INVITED COMMENTARY
                   The Past and Future of Nursing Research
                                          Margaret M. Heitkemper*, PhD, RN, FAAN
                                               Elizabeth Sterling Soule Chair in Nursing
                                 Professor, Department of Biobehavioral Nursing and Health Systems
                                      Director, Center for Womens Health and Gender Research
                                   School of Nursing, University of Washington, Seattle, WA, USA
              The past three decades have witnessed a remarkable growth in nursing science development. In both Korea
              and the United States, nurse scientists are poised to address important issues related to the prevention and
              management of significant health care problems. The need for greater nursing science development in the
              areas of self management, genetics, geriatrics, health promotion across the lifespan, technology, and mental
              health are briefly highlighted. Future research efforts will be enhanced by interdisciplinary collaboration
              and the creation of international nursing research centers. At the same time, we need to remain cognizant
              of the importance of mentoring future nurse scientists. [Asian Nursing Research 2007;1(1):4–10]
                                     Key Words health care research, nursing, nursing science
                Portions of this paper were derived from a keynote presentation at the Western Institute of Nursing in Portland,
                       Oregon, April 2007, and published as proceedings in Communicating Nursing Research, Vol 40.
             Thank you for the opportunity to be part of the         interventions,health informatics and evidence-based
             inaugural issue of this important Asian Nursing         practice to name a few.Compared to other sciences,
             Research journal.Research and nursing science devel-    nursing science is relatively young;however,we have
             opment have been at the forefront of Korean nurses’     made great strides and should be proud of these
             mission. This paper provides broad examples of          accomplishments.
             what nurse scientists have accomplished as well as         In the early years of nursing science development,
             some thoughts regarding priorities for future scien-    the conduct of research was viewed as a prerequisite
             tific efforts. Both in Korea and the United States      to full consideration as a profession.As Marge Batey
             (U.S.),nursing science as a discipline has retained an  (1968) noted in the Preface of the first volume of
             emphasis on methodological precision, while apply-      Communicating Nursing Research,“As nursing gropes
             ing  that rigor to increasingly complex issues of       for its maturity, it is coming to recognize its respon-
             patient health. Our science has progressed from         sibility as a profession to search for and to build a
             early papers and conferences focused on how to do       broader and a sounder knowledge base for its pro-
             research to substantive knowledge development in        fessional practice.” No longer should nurses be seen
             key research areas of health promotion,disease pre-     as only the focus or subjects of study from an anthro-
             vention,clinical therapeutics,family and community      pological or sociological perspective, but should be
              *Correspondence to:Margaret M. Heitkemper, PhD, RN, FAAN,Department of Biobehavioral Nursing and Health Systems,
              School of Nursing, Box 357266, 1959 NE Pacific Street, T601, University of Washington, Seattle, WA 98195, USA.
              E-mail: heit@u.washington.edu
               4                                                       Asian Nursing Research ❖ June 2007 ❖ Vol 1 ❖ No 1
                                                       The Past and Future of Nursing Research 
               seen as scientists conceiving and conducting the stud-           While genetic information may help guide deci-
               ies needed to inform professional nursing practice.          sion-making,it also brings with it ethical issues related
               In 2003,Donaldson urged nurse researchers to con-            to confidentiality as well as the impact of disclosure
               sider issues of professionalism or the elevation of the      of genetic risk in cases where there is no cure (Lea,
               status of nursing secondary to the development of            Williams, & Donahue, 2005). Schutte and Holston
               science related to health. She wrote, “...in deciding        (2006) wrote that we need to consider how ethnicity,
               future directions for nursing research and science, it       culture, and health literacy influence the utility and
               better fits nursing’s societal mandate to have as the        desirability of genetics information and technology.
               highest priority understanding and improving the             Nurse scientists and nurse ethicists are providing
               health status of those whom we serve.”                       critical guidance as we move forward in our under-
                  Based on the U.S. National Institutes of Health           standing of genetic vulnerabilities (Frazier, Meninger,
               roadmap initiatives,I have attempted to reflect in this      Lea,& Boerwinkle,2004).
               paper the contributions of nursing science to predic-            Increasingly, our attention must be given to the
               tive, preemptive, personalized (or patient-centered),        issues of mental health disorders because of their link
               and participatory health care.                               to physical health and quality of life. In 2006, the
                                                                            U.S. National Institutes of Mental Health Director
                                                                            Thomas Insel noted,“After six decades of progress,
               PREDICTIVE                                                   mental disorders remain unacceptably common,
                                                                            causing more disability in people under age 45 than
               Over the past two decades,we have seen a dramatic            any other class of non-communicable medical illness.”
