In this issue of Research in Gerontological Nursing (RGN), Helen W. Lach, PhD, RN, FGSA, FAAN, and Phyllis Gaspar, PhD, RN, FGSA, describe trends in gerontological nursing over the past 40 years by reviewing abstracts of research presented at the Midwest Nursing Research Conference in their article, “Progress and Changes in Gerontological Nursing Research in the Midwest” (Lach & Gaspar, 2018). Although only representing one regional conference, their findings are compelling and offer an opportunity to comment on research trends and needs.
Settings for Research
Lach and Gaspar's (2018) article suggests that gerontological nurse researchers favor conducting studies in long-term care and community settings. With short stays in acute care and the multiple potential confounding variables inherent in this busy and at times chaotic environment, it is not surprising that fewer studies are conducted in acute care. And yet, we know that hospitalization is where many of the iatrogenic events that negatively impact older adults occur (Sourdet et al., 2015).
Clinic visits are where individuals often connect one-on-one with a health care provider. What happens between health care professionals and consumers in these individualized encounters influences self-care behaviors, health outcomes, hospitalizations, costs, and patient satisfaction (Anderson, Camacho, & Balkrishnan, 2007; Beck, Daughtridge, & Sloane, 2002). Continued research on multiple factors that can optimize the relatively brief meetings and outcomes associated with these visits makes practical sense. So, let's keep up the important research being conducted in community and long-term care settings, but also focus on primary and acute care provided to older adults.
Nursing research would not have grown in such a relatively short period of time without the contributions from descriptive and explanatory studies. Our understanding of multiple concepts, lived experiences, and in-depth explanations that inform public health have been developed using qualitative methods. In addition, quantitative descriptive correlational studies provide important foundational insights that can inform the development of new intervention and efficacy studies. Although these primarily descriptive studies are important, we need a more rapid build from these foundational studies to intervention development, efficacy studies, and practice changes.
Although I am known to perseverate about measurement and sampling error, these problems are a concern in gerontological research because older adults are a highly heterogeneous group and because of the greater potential for adverse effects from intervention. I am particularly concerned about measurement and sampling problems in the many studies being conducted that involve large data sets and secondary analyses. For example, data collected from electronic health records has a long history of problems with data accuracy, completeness, consistency, credibility, and timeliness (Feder, 2018). Therefore, we must be extra vigilant in examining the match between our construct of interest and the information available in data sets that was originally collected for another purpose. Information in existing data sets needs to be a valid representation of the construct, collected with accuracy, and measured with the precision and time points that can capture changes proposed in the study.
Gerontological nursing has more breadth than many other fields of inquiry. Physical health problems, mental health needs, symptom management, self-care, health promotion, family caregiving, and prevention strategies are just some of the topics commonly researched. Moreover, individuals, families, aggregates, settings, environmental conditions, costs, and organizations are studied. Thus, simplistic questions that fail to consider the complexity of the human condition as well as the many factors that influence care and human behaviors will not help make important changes in public health.
Nurse scientists have overwhelmingly followed the adage of Aristotle that “the whole is greater than the sum of its parts.” This non-reductionistic stance explains the common use of an array of variables in studies. When four studies with similar research hypotheses use somewhat different constructs or measures, it is difficult to compare or combine study findings. Recognition of this problem has led the National Institutes of Health (NIH) to encourage the use of common data elements in clinical research, patient records, and other human participant research. The NIH supports a portal with access to information about common data elements and resources for developing protocols for data collection (access https://www.nlm.nih.gov/cde). The use of common data elements is important for making comparisons across studies but falls short of helping scientists systematically advance theory through a collection of studies from different teams using different samples.
Individual circumstances and events can influence research participants differently. These contextual determinants are important to nursing research and theory development. Our ability to develop research hypotheses that are informed by theory, to make comparisons across studies, and to deductively advance theory development would benefit from more systematic organization of variables that influence human states, human behaviors, and health care delivery systems. Although studies report rationales for the choice of contextual variables measured or controlled, the building of a body of knowledge requires a more systematic and planned approach to examining the influence of these variables. A classification schema could help researchers make more informed decisions about variables to include in studies. This type of schema could provide conceptual, theoretical, operational, and feasibility levels of abstraction.
We also need to figure out more and better ways to move science forward when studying events that co-occur or act in concert. Family members often play a major role in the treatment of older adults. The interplay of multiple factors between the older adult and family member(s) can influence health outcomes. A family member's knowledge, support, and actions toward achieving a treatment plan may be critically important to consider. When symptoms co-occur or occur in clusters, there may be important interactions and influences on health and the treatment needed. The mechanisms underlying the development of a symptom cluster, for example, may be different than for the emergence of a single symptom. Although research of coexisting symptoms, complex multimorbidity, and family dyads demonstrates acknowledgement of the need to study duality, a clear set of methods or models have yet to be developed for how best to study the complexity inherent in these types of studies.
Injecting new ideas into the field of gerontological research, especially those not rooted in a single discipline's mode of thinking, can help advance a new generation of research and health care. Gerontological research should maintain a healthy tension between the use of current theories and ways of providing care and the examination of new, innovative, and boundary-crossing ways of thinking about aging, needs, and health care delivery. Music and art progress by breaking original forms to invent new forms and expand meaning. The breaking of these forms precludes any attempt at closure or stasis. There are natural limits to continuing to think within the same boundaries set by a discipline, theory, organization, or set of research methods. In my role as Editor, I see the same theories used in multiple studies. This consistency is desirable to an extent because it is by deducing and testing hypotheses from theories that we determine over time the usefulness of a set of theoretical explanations and build a body of knowledge. But, when a new fresh model is developed, it can engender new ways of thinking, questioning, and researching. So, let's deconstruct some of our traditional molds of thinking.
The many fine studies published in RGN and the review paper published in this issue (Lach & Gaspar, 2018) provide evidence of the high-quality research being done in our field as well as the breadth of topics studied. While technology, analytics, and health care change, nursing's focus on science that will improve the health of individuals, families, and communities remains steadfast.
Christine R. Kovach, PhD, RN, FAAN, FGSA
- Anderson, R.T., Camacho, F.T. & Balkrishnan, R. (2007). Willing to wait? The influence of patient wait time on satisfaction with primary care. BMC Health Services Research, 7, 31. doi:10.1186/1472-6963-7-31 [CrossRef]
- Beck, R.S., Daughtridge, R. & Sloane, P.D. (2002). Physician-patient communication in the primary care office: A systematic review. Journal of the American Board of Family Practice, 15, 25–38.
- Feder, S.L. (2018). Data quality in electronic health records research: Quality domains and assessment methods. Western Journal of Nursing Research, 40, 753–766. doi:10.1177/0193945916689084 [CrossRef]
- Lach, H.W. & Gaspar, P. (2018). Progress and changes in gerontological nursing research in the Midwest. Research in Gerontological Nursing, 11, 231–237. doi:10.3928/19404921-20180809-01 [CrossRef]
- Sourdet, S., Lafont, C., Rolland, Y., Nourhashemi, F., Andrieu, S. & Vellas, B. (2015). Preventable iatrogenic disability in elderly patients during hospitalization. Journal of the American Medical Directors Association, 16, 674–681. doi:10.1016/j.jamda.2015.03.011 [CrossRef]