What is the new research paradigm referred to as Team Science?

MULTIDISCIPLINARY TO TRANSDISCIPLINARY TEAM SCIENCE AND BEYOND

What is the new research paradigm referred to as Team Science? Since health care problems are often complex and may be difficult to understand and improve via a one investigator or single discipline approach, a team science approach is advantageous and necessary for advancing science. Different disciplines can integrate their expert knowledge in designing a research study in order to address a complex health problem so that a positive comprehensive outcome is achieved. The degree of the complexity of a given problem, the desired outcome and level of analysis drive the depth and complexity of team science. The prototypes for team science have progressed from a multidisciplinary approach to an interdisciplinary approach to the emerging paradigms that include transdisciplinary and patient-engaged teams.  

TYPES OF RESEARCH APPROACHES

In order to illustrate how team science can be conducted, the class was given a group assignment to develop a study using each one of the study designs discussed in class. The research topic involved the role of nutrition in assisting older adults with cancer to maintain their weight while undergoing chemotherapy.

Multidisciplinary Research: Knowledge that is drawn from diverse disciplines but research questions and methods stay within the distinct boundaries of each discipline. Multidisciplinary research may consist of “multiple silos" or “parallel play” research. Members of different disciplines consult with one another and at the same time contribute their independent perspectives. 

Common Assumptions: Each discipline needs to recognize the limitations of their perspective; disciplines can hold contrary assumptions about the appropriate questions to be asked or the nature of the phenomenon under investigation. Cross-disciplinary understanding may result as the team members recognize the relevance of others' findings.

Theoretical Framework & Analysis: 

Research questions are constructed from each disciplinary theoretical framework, constructs, and world view. The analysis is done independently from the perspective of each individual profession. The study is done in parallel though the research questions to be answered are independent of each other but contribute to the overall study aims.

  

Example of a Study using Multidisciplinary approach:

Aims:  The goals of this research study are to describe and explore the changes in the nutritional and functional status of older adults who are receiving chemotherapy

Methods: Mixed methods, both quantitative & qualitative descriptive study

Research Team & Area of Interest:

RN/ PI: Quantitative: gather data on physical function performance status, instrumental activities of daily living, functional status, a mini-nutritional assessment (albumin/pre-albumin), and frailty assessment pre and post chemotherapy.

Dietician: Ask for diet diary, evaluate & look through the medical record to measure weight change, determine kilocalories, micronutrients and macronutrient, dietary changes over time (i.e., diet ordered, kilocalories intake over time)

Oncologist: Measure the dose of chemo, toxicities (including nausea and vomiting), and dose or treatment delays

Geriatric anthropologist: Qualitative interviews: How being a cancer patient undergoing chemotherapy has affected the meaning of food and eating habits (including social interaction r/t food). How eating has changed during the cancer diagnosis, conducts interviews on dietary likes/dislikes, social effects.

Pharmacist: Look at drug dose, drug interactions and effects on appetite, anti-emetics that may improve appetite depending on drug interactions with specific chemotherapy protocol

Interdisciplinary Research: Analysis, synthesis and harmonizing of links between disciplines into a coordinated and coherent whole, integrative and reciprocally interactive approach that synthesizes diverse disciplinary perspectives. In interdisciplinary research two or more disciplines mutually conduct research guided by a structure that reflects a blurring of disciplinary boundaries in the integration of perspectives of each involved discipline.

Common Assumptions: Ideally suited to complex and real word problems, individually each discipline is inadequate to solve the phenomena of interest, and more importantly interdisciplinarity assumes disciplinary perspectives are partial and biased.

Theoretical Framework & Analysis: Bridge epistemologic gaps between disciplines and building on theories posited by all disciplines involved.

