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Emory School of Nursing






 

 







Nursing researchers use a cutting-edge concept
to study symptoms and improve nursing practice
By Pam Auchmutey
     

       
 
     
        or years, nurses have observed that kidney patients often sleep during hemodialysis treatment, a phenomenon attributed to fatigue. In her clinical practice at the Atlanta Veterans Affairs Medical Center, Emory nursing professor Dr. Kathy Parker suspected the cause was something else. That hunch led her to undertake a National Institute of Nursing Research (NINR) study to examine the symptom of sleep in hemodialysis patients. Today, Parker’s work is part of an innovative research center she established in the School of Nursing to look at the relationships between and among symptoms in order to better manage them.
        Now in its third year, the Center for Research on Symptoms, Symptom Interactions, and Health Outcomes is one of nine exploratory centers in the country funded by the NINR to expand research, each in a particular area of nursing science. Emory’s research center provides a conceptual umbrella linking investigators who study symptoms in various illnesses together to advance nursing practice.         “We’re looking at one of the most problematic dimensions of chronic illnesses,” says Parker, who holds the Edith F. Honeycutt Chair in Nursing. “By understanding how symptoms occur and interact, we can develop creative nursing interventions to improve and extend patients’ lives.”     
         “The center cuts across a number of chronic illnesses and patient populations with a variety of symptoms,” adds Dr. Sandra Dunbar, director of the center’s pilot study feasibility core. “Pain, sleep disturbances, fatigue, psychosocial problems such as depression or anxiety, fluid overload, shortness of breath, or edema—the list is endless. As nurses, our practice involves a lot of symptom assessment and symptom management. We are building the science and the evidence to support this area of nursing practice.”
         Already, Emory’s center is showing great promise in growing the school’s research base and the number of faculty conducting symptom-related research.
          Since the center began, funding from the National Institutes of Health has increased 62.4%, while the number of total research awards has increased 12%. By the end of its second year, the number of faculty engaged in center-related research had jumped from eight to 17, and a growing number of doctoral and postdoctoral students were involved. This year, several more faculty will join in the center’s work, including Dr. Jo Ann Dalton, the new chair of the Department of Adult and Elder Health Nursing and an expert in pain research; Dr. Jill Hamilton, a new assistant professor specializing in the study of older African Americans with cancer; Dr. Roberta Kaplow, a clinical professor specializing in oncology nursing; and Dr. Barbara Powe, a special populations expert at the American Cancer Society.
         “The center has created a synergy for all of us who were engaged in individual projects before,” says Dr. Patricia Clark, one of four nursing faculty members who guide the center. “It provides an environment for collaborations in and outside the school to answer important nursing research questions.”
         Instead of studying the frequency and severity of a single symptom in a specific illness, center researchers are examining how symptoms relate and interact in multiple types of illnesses and patients. While current scientific literature suggests that addressing symptom relationships and interactions may lead to a more comprehensive approach to symptom management, research in this area is limited. The School of Nursing is filling that void. 

   
 
     
         

  



     
         
     
          ore and more, center researchers are using a new framework that Parker is developing to guide complex studies on symptoms, groups of symptoms, and health outcomes affecting patients and families.
        Generally, current research theories suggest that symptoms are multidimensional in nature and that relationships and
interactions among symptoms may occur. However, those theories do not address what causes symptoms, why they coexist, their potential relationships and interactions, or their related effects on clinical outcomes.
         The Center for Research on Symptoms, Symptom Interactions, and Health Outcomes has advanced this science further by creating the Symptom Interactional Framework to achieve two goals. One is to help researchers better understand what causes symptoms and how they interact. Second is to translate those findings into more effective nursing interventions that improve health outcomes.
         According to this framework, patients’ symptoms occur within the context of their environment and their age or developmental status. Additionally, symptoms are caused by factors in four categories (etiologic domains)—physiological, psychological, behavioral, and sociocultural—that influence how different symptoms develop, interact, and lead to certain clinical outcomes.
         The relationship between symptoms and the factors causing them is complex. “They are bi-directional,” notes Parker. “Symptoms may be caused by and affect factors in these categories, which may cause new conditions or worsen existing ones. If we understand why that happens, we can develop nursing interventions that may yield clinical outcomes superior to those that result from interventions focused on isolated symptoms.”