               increase in the inclusion of genetic markers into nurs-      Basic science can provide information on genetic sus-
               ing research studies. Understanding disease risk and         ceptibility to such disorders,neuroscience can inform
               vulnerability through genetic markers may be keys            us about neuroanatomical alterations linked with
               not only to predicting disease development but also          mental disorders,and neuroimaging can provide ear-
               to predicting who might benefit from a particular            lier diagnosis. However, research is critically needed
               therapeutic strategy. The sequencing of the human            to examine environmental influences particularly
               genome has taken us from understanding single gene           during early development, behavioral risk factors,
               disorders (e.g., Huntington’s disease, cystic fibrosis)      compliance with therapy, behavioral therapies, and
               to having the basic knowledge to examine more com-           family support.Because of nurse scientists’ expertise
               plex, multifactorial (multiple gene) disorders such          in both qualitative and quantitative measurements
               as heart disease, diabetes, pancreatic cancer, and           as well as behavioral therapy, we are well poised to
               alcohol abuse. As an example, in our laboratory we           contribute to this research agenda.
               have examined alleles of the serotonin reuptake trans-           Research regarding stress and depression and anx-
               porter protein as an approach to understanding the           iety suggests that stress may serve as a trigger of not
               link between depression and symptom experiences              only physiological responses but also of mental illness
               in women with functional bowel complaints (Jarrett           in genetically susceptible individuals. For example,
               et al., in press). Such results are intriguing and may set   exposure to stress during critical periods of develop-
               the stage for selecting tailored or personalized ther-       ment may lead to subsequent mental health problems
               apeutic options for patients based on their genetic          later in adolescence or adulthood. Stress and post-
               profile. In future, we may be using genetic markers          traumatic stress disorder are linked to a number of
               with critical care patients to determine therapeutic         functional disorders such as irritable bowel syndrome,
               strategies for those patients with acute respiratory         fibromyalgia, insomnia, migraine headaches, chronic
               distress syndrome or multiorgan failure. The next            fatigue syndrome, interstitial cystitis, and chronic
               step will be proteomics as we examine not only the           pelvic pain. Stress and depression are also linked to
               genetic susceptibility but the expression of genes.          heart disease as well as other medical disorders.
               Asian Nursing Research ❖ June 2007 ❖ Vol 1 ❖ No 1                                                                   5
                                                                M.M.Heitkemper
              One example from the Korean nursing community is               The last 25 years has shown us the impact of
              the work of Son (2007) who described a positive rela-       globalization on health, particularly in the area of
              tionship between hostility and serum homocysteine           infectious disease. HIV, hepatitis, tuberculosis, bird
              levels in patients with coronary artery disease.We are      flu, and SARS are but a few examples of infections
              challenged to consider “what is the physiologic link        that spread across geographic boundaries. At the
              between stress and physical ailments?” and “what is         public health level, there are monthly alerts about
              the interaction among stress, genetic predisposition,       the potential for devastation due to avian flu. Clini-
              personality, gender, culture, and environmental influ-      cians within our health care institutions are very
              ences and disease expression and outcomes?”                 concerned about methicillin-resistant Staphylococ-
                 Understanding genetic risks and disease prediction       cus aureus, vancomycin-resistant Enterococcus,and
              will increase the average lifespan as well as enhance       Clostridium difficile, which are pervasive and pose
              the quality of life of individuals living longer. An        grave risks for vulnerable clients.The work of Elaine
              examination of the demographic trends from Korea            Larson (Kretzer & Larson, 1998) has informed us
              and the U.S.as well as other industrialized countries       about the challenges of instituting and maintaining
              makes it evident that the percentage of individuals         routine procedures such as hand-washing and the use
              over the age of 65 is rapidly increasing. This antici-      of antimicrobial products.Several investigators have
              pated increase in the number of older adults makes          examined the impact of routine nursing practices
              it imperative that there is greater understanding of        (e.g., catheter care) on infections in hospitalized
              how to improve the quality of life of older individuals.    patients. Recent work has demonstrated that moni-
              For example, efforts are needed to reduce disability        toring systems can reduce the incidence of catheter-
              due to chronic illness,test health promotion strategies     related infections (Saint, Kaufman, Thompson,
              to reduce chronic illness, and develop strategies to        Rogers,& Chenoweth,2005).However,much work
              reduce caregiver strain. Nurse researchers have made        remains to be done in terms of preventing ventilator-
              profound contributions to the understanding of aging        associated pneumonia and C. difficile. Even less is
              in a number of important areas including the clinical       known about the long-term sequelae of these infec-
              management of dementia,urinary incontinence,heart           tions acquired in acute care settings.
              failure, as well as coronary artery disease and stroke         At the individual level,we have challenges related
              prevention.Centers of excellence focused on research        to identification and treatment of chronic infectious
              and education related to aging are needed.It is essen-      disorders including HIV,hepatitis B virus (HBV),and
              tial that these centers be collaborative and interdis-      hepatitis C virus (HCV).At this time,it is estimated
              ciplinary. Interventions to reduce caregiver stress         that 10% of the Korean population is chronically
              have been developed and tested but await broader            infected with HBV;1.25 million Americans are chron-
              implementation.                                             ically infected with HBV—the majority of whom
                                                                          are of Asian descent (Hepatitis B Foundation,2007).
