful
little 37 genome. >> Yvette Conley: It is
interesting, but like all the — all of the omics, you know, tools that we have — like when we talk about
how you can assess all the genes
at one time, you know, the mitochondria
is represented in those data collections. And if you pay attention, and you see how someone
publishes the results — >> Bernice Coleman: Yeah. >> Yvette Conley: —
there’s nothing said about mitochondrial data — >> Yvette Conley: —
that was collected, and it’s sitting there,
but no one analyzes it, so — >> Bernice Coleman: I think
that’s a very good point. And in our world
of transplantation, we’re beginning to see cell-free
DNAs, it’s called. One of the interesting questions was when one of the abstracts
was presented last year, someone took the mic and said,
“Is that mitochondrial DNA?” It was kind of a stumper — >> Bernice Coleman: —
for the person at the mic. >> Yvette Conley: Yeah. >> Bernice Coleman: But I think
another very, very, very key piece here that hasn’t been
brought up yet is that we’ve got
to use the data. And we — the future
has got to be set up in such a way
that the average nurse that’s taking care
of the patient can actually — okay, we’re going to go future
for a second, right? Can actually go to the EHR,
pick up that history. They’ve probably
filled the history out before they got
to the hospital because we’re all
electronically connected. Somebody routinely updates
that history and asks when there’s
a clinical visit around who’s gotten what, what are
the diseases happening? So, we’re actually code
named family history. So, we’re actually very adept at how to gather information
around family history. We are — we can
get genomic data in, in such a way that — in terms of throughput
that that’s also available. So, I think the future actually is very bright. >> Bernice Coleman:
But it’s going to require a lot of preparation
for us to do it. >> Yvette Conley: Right.
Right, right. And one of the things that I,
you know, had thought was, you know, we’re thinking
about all of this, you know, precision healthcare
and you know, personalizing how we’ll offer
interventions to folks. And I think a lot of people, their thoughts
immediately go to, oh, we’re going to look
at the genome. We’re going to look
at the variation that’s there, and we’re going to figure out
what drugs would work for someone. And that’s true,
but I think part of what’s being missed there is there’s a lot of variation
and response to non-pharma interventions.
You know? Not everybody
responds to cognitive behavioral therapy
in the same way. Not everybody
self manages — well, some people
self-manage very well. And how do we figure out
why that is? And then, who those people are,
and then say, well, there are interventions
for these folks, and it not always be pharma. It may be something non-pharma or some type
of intervention that, you know, isn’t even
on our radar right now that will come about
because of the data that we’re collecting,
and it points — the evidence points
to that being an efficacious intervention, but not for everyone.
And why not everyone? And I think that’s something
to keep on the radar as well. >> Bernice Coleman: I think
the symptom science notion is an incredible paradigm to hang on that information on. And imagine that
there’s repositories in which you can query. Because I think
that’s really the beauty of this omics toolbox. That it provides both some of
the biological underpinnings of typical medical
management — nursing management
that we currently do, but also explains
some of the outcomes, as they relate
to behavioral interventions. >> Yvette Conley: And you both
sort of hinted at, you know, in the future,
you know, it’s — right now, our barrier
isn’t collecting data, right? It’s managing it. It’s consuming it,
you know? >> Bernice Coleman:
Consuming it and understanding it is really key. >> Jessica Gill: And I think
translating it back to patients and how we can use this to — >> Bernice Coleman: Yes.
Absolutely. >> Jessica Gill: — really
transform the care that we provide, and I think that’s — >> Jessica Gill: —
where we’re at a critical point. And so, I think as nurses, we really need to think
about the skill set that we need to do this as we move forward,
because you’re right, we’re not going to be
at the bedside, always collecting the data. But we’re going to be
at different points in managing and translating this data. And that’s going to be
a big impact that we can make. >> Bernice Coleman:
It’s not just nurses. It’s everybody on that team. >> Bernice Coleman: Because we
all talk to each other, and the power of these
complex patients are beyond a specialty. It’s really
the synergistic pieces of all those team members
working together, and the ability
to call a consult, you know, literally
in a hospital setting, or at the bench, or wherever, to be able to utilize
the expertise of everybody that really makes this
the reality, I think. >> Jessica Gill: And I agree.
