Nursing Diagnosis

jean jenkins:we will now start recording the webinar. welcome to our final webinar in this series,which has been focused on the articles published in the special issue on genomics in the marchjournal of nursing scholarship. all webinars are archived and will be made available onthe site at genome.gov, along with speaker slides. today's topic, "a blueprint for genomic nursingscience," is presented by, next slide, please, kathy -- myself, dr. jean jenkins, dr. kathleencalzone, dr. alexis bakos, and dr. ann cashion. i will give you a brief synopsis of our informationso you know who you're hearing from today. as i mentioned, i'm dr. jean jenkins. i'mthe clinical advisor of the genomic health

care branch, division of communication policyand education, at the national human genome research institute, nih. i received my degreesfrom the university of maryland, catholic university of america, and a ph.d. from georgemason university. i've been active in providing leadership in the development of revisionof competencies, both at the national coalition for health care professional education andgenetics, or nchpeg, and building on these efforts with dr. kathy calzone, coordinatedthe development and consensus of essential nursing competencies and curricular guidelinesfor genetics and genomics, and have also been instrumental in the g2c2 site, and the web-basedcase scenarios site with dr. calzone, or g3c. dr. kathy calzone is a senior nurse specialist,research in the genetics branch of the center

for cancer research at the national cancerinstitute. she is credentialed in genetics by the genetic nursing credentialing commission,and is a fellow of the american academy of nursing. dr. calzone is past president ofthe international society of nurses in genetics. dr. alexis bakos is the acting director ofthe division of nursing within the bureau of health professions at the health resourceand service administration of hrsa. prior to this appointment at hrsa, dr. bakos servedas chief of the diversity training branch within the center to reduce cancer healthdisparities at the national cancer institute. dr. bakos also served as the program directorat the national institute of nursing research, nih, and she has chaired the nih-wide endof life scientific interest group. she received

her b.s.n. and m.s.n. from catholic universityand school of nursing in washington, d.c., an n.p.h. with a concentration in epidemiologyfrom george washington university, and a ph.d. in nursing from johns hopkins. dr. cashion is the acting scientific directorof ninr's division of intramural research. and before coming to nih, dr. cashion heldthe position of professor and chair of the department of acute and chronic care in thecollege of nursing, university of tennessee health science center, memphis, tennessee,where she held a faculty position since 2000. her previously funded research and clinicalinterests target genetic, genomic, and environmental components associated with outcomes of organtransplantation. and in her most recent nih-funded

study, she combined emerging technologiesof microarrays and behavioral questionnaires to investigate gene-environment interactionsleading to obesity, and recipients of kidney transplantation during the first year aftertransplant. welcome, to each of these speakers. we arevery pleased to have them. they are the coauthors, along with others, on this "blueprint forgenomic nursing science" paper. next slide, please. today's webinar includes information aboutthe purpose, the methods to establish, and the focus of the blueprint, as well as considerationof next steps. this blueprint targets research to build the evidence base to inform integrationof genomics into nursing practice and regulation.

next slide, please. funding for this effort was provided by severalintramural programs of the national institutes of health, including the national cancer institute,the national human genome research institute, and the national institute of nursing research.next slide, please. so why is this blueprint so important? well,as many of you are aware, genomic developments are changing health care, and because nursingis a fundamental provider of health care, genomics is also changing the profession ofnursing. discoveries such as the mapping of the human genome and the illumination of genomicvariations associated with health, disease, and management options are now being translatedinto practice because of a lot of your efforts

and work. all aspects of the health care continuum areimplements by genomic developments. and as such, the use of genomic information and technologyis no longer dependent on referral to genetic specialists, but rather has translated intonon-specialty health care delivery. clinical applications begin at the beginningof life and across the entire health care continuum and our continuum of life. for example,preconception or prenatal period, newborn screening, risk identification both in adolescentsand young adults, screening and diagnosis of disease, disease characterization, lookingat prognosis, and either genetic markers that may indicate what individualized therapy wouldbe best served to be provided to the patient

and improve health outcomes. even management at the end of life incorporatesgenomic information. for example, in pain control, some individuals respond better becauseof a genetic contribution to their pain pharmacogenomic dynamics, and will respond better to treatmentbased on their genetic makeup. and even after end of life, individuals may have informationthat needs to be passed down to the family in regards to why they were at risk for diseasethat perhaps ended their life. so as you can see, nurses must be competent in genomicsto provide safe, cost-effective, and quality health care, both for today and for tomorrow.next slide, please. i would like to give you some background informationof this genetic/genomic nursing competency

