Asking questions and trying to find answers — that is research. The search for answers led Jamie Gilley to complete a Master of Science in Nursing (MSN) degree and a PhD. She is one of about 700 Advanced Practice Providers (APPs) — nurse practitioners (NPs) and physician assistants (PAs) — at Texas Children’s Hospital.
“Sometimes when there are things that occur and we don’t understand them fully, or there are questions or gaps in our knowledge, I try to seek clarification, said Dr. Gilley, an Advanced Practice Registered Nurse (APRN) and board-certified Neonatal Nurse Practitioner (NNP). “Or I ask a question that someone has never asked before and try to find an answer to it. With research, I want to fill that gap and try to figure out the ‘why.’”
In an academic health setting like the Department of Pediatrics, research is a team sport involving APPs, nurses, pharmacists, technologists and others, including MDs and PhDs. APPs collaborate to care for patients, contribute to research efforts and teach.
“It's important to remember that we all work together, and there are a lot of things that we can learn from each other,” said Wendy Nasser, DNP, APRN, CPNP-AC/PC. Nasser is Associate Vice Chair of Baylor APPs, an Associate Chief in the Division of Critical Care Medicine at Texas Children’s and an Associate Professor of Pediatrics at Baylor College of Medicine. ”Only when we utilize each other's knowledge and really listen to what the other person has to teach, are we successful. We’re all working toward the common goal of getting to an answer or seeing what other questions there are.”
APPs also lead broader efforts to share knowledge and improve care.
“Many APPs who are heavily clinical don't have a lot of time to do research, but they are driven by their interest,” Nasser said. “Many of them do it on their own time. They may come up with proposals for new protocols, or assist some of our fellows to complete their projects.”
Nasser’s own research has led to quality improvement (QI) in the process of weaning children from addictive medication when they no longer need it for its pain control or sedative properties. Addictive medication weaning is an international concern for hospitals.
“What draws my research interest is knowing that I don't know everything,” Nasser said. “But if I try to understand the information that is posed in front of me and ask more questions, we're going to keep moving forward.”
Cassandra Duran, DNP, RN, FNP-BC
Assistant Professor, Pediatrics
Baylor College of Medicine
Cassandra Duran grew up without health insurance or regular access to a doctor. Her father was an immigrant from Mexico. Her mother was often sick and frequently in the hospital.
“Maybe that’s why I'm so passionate about making a difference in people's lives and going the extra mile,” said Duran, DNP, RN, FNP-BC, an Assistant Professor of Pediatrics at Baylor who works with underserved and under-resourced communities via Texas Children’s mobile clinics.
Most of the clinic’s patients are newly arrived from other countries so they are all screened for tuberculosis (TB). Many of them show evidence of latent TB, meaning they are infected with the bacteria, but do not exhibit symptoms. Many newcomer families are intimidated by the size of the Texas Medical Center, where Texas Children’s Infectious Disease Clinic is located. Knowing this, Duran and a colleague partnered with the Houston Health Department to develop a Latent TB Infection program at the mobile clinic.
Duran’s prior research revealed that many high school seniors in underserved areas do not know how to prepare a meal or shop for groceries on a budget.
“They rely heavily on fast food,” Duran said. “A lot of these kids are overweight and at risk for chronic health conditions like diabetes and hypertension.”
Duran is now seeking funds to develop a cooking class to teach patients how to prepare five budget-friendly, quick, easy, healthy meals. Helping her patients and their families access needed resources for food, housing, education and health care, is fulfilling for Dr. Duran.
“I understand that our patients are also very fulfilled because on a daily basis, we receive a million thank yous,” she said.
Jessica Geer, MSN, APRN, C-PNP, CNN-NP
Instructor, Pediatrics
Baylor College of Medicine
A QI project to increase vaccination rates among children with end-stage renal (kidney) disease helped Jessica Geer, MSN, APRN, Certified-Pediatric NP and Certified Nephrology Nurse-NP, get her foot in the research door. An Assistant Professor of Pediatrics-Renal at Baylor, she was named Texas Children’s Nurse Practitioner of the Year in 2014.