Example of a Study Using an Interdisciplinary Approach: 

Aims:  An interdisciplinary approach to maintaining healthy weight in the elderly patient experiencing chemotherapy

Key disciplines: Nursing, Pharmacy, Dietitian, Behavioral Health Specialists, Physician

Methods: Qualitative with interviews with caregivers; Baseline data on patients

Insights and lived experience with regard to this patient problem from caregivers perspective.  The questions will be crafted by a nutritionist, nurse, social worker, and medical oncologist.  Each question will ensure integration among the disciplines.

Transdisciplinary Research: Integration of natural, social and health sciences, holistic approach, creates a common conceptual-theoretical-empirical structure for research.  There are no boundaries between disciplines; in fact it may result in a new integrated discipline such as neuroscience.

Common Assumptions: Disciplinary boundaries must be dissolved in order to develop novel methodologies, traverses all disciplines, concepts are transdisciplinary in nature, and the knowledge in between disciplines is as important as those within the disciplines.

Theoretical Framework and Analysis: One theoretical framework is developed which crosses all disciplines. The Socio-ecological Framework provides one model for the transdisciplinary approach

Example of a Study using a Transdisciplinary Approach:

Research Question: How can older adults undergoing chemotherapy maintain weight through nutrition?

Team: Aging Services, City planning, Geriatric Oncologist, Nutritionist, Gerontologist, Dentist, Oncology nurse scientist, Geographer

Factors: taste changes, nausea, mucositis, lack of energy to prepare meals, lack of support system, lack of availability of food, lack of accessibility to food sources, e.g. transportation

Research Design: Descriptive study on how these factors affect older adults' nutrition & weight

Methods One model would be created but each discipline might contribute as follows:

·         Geography- GIS mapping

·         Aging services & city planning- explore existing resources and what are lacking (gap analysis)

·         Dentist- Assessment tool to assess oral health

·         Nutritionist- history, biomarkers, monitoring intake, weight

·         Geriatric oncologist & nurse scientist- type of chemo, clinical factors, antiemetic intervention efficacy

Patient Engaged Research: focuses on patient and family engagement in research to help inform the research questions, study design, and interpretation of results.

Common Assumptions: The whole patient needs to be considered, the patient/family/community all contribute to research, the patient is representative of the community as a whole.

Theoretical Framework and Analysis:  Patient engagement is conceptualized to include self-awareness, clinical alliance, tool for health self-management, citizen empowerment and effective disease self-management. Reference:  http://www.jopm.org/evidence/reviews/2014/06/11/the-challenges-of-conceptualizing-patient-engagement-in-health-care-a-lexicographic-literature-review/

Example of a Study Using Patient-engaged Research Approach:

Research Title: Using technology to delivery personalized meal plans for the older adults who receiving chemotherapy

Rationale: Even though older adults may have technology challenges, there is study reporting that old people are willing to use technology to get personalized care. Remote technology has interactive features that will allow older adults to have timely information regarding their care plan meanwhile reduced travelling and caregiver burden. 

Aims:  Engage patients, families or caregivers in the research design and implementation –One example is to conduct focus groups but this is a low level of engagement. A better approach is

to build partnerships with medical and non- medical stakeholders in the research design and implementation. One focus might be to describe the barriers to, facilitators of smartphone use as an approach to engage patient and family or caregivers in the personalized meal plan in older adults who receiving chemotherapy

Methods: Mixed Methods: two stage 

·         Focus group with older adults receiving chemotherapy to determine what current nutritional interventions they are doing and identify unique dietary needs of this population. Additionally the focus group will be asked regarding their use of technology (internet, smart phones, and tablets).

·         After needs are identified, an intervention study will be designed by all members of the research team including nutritionist, case management nurse, social worker, medical oncologist, as well as members of the focus group. 

What is noteworthy about the examples is the team members may be the same but how they work together as team scientists is quite different!