   





     
 



 

         arker has applied this framework to her own research regarding how hemodialysis (HD) affects the sleep/wake cycle. To dispel the notion that fatigue causes patients to sleep during HD treatment, Parker sought to establish the presence or absence of daytime sleepiness in these patients. Working with colleagues from the Emory Sleep Disorders Center and the Renal Division in the School of Medicine, Parker confirmed that HD patients experience short, fragmented nighttime sleep, accompanied by excessive daytime sleepiness, and that daytime sleep occurred during and following dialysis treatment. In a related study, Parker found that HD treatment caused fever in dialysis patients and that their body temperatures fluctuated throughout the day. The next logical step was to determine if lowering body temperature during HD could help patients achieve a more normal sleep/wake cycle.
         Consequently, Parker extended her NINR study to conduct a clinical trial comparing symptoms in dialysis patients who receive the standard warm dialysate (37 degrees C) and cool dialysate (35 degrees C) during HD. She is using the Symptom Interactional Framework to evaluate the effects on selected physiological (body temperature patterns), psychological (mood), behavioral (daytime activity and cognitive function), and sociocultural (effects on sleep as related to age, gender, and race) factors and general health outcomes (quality of life and functional status).
         Parker hypothesizes that turning the temperature setting down 2 degrees on the dialysis machine may have important implications for nurses and HD patients. “Nurses may be able to reduce or prevent fever and restore more normal sleep patterns in dialysis patients and possibly extend their lives.”

   
     

         arker’s work and that of her colleagues form the center’s research base. The center provides them and new center investigators with important resources
and collegial support.
         “The center definitely has given us a broader forum for learning and exchanging ideas,” says Dunbar, the Charles Howard Candler Professor of Cardiovascular Nursing.

         That in turn has strengthened her symptom-related studies of patients and families affected by heart disease. Dunbar is the lead investigator for “Psychoeducational Intervention in Internal Cardiac Defibrillator (ICD) Patients,” known as the PEACE trial. She is testing the effect of two approaches—symptom management and coping skill training—to improve patients’ physical and emotional recovery in the year following ICD implantation. Patients are randomized to receive symptom management training before leaving the hospital and to one of two interventions—telephone counseling or support groups—in comparison with usual care. “This study is designed to bridge the gap between acute care and outpatient care,” says Dunbar. “We are looking at the symptoms of pain, sleep, and defibrillator shocks, and ways to help patients cope after they leave the hospital. Our goal is to help patients learn
active coping skills to deal with the emotional aspects relating to having a life-threatening heart rhythm and ICD.”
         Helping patients and families cope also is central to research conducted by assistant professor Dr. Patricia Clark, whoseinterests include Alzheimer’s disease, heart disease, and stroke. “It’s important to help families find ways to deal with stress so that the caregivers remain healthy,” explains Clark, who leads the pilot study feasibility core with Dunbar. “If you can keep the family caregiver healthy, that person is more likely to have a positive impact on the person with the illness.”
         Clark is one of three faculty awarded postdoctoral fellowships by Dean Marla Salmon. Clark’s fellowship provided the perfect springboard into her current R01 study regarding family function, stroke recovery, and caregiver outcomes. Her work complements a national clinical trial, Extremity Constraint-Induced Therapy Evaluation (EXCITE), directed by Dr. Steven Wolf in Emory’s School of Medicine. The trial seeks to improve hand and arm function following stroke.

         Using the same patient base, Clark has interviewed 132 caregivers at five US sites about their own symptoms of depression and fatigue. She also asked them about stroke survivor’s memory and behavior changes to learn how they view those changes and how they deal with them. Identifying these factors will help Clark develop and test new interventions to improve the physical and emotional well-being of caregivers and stroke survivors.
         “One of the things we did in this study was to develop a family conflict scale around stroke,” says Clark. “We actually found that more than 50% of families have some conflict surrounding the stroke survivor’s recovery over things such as how the person has changed or how much help they were being given.”
         Clark also has learned that 20% of caregivers have possible symptoms of depression. As a result, she undertook a center-funded pilot study to look at developing a web-based intervention program for stroke caregivers. The program combines interactive learning with video clips of stroke survivors and caregivers talking about their depression. It is the first step in creating a comprehensive online caregiver program for future testing.
         “During recovery, the focus is on the stroke survivor, who often has physical, cognitive, or behavioral changes to overcome,” Clark says. “But it can be very stressful for family caregivers trying to help with that recovery process. We do know from the scientific literature that stroke survivors with good social support actually recover better. That’s why it’s important to support the entire family.”