I think that’s where the depth and the wealth
of the data comes, is really being able
to work together with different disciplines — >> Jessica Gill: — and come
together for this complex issue. And you brought up
the symptom signs, and really looking at symptoms across different disorders — >> Jessica Gill: — so we can
understand how fatigue is different in post-traumatic stress
order than it is in cancer. What the commonalities
and what the differences are, and how that’s going
to move us forward is looking at symptoms,
and not just necessarily orders. >> Bernice Coleman: And PMI is not
going to be the panacea, right? It’s not going to be
the answer for everything, but what we hope
is that the care that we deliver
ultimately is specific for that individual, and that’s a lot of work. That’s a different
paradigm shift than the way
we operate right now. >> Yvette Conley: So,
the other question I wanted to throw out
there for us to entertain is, you know, what advice do we have to offer
to nursing scientists who want to incorporate omics
and data science into their research trajectory? >> Bernice Coleman:
Okay. I’ll start. So, I think the community piece is really, really important. I think it’s been — it’s a difficult piece to add to our science
that we’re currently doing because it’s not part of
the usual infrastructure for setting up research. So, you know, how do you do it if you don’t have
a way to do it? Or you have no
experience doing it? Well, I think the advice
is to collaborate. You know, we just don’t — we are not experts
in everything, but to be able
to be at the table, and to call the right people
to the table that can help you
get the information you need is important. So, to get information
as it relates to what particular
populations might want, or you’re studying
something at the bench and you’re wondering
how would this translate. If I want to engage people
from the community, how do I do it? My experience has been
that I was lucky in that, you know, nurses wear
a lot of hats, so part of what I do is
a lot of community engagement type practice. And I’m actually working
in a church base right now. Not around transplant,
but actually around sodium. Why sodium? Because sodium leads
to hypertension. Why hypertension?
Because for African Americans that go to transplant, it’s idiopathic cardiomyopathy.
Why is that? It’s often related
to hypertension. So, it just keeps backing up, and you fill in the blanks
in such a way. And I’m working with an interdisciplinary team. We are used —
we’re going to be using V.R. as one of our interventions, but we’re also going to add some genetics to this. It’s not live yet. It’s a work in progress, but just tapping
into colleagues that have experience
working in the community is one of the ways to do it. And I think that’s probably
a good way to start. >> Jessica Gill: Sure,
and I’ll add to that, too. So, I think there are a lot
of critical questions that nurses raise once they see
clinical observations — unmet needs,
questions that come up. And I think it’s taking
those critical questions and thinking through
which biomarker best would answer
or address this issue? So, is it genomics? Or is it proteomics? And then,
really collaborating — and I don’t think
you need your own wet lab, but finding — >> Jessica Gill: —
the right people to work with to address that question. So, you’re collecting
the right type of biomarker, and you’re collecting it
the right scientific way. So, for example, if you’re
going to collect proteins, you’re going to want to get it
at the right standard time during the day. You’re going to want to decide
if that person should be fasting. So, there’s a lot of just
general issues related to that. So, make sure that your science
is sound as you move forward. And there’s a lot of ways
to start doing that, to think about the biomarkers
that best address the question, and what’s realistic,
I think, in the population, too, to really start moving
that science forward. And I think that nurses, again, are at a really good place
to be able to good that. We tend to be
good leaders of teams, bringing people together to
address these critical issues. To look at change over time
in some of these biomarkers, and how they relate to outcomes. And to really start
this type of conversation, and to start
the infrastructure building, so that way we can address
these questions, I think, as science moves forward. >> Bernice Coleman: I think
publishing the how-to’s are going to be
very important for sharing that important out
with our colleagues who also want to do the same. >> Yvette Conley: Right.