Geer is involved in a research project that is impacting on the way dialysis is performed. Working with the Department of Cardiology to do echocardiograms before, during and after dialysis, the research team was able to see that dialysis caused a strain on the heart muscle.
“Even though you think kids don't have clogged arteries like adults, and they don't have other risk factors that adults may have, we found that doing dialysis put a strain on their heart,” Geer said. “The more fluid that was removed, the more change in their blood volume and the more strain on their heart. We have to be very careful with fluid removal during our dialysis procedures to make sure we're protecting all the organs, not just the kidneys.”
Geer, whose mother was a nurse, knew what her vocation would be even as early as preschool, professing, “When I grow up, I want to be a nurse." She later became one of the first two NPs in nephrology at Texas Children’s.
“I took it as a challenge to be able to work with the medical team in nephrology and show what NPs can do and what a benefit they are,” she said. “That was almost 13 years ago. We now have 10 NPs and PAs on the renal team.”
“In nephrology, we have dietitians, social workers, nurses, child life specialists and quality of life specialists,” Geer added. “APPs work very well on the team. They are great at communicating, making sure we have good follow-through with our patients and coordinating care so we can provide the best outcomes.”
Jamie Gilley, PhD, MSN, APRN, NNP-BC
Instructor, Pediatrics
Baylor College of Medicine
Congenital diaphragmatic hernia is diagnosed most often in a routine prenatal ultrasound, but predicting how serious its effects will be is far from routine.
Fetal diaphragmatic hernia occurs in utero when organs from the abdomen, such as the stomach or liver, push through a hole in the diaphragm into the chest. When infants with this congenital condition are born, some of them have pulmonary hypertension (high blood pressure in the lungs).
“We don't know why it happens, and we don't have any prenatal markers that determine how severe their pulmonary hypertension will be,” said Jamie Gilley, PhD, MSN, APRN, NNP-Board Certified in the Level IV NICU at Texas Children’s. “Unfortunately, that is probably the main contributing factor to the 25% to 30% mortality for congenital diaphragmatic hernia in the neonatal period. My research goal is bridging that gap between what you see in the laboratory and how you apply that to clinical practice to improve patient outcomes.”
The lack of progress in preventing morbidity and mortality in these infants drove Dr. Gilley to obtain her PhD. Her research suggests that with congenital diaphragmatic hernia:
Dr. Gilley has presented her research at national and international conferences.
An instructor in the Pediatric Newborn Section at Baylor and a member of Sigma Theta Tau International Honor Society of Nursing, Dr. Gilley is Co-founder and former President of an organization for nursing PhD students at The University of Texas Cizik School of Nursing at Houston. Former Chair of NNP Retention and Recruitment at Texas Children’s, she also developed a mentor program for NNPs.
Susan Kirk, MSPAS, PA-C
Assistant Professor, Pediatrics
Baylor College of Medicine
Before becoming a PA, Susan Kirk, MSPAS, PA-C, traveled with some pediatricians to Tanzania. Watching a pediatrician diagnose a patient with sickle cell disease just by drawing blood and looking at a slide under the microscope sparked her interest in hematology.
Now Assistant Professor of Pediatrics-Hematology/Oncology at Baylor, Kirk has been treating children with blood disorders for more than 15 years.
“The physicians and other APPs I worked with were so passionate,” Kirk said. “They encouraged me to think outside the box and ask questions. If something didn't make sense, they prompted me to look at the data in a methodical way.”
“I never thought I would be able to do all I've done outside of seeing patients — being able to educate other people, to not just do my own research, but also participate in international trials,” she added. “I've had so much support from my physician and APP colleagues to shoot for the moon, it's just been fantastic.”
Her favorite research projects are those she initiated and saw to completion. One project — and the subject of her first journal article — followed young children with primary autoimmune neutropenia (AIN) who presented at Texas Children’s Emergency Center with fever. In AIN, the immune system attacks white blood cells (neutrophils) that fight infection. After extensive evaluation, no bloodstream infections were identified in this project. Subsequently, a less-intensive, more cost-effective management protocol was recommended for young children with AIN.
On the first paper on which Kirk was senior author, she mentored a PA student working on research for a master’s degree. To improve her teaching and mentoring skills, Kirk participated in the Texas Children’s Health Professions Education course and, later, completed a two-year Master Teachers Fellowship at Baylor.