CHALLENGES OF THE NEW PARADIGM

Conflict, controversy, tension between the paradigms 

Beside group dynamic challenges can occur when working with researchers that hale from several different disciplines. There are some other potential conflicts that can arise when team science evolves to an interdisciplinary, transdisciplinary or patient-engaged approach. Historically infrastructure and incentives in academia have rewarded “independent investigator-initiated” research. Conflicts can arise from ambiguity among the disciplines related to integrated research approaches; unclear expectations and norms; differences in language and terms used to describe similar phenomena; engaging with unfamiliar would-be competitors in an unsupportive environment; confusion in identity for securing grants and sharing funds ;and  the devaluation of multi-authorship publications toward tenure. . 

Barriers to adoption of new models

A patient-engaged research approach requires patient involvement which is becoming paramount to conducting health care research; however there can be barriers to sustaining such research. Currently there is funding and incentives for patient-engaged projects; however there is a concern about how such research can be sustainable once the funding and incentives expire. There can also be disagreements between academia, private industry, and consumers in identifying which projects should be funded as a priority in improving our nation’s health. Other potential barriers pertain to proprietary rights to research innovation. In order to conduct rigorous and ethical transdisciplinary or patient-engaged research, a good infrastructure and shared norms need to be in place. Training and practices that incorporate ethical principles, group cohesiveness strategies and a commitment to learning from mistakes is essential. 

POTENTIAL IMPACT 

The potential impact of research conducted within the new transdisciplinary paradigm can be significant. Each different discipline brings a diversity of research methods based on theoretical frameworks in which to generate hypothesis that would not be possible via an interdisciplinary approach. Levels of analysis between disciplines can be bridged to bring about conceptual theories that are utilized to improve health interventions. Involving patients as stakeholders in research can have an effect on designing interventions that are practical and acceptable, eliminate health disparities, decrease gaps in knowledge and promote the efficient use of health care resources.

FUTURE DIRECTIONS AND QUESTIONS

The new paradigm of team science that includes transdisciplinary and patient-engaged research is still evolving.  The Affordable Care Act of 2010 established the Patient-Centered Outcomes Research Institute (PCORI) in order for health care research efforts to be truly patient driven and focused. PCORI research can be conducted via a transdisciplinary approach as it encompasses many different stakeholders from many different disciplines with the same goal: to improve the health of the Nation. Future directions of team science should include research that focuses on preventing disease, improving health care systems, disseminating and implementing research into practice and decreasing health disparities. There is no doubt that mistakes and new questions will arise as research is conducted in the new paradigm; however a key component to success is prompt identification and resolution of such concerns and never losing sight of the intended goal of the research.

RECOMMENDED READINGS OR LINKS FOR MORE INFORMATION

Relevant Readings

ü  Fawcett. Thoughts about multidisciplinary research found @ http://www.ncbi.nlm.nih.gov/pubmed/24085679

ü  Hall. Feng. moving the science of team science found @ http://www.ncbi.nlm.nih.gov/pubmed/?term=hall+and+feng+and+moving

ü  Nash. Transdisciplinary training found @ http://www.ncbi.nlm.nih.gov/pubmed/18619393

  

ü  Interdisciplinary research in Hartford Program found @ http://www.ncbi.nlm.nih.gov/pubmed/22881481

ü  PCORI-Patient-and-Family-Engagement-Rubric found @ http://www.pcori.org/assets/2014/02/PCORI-Patient-and-Family-Engagement-Rubric

ü  pcori.agenda found @ http://www.pcori.org/assets/PCORI-National-Priorities-and-Research-Agenda-2012-05-21-FINAL1.pdf

Some Other Useful Links

http://www.teamscience.net/index.html

http://sites.nationalacademies.org/DBASSE/BBCSS/CurrentProjects/DBASSE_080231

“The Science of Team Science: Dr. Stephen Fiore”  www.youtube.com/watch?v=R1FnxSvjoh0

                                                                                                                              

Created by Participants in Nursing 7106 Context for Advancing Science (and Improving Health)

University of Utah College of Nursing PhD Program Summer 2014 

Submitted by: 

Tracy A. Ruegg MS, CNP, AOCN and Meghan Routt MSN RN GNP/ANP, AOCNP

(Lead Authors)

Analysis of Shifting Paradigms 1: National to Global (but Local)

The class collaborated in creating this first analysis using EtherPad. It was amazing how many ideas we generated in a short period of time-after being primed by some excellent reading and discussion. 