And not missing out on opportunities. >> Yvette Conley: You know,
not adding omics on, you know, as an add-on that wasn’t given much thought. But thinking about — when you’re thinking about
your program of research, are you going to be remiss
10 years from now, when you have nothing
in your freezer, or no freezer? You know, no samples. And you wish you could go back and reflect upon
the biologic mechanisms around a lot of the phenotypic or clinical data
that was collected, and how those are
missed opportunities. And a lot of times, it’s hard
because people think, well, I’m not going
to get that many. But if you don’t ever start, you’re never going
to get critical mass to be able to answer
some of these questions. You know, and then you think
about the resources that that generates, and how those resources
could be incredibly valuable, not just to your
program of research, but to other folks’ program
of research. And, you know, tapping into existing data, you know, is another, you know, area that could help us
move our science forward. There’s a lot of data in,
you know, genomic and proteomic data available
for investigation. And I do think that
that’s another way to even conduct a pilot study to see if genetics or any type of omics would
actually be fruitful for your program of research
at this point of time. Without actually
recruiting phenotype, you know, or collect
any samples of your own. It’s a pretty good way
to get some more bang for the buck out of,
you know, what these projects have already
been able to accomplish. So, on that note,
one of the things that the panel
wanted to make sure that we sort of ended on, from the point of view of advice and resources
was to mention ONSEN, which is the Omics
Nursing Science and Education Network that is being developed. It’s in beta testing. It’s going to be
a web-based resource. It’s going to be available
to scientists. It was born out of the nursing
genomics science blueprint. The idea with ONSEN
is that there would be a — you know, it’s three-pronged. We’re thinking about
common data elements. What should people
be thinking about, from a common data elements
point of view for symptoms? And where would — you know,
could we have some one-stop shop for that information? And how wonderful
that would be. And then, also,
thinking about training and education opportunities. Wouldn’t it be great
if there was a place for someone to go
to and find out — if I’m a nursing scientist, where could I go to get
that education and training? What are the essentials
that I should know? And then,
the third part of that, ONSEN is the research network. Kind of a like match.com
for researchers. So, you know, we were talking
about how, you know, existing resources —
existing samples. You know, there are folks
sitting there with lots of data and lots of samples,
and they would love to collaborate. So, the idea
is to put together to increase collaborations and move science forward with,
potentially, you know, with resources
that already exist. So, you know, I know
that’s something the panel wanted to make sure
that we brought up. We’re hoping that that
ONSEN portal is up and running soon, and I’m sure that it will be
put out to everyone when that is available. So, we wanted to kind of leave
on a happy note resource, so — okay.
All right. Okay. So, I think, you know, we can now take questions
from the audience. We’d love to hear your
viewpoints on precision health and omics science. And, you know, as with
the previous session, please use
the microphones places around the room
to ask your questions. >> Female Speaker: We have one —
in yellow. >> Elizabeth Cohn: So,
can we just start? >> Female Speaker: Oh, okay. >> Elizabeth Cohn: So,
I’m Elizabeth Cohn from the Columbia University Cornell Harlem Hospital
Precision Medicine Initiative. We’re one of the grantees, and I wanted to invite
everyone here — and I have brochures up here. In two weeks
on September 26 in Bethesda, we have a community engagement
precision medicine PMI pre-launch workshop so that we can hear
from the communities about their thoughts
about precision medicine — everything you just said,
common data points, what nurses need from the
Precision Medicine Initiative. It’s an open invitation. There’s a link
on the postcards; you can register yourself. We really want to get
a critical mass of nursing voices there because now is the time — while we’re developing the Precision
Medicine Initiative for us to have input so that
we’ll be able to use the data as it
becomes available. And thank you so much
for your call out for community involvement. We are working very hard
to have those voices heard. >> Female Speaker: Thank you
very much. I’ll be over here. [laughter] >> Female Speaker: No question. >> Susan Dorsey: So, hi. Susan Dorsey from
the University of Maryland. Thanks for a very
thought-provoking panel. And I have a practical question. So, Bernice,
you were talking about sort of actionable mutations that will pop up in the
electronic health record, and we’ll know,
you know, to intervene. And, Jessica,
you talked about looking at sort of omics
across the symptoms spectrum. When will we know
that we’re there? When we will think that
there’s enough information on the omics of symptoms to be able
to say ah-ha! Here’s a short list of snips that are going to predict your susceptibility to develop a chronic pain condition,
for example. So, I’d love to hear
your all’s thoughts on when will we have
practical ability to move our work forward in a clinically
meaningful way? >> Bernice Coleman: So,
I appreciate your zeal. [laughter] But it’s not going
to happen overnight. [laughs] And I think it’s going