“You learn a lot about how adults learn, how to help people who are struggling and how to teach in different learning environments,” she said.
Mili Vakharia, APRN, FNP-C
Assistant Professor, Pediatrics
Baylor College of Medicine
An inner drive to do and learn more in life pushed Mili Vakharia, APRN, FNP-BC, to become an NP.
“As I look back at my decade as an NP, it's led to great opportunities in so many ways — whether being able to present at national and international conferences, publish articles, network with and mentor wonderful professionals across the country or serve in leadership roles. I cannot forget my patients and families because I get the most joy in giving back to them,” said Vakharia, who serves as Assistant Professor of Pediatrics-Endocrinology and Diabetes at Baylor and QI Co-Leader of the Diabetes Education Care Process Team (CPT) in the Division of Diabetes and Endocrinology at Texas Children’s.
Within the Education CPT, Vakharia collaborates with a multidisciplinary team of diabetes educators, dietitians, nurses, physicians, APPs and hospital leaders on numerous QI initiatives to improve health outcomes for patients with diabetes. Some of the projects included increasing the use of diabetes technology for youth with diabetes and creating a transition curriculum for patients transitioning from pediatric health care to adult medicine. Others focused on developing evidence-based guidelines on low glucose or ketone management.
”Leading QI work is invigorating because I often collaborate with stakeholders across the Texas Children’s system to develop and implement innovative ways to improve patient care on a larger scale,” Vakharia said.
One of her research projects examined the potential of ultra-long-acting insulin to help reduce recurring diabetic ketoacidosis (DKA), a serious, life-threatening complication in which the body produces ketones as it does not have enough insulin to allow glucose to enter cells for use as energy. Subgroup analysis showed that Hispanic patients had a decrease in DKA rates compared to their African American and non-Hispanic white counterparts. These findings were presented at the American Diabetes Association annual meeting, and an article has been accepted for publication in a peer-reviewed journal.
“I am very thankful to my mentor, Dr. Siripoom McKay, for being my guiding force as I navigated through the research process. Mentors are so valuable in any scholarly activity like research, and I am grateful for many mentors here at Baylor and beyond,” Vakharia said.
Diabetes has been personally important to Vakharia, too. Raised primarily by her grandparents, she accompanied her grandfather to doctor’s appointments when he developed diabetes.
“I lost him a few years ago to diabetes-related complications,” she said. “I know he's watching over me as I take care of children with diabetes. I know he couldn't be more proud.”
Elise Whalen, DNP, APRN, FNP-C, CPN
Instructor, Pediatrics
Baylor College of Medicine
An NP’s QI/research study has changed mental health screening for patients of Texas Children’s Pulmonary Hypertension Center.
The study was directed by Elise Whalen, DNP, APRN, FNP-BC, CPN, as part of her doctoral work at the UT Health Houston Cizik School of Nursing and Assistant Professor of Pediatrics-Pulmonary at Baylor. For about six months, the center screened all patients 12 and older for anxiety and depression. High scores on the screening instrument led to suicide prevention screens for four patients and the discovery of physical marks of self-harm for two patients.
“Screening these kids opened the door for better conversations during the clinic visits,” Whalen said. “Now we screen everybody 12 and older, who can fill out the forms on their own.”
Whalen partnered with an NP in San Francisco to screen 88 patients with pulmonary hypertension across 11 centers in the United States and Canada. They found that more than 50% of patients ages 12 years and older had anxiety and depression. Whalen presented her research at an international conference and is working on an article for publication in a professional journal.
“We’re hoping to get this out there so we can better advocate for screening practices across the board,” she said.
“Working on research projects has been phenomenal to help me explore this aspect of my career,” she added. “I'm very thankful to Baylor for helping me. With Baylor, I was able to attend a lot of workshops. Then through experience and mentorship with some of my physician and APP colleagues, I was able to learn more.”
“I've wanted to be a nurse since I was in high school, but I don't know that I ever envisioned myself being as integrally involved in research as I am,” Dr. Whalen said. “I became an NP so I could know more about the ‘why.’”