   
         
 





























































     
       
       
     

        ach year, angina pectoris, the chest pain associated with coronary heart disease, affects some 6 million people. Dr. Laura Kimble, research associate professor and assistant director of the research center, has concluded a five-year NINR study examining gender differences in patterns of chronic anginal pain. Her study of 100 patients found that quality of life outcomes differ for men and women with similar symptom patterns.
         In a related pilot study, Kimble tested an intervention to help male and female patients with angina learn to manage their condition, reduce anxiety, and improve quality of life, especially their physical function. Results were mixed.
 
          “We talked to patients about how to manage their symptoms, how to take their nitroglycerin, and how to monitor their symptoms in relation to their physical activities,” Kimble explains. “This intervention led to better physical function for men, but not for women. Men
may monitor their symptoms differently than women, so what we say to women to educate them about how to manage their symptoms may need to be different from what we tell men.”
         In her NINR study, 100 patients kept a weekly chest pain diary and filled out questionnaires to assess their patterns of chest pain and quality of life over six months. The results show that men and women respond differently to the same symptom pattern.
         Men who reported that their angina was becoming a more serious health problem had poorer physical function than men who did not perceive their angina as a health problem. In contrast, women’s perceptions of angina as a health problem did not influence their physical function.
         Why, then, do women and men respond differently to similar symptom patterns? To find the answer, Kimble is developing another major study on chronic angina and physical function in women.
         “Symptoms are the patients’ reality,” she says. “But what causes a symptom in one patient population might be very different from what causes it in another. There may be some overlapping interventions and some very different things we can do to help our patients. As the symptom-related research in our center grows, the next few years will be key in moving that science forward.”

   
 

     
     

         entral to that mission is funding new pilot studies to expand the number of center researchers and the school’s research base. In its first year, the center launched three pilot projects. In year two, the center awarded pilot funds to three researchers, including Drs. Donald Bliwise and Jason Cole, researchers in the School of Medicine. Four additional pilot studies will be funded this year.
         Bliwise is among those drawn to the center because it allows him to look at the symptom of sleep in a new light. “Everybody brings something different to the table,” says Bliwise, whose studies focus on sleep and sleep abnormalities in the elderly. “That’s fundamental to advancing the knowledge and science leading to better clinical practice and clinical management for patients.”
         “We all benefit as a result,” adds Parker, a frequent collaborator with Bliwise. “In the process, we are building the school’s research base and interdisciplinary relationships that strengthen our research.”


   
 


   
   Dr. Donald Bliwise, a    School of Medicine faculty    member, often collaborates    with Dr. Kathy Parker in the    School of Nursing. Bliwise is    studying alternative and    conventional medical    treatments for disturbed
   sleep in Parkinson's disease    patients.
   


         he Center for Symptoms, Symptom Interactions, and Health Outcomes has a big name and an even bigger mission—to help nurses better manage the symptoms of chronic illness and ultimately improve and extend the lives of their patients. In addition to those studies conducted by its directors, the center’s research base includes other investigators.
         Dr. Donald Bliwise, professor of neurology in the School of Medicine, is leading a clinical trial (funded by NIH) comparing two alternative and two conventional medical treatments for disturbed sleep in Parkinson’s disease patients. Bliwise also serves on the
center’s advisory board, which includes experts within the Woodruff Health Sciences Center and outside Emory.
         Dr. Jill Hamilton, assistant professor of nursing, has focused her research on family support systems and related outcomes in African-American cancer patients, including men with prostate cancer. Her goal is to help older cancer survivors cope with their disease.
         Dr. Marcia McDonnell, assistant professor of nursing, is conducting an NINR-funded study involving women with HIV. She is using group sessions to motivate women to remain on antiretroviral therapy and reduce risky behaviors. These sessions help women address what they see as barriers to adherence, including anxiety, depression, and side effects of medication.


   
       
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