to happen as it slowly has. I mean, if we think about
when the genome got explicated, and the main focus — the beginning focus was
looking at mental health issues, there was a lot of dollars
that were put into that, and repository was made. And things were
embargoed for a while, and then, researchers could
begin to ask that question. In our minds,
our grandiose minds, the three of us, we believe ONSEN will do that. We believe this website
will help us do that because in our match.com, we’ll have the common
data elements. We will have — we’ll have data
in a central place. You’ll be able to connect with researchers, et cetera, in preparation
for collaboration. That’s at that level. At the level
of the staff nurses, we have a lot of work to do. We really do. It — and that really, from an institutional
perspective — this would be a hospital
institutional perspective; it’s going to require leaders, the leaders to really
buy into the fact that this is really important. I think we are sitting
on the precipice of that, though, right now. I think there’s a sea change
that’s about to happen. The wind — I wish
I had a crystal ball and I could tell you exactly
it was going to be 2020. >> Yvette Conley: I mean,
I think if we look at what’s going on outside
of symptom science, and when we think
about incidental finding issues
around the human genome — now that we can sequence
the human genome, we’re finding out things
about someone that maybe they didn’t
want to know, but — >> Yvette Conley: —
hey, by the way, we know it. What do we do with that? There are — there’s a list
of actionable genetic mutations that we are supposed
to report back on, and those are
actionable mutations. So, I feel like at some point, we might get there
for symptom science. You know, there are
actionable things that we know about that, you know, we can
add to the list, but instead of it being for Huntington’s disease — >> Yvette Conley: — it’s for,
you know, fatigue and pain, and you know, symptom clusters,
and things like that. So, I could see us
moving in that direction. I don’t know
if that helps answer your question, Susan, but — >> Bernice Coleman: I think we
are moving in that direction — I won’t go long;
there’s folks at the mic. But when we know
we’re there is when you check into a hospital, and the nurses
taking care of you knows exactly what to do. And from a red flag perspective.
And she knows — she doesn’t have to know
genomics the way we know it. But she knows that, oh, I need
to call this colleague because I know
that’s what we need to do. Then, we are there there because that moves out
into the community, and the clinics are all linked,
and the EHR is working. And, of course,
I’m in a grandiose place. [laughter] >> Jessica Gill:
And I also want to say, before we go to the next question,
I think it’s going to be beyond mutations also. >> Jessica Gill:
It’s really going to be things like epigenetic modifications that encapsulate things
like environment and stress and nutrition that we can look
in these biomarkers and understand kind
of trajectories of symptoms and how they
connect over time. So, I think
it’s going to be really combining
these different laboratory methods to understand these more complex
relationships too. >> Bernice Coleman:
With throughput. >> Yvette Conley: Very true. >> Maureen Groer: Hi, I’m Maureen
Groer from the University of South Florida. Hi, Yvette. You’ve heard me
say this before, but I think we need
a real sea change, a real paradigm shift
in our PhD programs. If we’re going to
prepare people — >> Female Speaker: I’m with you. >> Maureen Groer: —
for this omics future, what content are
we giving them, other than how
to do research? What about the content
in genetics and omics,
you know, content? That’s my — >> Female Speaker: Yes. >> Female Speaker:
Excellent, yeah. >> Bernice Coleman: Yeah.
This is the choir here. Preach — but, yes, and I think that’s part
of the foundation. If we have these
expectations going forward for nursing and science, then I think we need
to have the same expectations in our education programs. Lois Tully: So, Lois Tully
from NINR. You mentioned
the mitochondrial genome, and I’ve always been intrigued
by the mitochondrial genome because it kind of follows
a different set of rules than the nuclear genome. I agree with you
that it’s underappreciated and underutilized, though I would like
to recognize the work that Yvette has published
on mitochondrial polymorphisms and patient outcomes. But my question is, do you think
there are unique challenges related
to the mitochondrial genome that is kind of keeping it
from being incorporated into research like
we would like to see it? I mean, I think of how,
you know, it could — there could be differences,
tissue to tissue, within an individual. It’s — you know, heteroplasmy. Does that impact, or what your general thoughts? Because I agree. I think that’s something
we should be doing more of. >> Bernice Coleman: I think there
are unique challenges. First off, you have to have a really knows
how to deal with mito. I reached out
to an ophthalmologist because she has done
a lot of work. She’s just right down the road
from me at UC Irvine. And I also have a mentor. And so — and she’s got a huge lab. Two thousand square feet,
and that’s all she does — is mito. So, you’re right,
and I think there’s — I think it’s underrepresented. You sort of mentioned
that as well, Yvette. And it’s something — we just need to
talk more about it. We need to bring it up, and certainly, in — as we continue to work out
the omics related to nuclear, that we remain mindful
of the fact that mito is very important
to these processes. >> Yvette Conley: Right.