                                                                          At the same time,4.1 million (1.6%) Americans have
              PREEMPTIVE                                                  been infected with HCV, of whom 3.2 million are
                                                                          chronically infected.With drug therapy seroconver-
              Preemptive therapies are those directed at a time           sion rates less than ideal, liver transplantation is
              before the symptoms and damage occur such as in the         increasingly used. Enhancing self care and ultimately
              case of osteoporosis, heart disease, and type 2 diabetes.   quality of life for these vulnerable individuals remain
              We now realize that many diseases such as osteoporo-        a high priority. We are beginning to understand the
              sis and cardiovascular disease seen in adults actually      linkages between infections and other disorders
              have their origins in childhood.As such,interventions       include gastric cancer, cervical cancer, hepatocellular
              directed earlier may avert or postpone problems             cancer, and autoimmune disorders. Vaccines when
              later in life.                                              available have substantially reduced the risk of
                6                                                           Asian Nursing Research ❖ June 2007 ❖ Vol 1 ❖ No 1
                                                    The Past and Future of Nursing Research 
              chronic HBV. Longitudinal studies are needed to           the number of bariatric procedures is rapidly rising as
              determine the impact of vaccination on the rates of       well (Lee & Wang, 2004). While nurse researchers
              HBV-associated hepatocellular cancer. However,            have been engaged in obesity research at a number
              access to vaccines is not universal.                      of levels including genetic predisposition, metabolic
                 While basic scientists rush to develop vaccines        syndrome,and exercise adherence,even greater atten-
              and better antibiotics, there is still the challenge of   tion is warranted. The results of studies need to be
              developing safe interventions to enhance prevention       disseminated and used to form the basis for public
              and compliance. Investigators remain concerned            policy changes such as mandatory physical exercise
              about disparate health literacy levels among our pop-     in grade schools, healthy food choices in vending
              ulations and its impact on health promotion as well       machines,foods in school cafeterias,and health pro-
              as self management.For example,the recently devel-        motion activities in the work place.
              oped human papillomavirus vaccine will necessitate
              understanding of how persons from a variety of
              sociocultural backgrounds make decisions related to       PERSONALIZED
              prevention and health behaviors.
                 Prevention infers changes in health-related behav-     Given the growing database related to genetic predis-
              iors. Nurse scientists have explored strategies to        position,disease pathogenesis and behavioral factors
              enhance smoking cessation,reduce alcohol consump-         that predict successful outcomes,individualized inter-
              tion, and increase weight loss as important routes to     ventions can now be designed and tested. One area
              decreasing disability. Globalization has made obe-        for which tested interventions are clearly lacking is end
              sity a growing worldwide problem in industrialized        of life (EOL) care. The bulk of the science to date
              nations. Recently, while in Seoul, Korea, I noted 3       is derived from patients in the last stages of cancer.
              Starbucks, 3 Dunkin Donuts, 1 Krispy Kreme, 1             Despite the substantial number of deaths due to car-
              Burger King, 1 MacDonalds, and 3 Outback Steak-           diovascular, respiratory, and neurological disorders
              houses within walking distance from my hotel.The          and injuries,there is a dearth of data-based literature
              associated increased risk of cancer, arthritis, sleep     available to guide EOL practice for patient groups.In
              disturbances, diabetes and its complications, and         December 2004,the U.S.National Institutes of Health
              cardiovascular disease have resulted in concerns about    convened a conference to review the scientific evi-
              the overall negative impact of obesity on the average     dence related to EOL care.This state-of-the-science
              lifespan.                                                 conference brought together researchers from a vari-
                 The rising rates of obesity, metabolic syndrome,       ety of disciplines (nursing,medicine,social work,psy-
              and type 2 diabetes are multi-component problems.         chology,public health).Nurse investigators presented
              Decreasing levels of physical activity beginning early    on diverse topics including EOL care for pediatric
              in life and increasing access to high fat foods con-      patients, family support during palliative and EOL
              tribute to expanding waistlines of many individuals       care, symptom management, and interprofessional
              living in industrialized countries. From a women’s        communication challenges.Research priorities were
              health perspective, there are vulnerable periods          identified including strategies to enhance communi-
              (puberty,pregnancy,menopause) when weight gain is         cation among patients, family members, and health
              more likely. There are clear gender-related differences   care professionals,symptom management,and care-
              in where weight is gained as well as the metabolic        giver burden.
              consequences of that gain.At the same time,there are          By the 1990s, chronic disease had superseded
              discouraging data about the efficacy of diet therapy      communicable diseases as the leading cause of death
              and exercise adherence. In the U.S., the number of        in all parts of the world except sub-Saharan Africa
              bariatric procedures has increased from 11,111/year       and the Middle East.In all likelihood,chronic diseases
              in 1996–1998 to 106,242/year in 2002–2004.In Asia,        will be the predominant global source of morbidity,
              Asian Nursing Research ❖ June 2007 ❖ Vol 1 ❖ No 1                                                             7