The Way Things Have Been (and still are)

The health care system in the United States has centered on improving health within its own borders with limited attention to global health. The US system is extremely expensive with a growing amount of the GNP spent on health care. In spite of the growing expenses associated with health care, the outcomes remain unacceptable when compared to other countries.  http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror?omnicid=EALERT495214&mid=mh@cmwf.org

The US system is based on a capitalist model in which individuals obtain private health insurance to cover the costs of care.  Within this predominant model, there are some large government-financed and administered programs including Medicaid (for the poor), Medicare (for those 65 and older) and the Veterans Health Administration. The predominant financial model is disease-focused, provider-centric and based on fee for service which incentivizes costly and often unnecessary diagnostic tests and treatment. The system is highly focused on the use of specialists versus effective primary care, with the majority of resources spent on treatment of disease rather than prevention. The system is plagued by waste and fragmentation which is inefficient and frustrating to care providers and recipients and costly to the nation. 

Core values that have contributed to this paradigm are entrenched in a competitive, for-profit system with individualistic values of freedom of choice and a restricted view of health. Because of the leading role of the US in advances in science and medical technology  (i.e., new drugs, treatments, technologies)  the prevailing view is that we are superior to other countries even though this belief is not supported by comparative outcomes. The top ten countries, as evidenced by life expectancy and health care costs are Hong Kong, Singapore, Japan, Israel, Spain, Italy, Australia, South Korea, Switzerland, Sweden (http://www.bloomberg.com/visual-data/best-and-worst/most-efficient-health-care-countries).This national arrogance prevents us from learning what works well in other countries and in recognizing that health is now a global issue. 

The Way Things are Becoming 

New legislation, The Affordable Care Act of 2010  http://www.hhs.gov/healthcare/rights/

is driving health care transformation in the US including insurance reform, payment reform including value based purchasing and bundled payments, population based care, health care homes, and patient/family centered care models. Many of these new models of care will increase the focus on prevention and will rely on the use of interprofessional teams to provide “health” rather than “sick” care. 

In addition, there is a growing realization that the health of the world is interconnected. Notable are the realizations that the risks for spread of infectious diseases are greater than ever. Rapid spread of diseases, such as ebola, H1N1, SARS and now MARS, provide evidence for the potential for international epidemics. Maps of international air travel support the notion that a pandemic is only one plane ride away  http://www.theguardian.com/world/ng-interactive/2014/aviation-100-years

Healthy People 2020, the US roadmap for improving the health of the population http://www.healthypeople.gov/2020/default.aspx, now contains goals related to international health-but from the perspective of how problems such as infectious diseases might affect the health of US citizens. This approach sustains a nationalistic perspective. 

The health care needs of the world population are now converging in a new way. Improvements in worldwide health, especially in prevention and treatment of communicable diseases, have led to increased longevity in the developing world and concomitant rises in non-communicable diseases including cardiovascular disease, diabetes and cancer.  Issues related to demographic shifts in population growth and the exponential growth of the elderly worldwide are integral to the rise in chronic illness. As these common diseases increase, the world demands the translation of known solutions to be put into practice and for shifting the paradigm from disease to prevention. There is also a growing recognition that effective solutions must be generated within the context of local communities. The demand to “Think Global and Act Local” is particularly salient to improving health at the community level. 

The core values needed to advance health globally will require a shift from a purely nationalistic perspective.  here is much to be learned from other countries if the US can move to a more open and collaborative framework. Other countries can teach us about controlling costs, for example by not allowing insurance providers to compete, as is done in Japan. In Hong Kong, touted the most efficient health care system on the planet with health care costing 3.8% of their GDP, most hospitals are public. A recent article in the Huffington Post provides some startling infographics regarding the more efficient health care systems across the world. http://www.huffingtonpost.com/2013/08/29/most-efficient-healthcare_n_3825477.html Ultimately a real shift in values to a more humanitarian and altruistic approach will be needed to advance the health of our planet.