And I think, personally, too, some of it is analysis. We — >> Yvette Conley: —
you know, we sort of look at the autosomal DNA because we know
how to analyze all of that. And you put it
in your analytical, you know,
software in through-put, and it spits it out and tells
you what’s interesting. But we don’t have
that through — you know, easily
throughput analytical way of looking at mitochondria. But along the way,
we’re generating all this data. So, the bottom line
is the data’s there. We just haven’t
looked at it. >> Bernice Coleman: Yeah. [laughter] Do we — I can’t read it
from here, sorry. So, one more?
One more question? >> Female Speaker: Two more.
Two more questions. >> Steven Wartman: I’m Steven
Wartman from the Association of Academic Health Centers. Want to congratulate the panel
on a stimulating discussion. I wanted to emphasize
a very important point that I thought
the panelists made earlier, and that has to do
with the skill sets that nursing will need
looking forward in the year
of precision medicine. You know, precision medicine
seems to me to be a bit of a misnomer. It’s really an intensely
complicated and complex environment
of data points. And it seems to me that the data points
on individual patients will be in the hundreds
or thousands fairly soon, and that there will be
machines like Watson and other similar machines that will give the nurse
a list of probabilities — either diagnostic probabilities
or therapeutic probabilities — 91 percent chance of this,
82 percent chance of that. And the nurse is going
to put in all conditions. They’re going to be put
in the position of interpreting those probabilities
for a patient, with the patient’s
own individual, human complexities. And it seems to me
that the point was made earlier by the panelists
and the discussion just now, that’s something that I think
nursing really needs to focus on. How do you address
probabilities in the face of unique human complexity? >> Female Speaker:
Excellent question. >> Bernice Coleman:
I think numeracy is a really big point, and congratulations
for bringing it forward. We didn’t say the actual words,
but we were implying that. But it is really large. It’s a large problem. I know on our research council,
locally, at our hospital, we are taking that on
as a challenge for this year, and trying to improve
the numeracy, just generally. But around the issues
of probability related to genomics. One of the things that came out
of our community studios when we asked patients
about the value about getting to participate
in this PMI, one million people
recruitment project. If we give you your data,
do you want them? Do you want that data? And they said,
“Yes, we want that data, but who’s going
to help me understand what you just gave me?” And they said,
we’ll write that down. So, looks like they’re
telling us times are up. We read well. [laughter] [applause] >> Afaf Meleis: Wow. Wow. So much food for thought. Such an exciting panel. Thank you, Dr. Conley, Dr. Gill, and Dr. Coleman
for really stimulating and inspiring us
with so much information. And especially about
the future, too. And it was really
inspiring to hear how you got to where you are, in terms of really becoming
interested in that. Let’s give them
a round of applause. [applause] Again, the success of a panel is that it leaves us
with so much more thinking, and we want to go on
and on and on. We promised you a stimulating
and inspiring symposium, which was very easy to do, once we found out
who the panelists will be. So, if you had any doubt about progress
in sleep research, and how vital sleep is
to every outcome in our lives, it’s probably
completely dispelled after our two panels today. So, NINR mission
is to promote and improve health
of individuals, families, and communities. This scientific symposium, which is really
a closing symposium for a year of celebration. So, it’s a really
important symposium. I think this symposium
really exemplified the importance
of the mission of NINR and highlighted nursing science importance
and discoveries, and how they are important to influencing
everything in our lives. So, these two panels
reflected on the importance — or reflected on importance
of today’s theme, which is to just remind us: Advancing Science,
Improving lives: A window to the future. So, I have just
few reflections about — as we move forwards. I think there are four, five words that I come to mind,
from listening. And this is not a summary,
by any means, but moving forward, we need to think
of diversity, policies, global health,
SDGs, and theory. I’m going to say
just couple of words about each one of those. And you thought you were
going to get out of here without my saying
something about theory. [laughter] Well, you’re wrong. So, we think —
we must continue — and I think we heard
from our panelists that we must continue
with research and findings that reflect
our diversity in the society and our diversity
internationally. Gender diversity. Sex differences, as well as the differences that are imposed
by the lifestyles that have been imposed on us because of our race,
because of our culture, because of our
sexual orientation, socioeconomic status,
and heritage. We can’t afford
to develop science without careful attention
to this diversity and making sure
that the science we produce will be effective
in our society to meet the needs
of the diverse people. We heard that we need
to focus on outcomes. We have to have toolboxes
about biological underpinnings. But we also heard that we really
should be translating — that there is still gap between the science
that’s produced and how it gets out
to be used. Questions about social rules,
imposed or selected, and how they influence
the quality, the experience, and the nature of speak — of sleep, and in turn of health
and well-being. I think that’s really important for future science
also to consider. And I think there is
barely ripe opportunity for investigation, particularly for about girls who are facing socially
imposed challenges. So, again, I go
to the girl child and the challenges
related to adolescence, and women as caregivers. Women as caregivers
is a population of elderly who become,
themselves, caregivers, and there is so much — and it’s an area,
ripe area, for research. We heard a little bit
about policies, and I think — I would urge all
sleep scientists, any scientist, to consider how their work may influence voice
and advocacy. It’s not enough that
we produce it and output it. And we heard that from
our wonderful panelists that we need to translate
it to clinicians, but we also need
to translate it to policies related to changes that work, education, benefits for caregivers, including elderly care. In Pennsylvania,
I was really pleased to hear about the progress, in terms of changes
in school times that will reflect
the circadian rhythm of particularly teenagers. Well, it’s really in our papers
now in Pennsylvania that the teenagers themselves are collectivizing
to change the hours. They don’t want to walk up
that early in the morning because they say
sleep research is saying we need to sleep more. Our sleep cycle is different — they are using those words.
It’s crazy. So, voices of sleep
researchers are needed to translate research
into policies, and to advocate for it,
and to work on it. But let’s not forget
our global role — all of us. So, there are new set of goals
for 2015 to 2030. They are developed
by United Nations, and they are agreed
upon by 70 nations, and they are the sustainable
development goals. They are composed of 17 goals, and 169 targets
that are only — and they are not only
for the developing countries. We are — unlike the previous
development goals, millennium development goals, these are not developed
for developing countries. These are for all —
the whole world. There is one goal,
which is number three — it’s about health
and well-being. So, we think that this
is really out of the 17, that’s what we need
to think about it. It’s not really true.
We think about environment. We think about hunger.
We think about poverty. We think about
how these are affected — affect sleep, and how sleep
is affected by them. So, I urge sleep researchers not only to study those goals, but perhaps —
and to look at them carefully. I think everybody
in our community should really know
what those goals are because we are a part
of this whole world that have approved the goals, and we’re going to look
at the effect of it in 2030. But to really think about them,
in terms of driving some of the research questions,
too, and connecting to them. I would hate it that in 2030, they would look what we have
accomplished, and never mentioned, and never include research that has come up
from nursing science. So, I think
that’s really important to think
systematically about that. Now, theory. I think there’s been
incredible research programs, exemplified in this symposium, and exemplified
in the writings — fantastic literature
that I got into it just because
I was going to be — whatever one my name is today, which is the director
of ceremonies. So, you know the theories
that have driven your research because you are the experts
in that field. However, we are now ready
to develop some theories from the research
that you have done — the determinants
and risks of healthy sleep. There are models
to be developed, and Dr. Gill has a really nice
about models, so that’s a beginning. And it — best practices and best interventions
that produce productive sleep. The self-management,
or others management. These are all areas that area
ripe for the development, not only of middle-range theory, but situation specific theories. I think in terms
of the populations, specific to the population — and let’s not forget, also, a major population
all over the world now, and it’s the population
of refugees who are faced with
so much violence and lack of access
to healthcare. And also, their sleep
affects their sleep, and sleep is affecting
their functioning. You are the experts. You need to reflecting
on the kinds of theories that could be developed. Our literature needs that. And programs of research
in the future could benefit
from a current approach, theoretical approach to the work
that’s being done. So, I think future
sleep research should include attention to translating
research findings, as you all said,
translating it into practice, translating it into policy, and translating
into raising it up in a coherent form to theory. So, congratulations
on accomplishments of 30 years. It’s just absolutely fantastic
to see the result of that. Thank you, the panelists, for stimulating
and inspiring us, and challenging us
about the future. And thank you all
for taking the time and making a commitment — and investing the time
to be here today. And now, I turn the podium to our fearless leader Dr. Grady who will provide
some final remarks. Thank you. [applause] >> Patricia Grady:
Thank you so much, Afaf. Thank all of you
for sharing your expertise and insights
with us today and your interesting
and thoughtful questions and sharing that expertise.