Key Drivers 

The key forces that are contributing to this shift include the rapid spread of business and markets from a national to a global level. The economic conditions of the world are intertwined more than ever before. Businesses care about the health of people from other countries as these individuals are now their employees and the environments in other countries contribute to to the health of US employees who may be working there. International business models have even extended to selling health care with the growth of the “health tourism” industry in countries like Mexico and India.

The ability to communicate cheaply through enhanced computer and smart phone technology has created new international networks, businesses, and communities. For example, Skype now has surpassed two billion minutes per day http://blogs.skype.com/2013/04/03/thanks-for-making-skype-a-part-of-your-daily-lives-2-billion-minutes-a-day/. The ability to travel easily across the globe has been another major driver. In many regions (example the Eurozone), the ability to cross borders has become more flexible. Major patterns of shifting immigrant and refugee populations are diversifying the peoples within nations. Almost all countries are becoming more diverse- multi-racial/ethnic and multicultural.

The international issues about the health of our planet and predictions related to climate change are also leading to shared global initiatives to protect our environment-our agricultural lands, water and air. These factors are integral to the health of the world. 

Challenges 

The shift to a cooperative and collaborative model to improve global health remains challenging in a world marked by terrorism, war and revolution. How will unstable governments (dictatorships, theocracies, etc.) affect global health (violence, refugees, etc.)? Where will refugees go and who will be responsible for their health?  Will a pandemic, natural disaster, or the rising seas wipe out communities or countries?

Barriers to shifting to a paradigm of global health include lack of understanding across cultures, corruption, a lack of social or public trust, weariness and skepticism of governments, economic  instability and a lack of resources and infrastructure. Cultural definitions and values of health differ as well.

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Question to Consider

Global agencies, (e,g. the UN, World Red Cross and WHO) must take the lead and create international strategies to raise awareness, promote collaboration, networking, shared learning and promote effective policies. International business leaders must join forces with governmental and nongovernmental partners to address issues relate to global health. Local communities must engage and lead at the local level.

 Major questions to consider include: 

1. How do we  scale up and promote adoption of interventions that work in a way that promotes their sustainability in diverse communities? 

2. How do we create low cost and feasible solutions to some of the major barriers to advancing health? The Bill and Melinda Gates Foundation contest design effective toilets without water or electricity  is an excellent example http://www.gatesfoundation.org/media-center/press-releases/2012/08/bill-gates-names-winners-of-the-reinvent-the-toilet-challenge

3. How do we leverage technology to promote health and encourage global collaboration? 

4. How do we advance health without addressing core determinants such as poverty, lack of education, and income? 

5. How do we promote equity to all societal members by decreasing barriers to health access, and decreasing gaps in quality of care that go beyond race and socioeconomic status? 

6. How to globally collaborate with each other to solve inequity, environmental and other health issues?

7. How do we promote a value of learning from each other to improve the health of the whole? 

8. How do we identify and engage communities in identifying their health priorities? How can we collaborate to address shared priorities?

9. How do global communities respond to natural catastrophes-earthquakes, hurricanes, tsunamis?

10. How do we engage all countries in preventing the health and other consequences of climate change? 

Some additional readings and resources

Health People 2020 

 http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx

Top 20 Global Health Priorities 

http://content.time.com/time/health/article/0,8599,1687159,00.html

Ten facts on the state of global health 

http://www.who.int/features/factfiles/global_burden/facts/en/

Social Determinants of Health 

http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/

Created by Participants in Nursing 7106 Context for Advancing Science (and Improving Health)

University of Utah College of Nursing PhD Program Summer 2014 

Submitted by Dr. Susan Beck (Lead Author) 

Follow me on Twitter @Susan Larsen Beck