We really appreciate it, and it makes it
so much more exciting to have that interaction
across the room. Let me add my words
of thank you also to Afaf, the director of ceremonies,
another first for her. For her energy
and enthusiasm, leading all the way up to this
event and throughout today. And also, thank you to — my words of thank you
to the panelists as well. We appreciate that there
has been a lot of work going into this ahead
of time in order for it to be as good as it is. I’d also like to
thank the NINR team because they have been
working on this for about a year now. And so, we do really
owe a debt of gratitude to all of you to make this work as well as it has. [applause] Yeah. So, again,
just a few words, as we’re finishing
thinking about — you know, we really recognize
your unique contributions to nursing science.
We recognize — we’ve heard so much of that
in the room this afternoon, but we’re pleased
to hear all of that and to participate with you
in this venture. We look forward to
supporting your research as we advance science
and improve lives together. The centrality of nursing
and nursing science to health and healthcare, in fact, led, directly, to the public laws
that established the National Institute
of Nursing Research at NIH some 30 years ago. And today’s symposium
illustrates the impact of that NINR’s 30 years of having that stable funding. The work that
we have accomplished collectively reflects
the efforts of the nursing and nursing science
communities as well as the combined efforts of all of our efforts
of all of our colleagues and partners
from diverse science, healthy, and policy-related fields. Our public service mission is achieved through the work
that you do every day. Nursing science
is about people, driven by our desire to improve lives of people
and their well-being. So, let me encourage you
to continue to work hand in hand and side by side
with the people whose lives you are
seeking to improve. The individual’s families
and communities that will be benefit
from all of this work. As you develop
and implement your research ideas,
seek them out. Not simply as
research participants, but as research partners. Ultimately, they are
the end users of all of our science, and they will determine and define the relevance,
the effectiveness, and the sustainability of the innovations
that we create. Similarly, I want
to encourage you to seek out opportunities
to work in interdisciplinary teams. We’ve heard a bit about
that this afternoon, but if you seek out
those opportunities and provide your leadership in these collaborative efforts, working collectively does not
diminish the creative spark of the individual
inspiration and drive, but rather, it can lead
to extraordinary synergy. In our experience,
curiosity begets curiosity. And I’ve been fortunate enough in my own research
in my experience to have been enriched
and advanced through my partnerships
with scientists and colleagues from a wide variety
of backgrounds and professions, as have so many of you. And that will be so important
as we face a future that is so increasingly complex from a scientific
knowledge point of view. It is truly an honor to serve
the American people every day, with deep humility
and gratitude, and with great optimism
and enthusiasm we go forward. This is an amazing time
of transformation in the healthcare sciences,
and the healthcare itself. And we look forward
to the challenges and opportunities
that we will face together as we continue to advance
nursing science, and advance science generally
and improve lives. I want thank each one
of you here today. It is through your efforts
and excellence and partnerships
with our colleagues around the country
and around the globe that NINR is able
to fulfill our mission to serve the public. Thank you all so very much, and I invite all of you, each one of you,
to pick up a copy of the strategic plan
as you leave the room. Thank you again so much, and we look forward
to continuation. [applause] [music playing]

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