initiative, or ggnci. if you'd like to readadditional information, there is a publication from 2011 that dr. calzone and i contributedto in the annual review of nursing research. in 2004, the national human genome researchinstitute and the national cancer institute collaborated to establish the u.s. genetic/genomicnursing competency initiative. and as you can see from this timeline, which is alsotaken from that 2011 paper, a lot of this work began all the way back in 1995. but whati wanted to highlight for you along this extensive timeline is a meeting that was held in 2006.so if you look at the arrow on the timeline, this indicates a meeting that was held. inan attempt to address this competency gaps that were identified within the nursing profession,ggnci convened a meeting of key stakeholders

to establish a genetic and genomic nursingcompetency strategic implementation plan. recommendations from this meeting includedcoordinating strategic plan activities around three priority areas: practicing nurses, academics,and regulation and quality control. the recommendations also identified the need for an infrastructureto coordinate strategic plan activities. next slide, please. one of the outcomes of this ggnci effort wasthe identification of the need for what would be competency indicators that were essentialfor all genetic and genomic nursing. we worked with a group, an advisory group, to definethe essential genetics and genomic competencies for all nurses, regardless of level of academicpreparation, practice setting, or specialty.

and to date, these competencies have beenendorsed by 50 nursing organizations. the second addition incorporated outcome indicatorsin response to academic faculty that were requesting specific areas of knowledge andclinical performance indicators that would be a value to teach in the curriculum andacademic settings. additionally, since then, as indicated in the next slide, there havebeen essential genetic and genomic competencies for nurses with graduate degrees developed.and these also define essential genetic and genomic competencies for all graduate nurses,regardless level of academic preparation, practice setting, or specialty. and they,too, were established by a process of consensus. another goal of the ggnci was to determinethe gaps in the evidence. now that we had

competency identified, what was the evidenceof genomic nursing science, and chart the path towards filling the gaps through a nursingscience blueprint. to achieve this, a genomic nursing state of the science advisory panelwas established. next slide, please. the significance of moving forward with agenomic nursing science initiative was to be able to provide the evidence specific tooutcomes of genomically-competent nursing practice, and the impact on the public healthbecause this was extremely limited, as far as we were aware, if not entirely absent.so we wanted to be able to document whether or not our perception of that gap was accurate.the paucity of outcome data was also thought to be hindering efforts to incorporate genomicsinto curricular, licensure, academic, and

health care organization accreditation. and just a side note, no one health care disciplineis at the forefront in the assessment of this evidence, and that was also recognized throughour work with interdisciplinary colleagues, realizing that evidence was something thatall of us were wanting to have but was not yet available. nurses are one of the primary health professionson the leading edge in the integration of genomics. and therefore the outcomes of thisinitiative can be used as a model to advance similar efforts to establish a research outcomeagenda across other health care disciplines. so let me give you a little background ofthe genomic nursing state of the science initiative.

next slide. the aims identified were to establish a blueprintfor genomic nursing science that can be used to focus research efforts to fill identifiedevidence gaps, and therefore provide an established blueprint through the analysis of the evidence,expert evaluation of the current state of the science, and public comment. next slide,please. and now i will turn this speaking opportunityover to dr. calzone. kathleen calzone:so the next thing we're going to talk about is the methods to achieve these aims to actuallyestablish the blueprint. and so the very first step is -- jeanie already mentioned -- wasthat we did convene a panel that we titled

the state of the science advisory panel. wealso did evidence reviews. we had meetings both by webinar, similar to what we're havingtoday but with our state of the science advisory panel in attendance, as well as in-personmeetings, followed by public comment. so let me walk through this for you so thatyou have an understanding. the two coordinators of the panel were both dr. jenkins and myself,as well as 14 invited members. and members were selected based on their expertise ingenomics or their expertise in nursing research, expertise in nursing workforce issues, peoplewho had expertise in system change, health services measurement, and evidence-based synthesis.by no means did we have people who fulfilled all of these criteria, so our invited membersfulfilled one or more of these specific kinds

of expertise. we also had invited members that were representativeof the practice environment and the academic environment, underrepresented populations,interdisciplinary groups, and a variety of federal agencies, including hrsa, and multipleinstitutes in the national institute of health, including the national institute of nursingresearch, in particular. this is the list of the panel members. andyou have the top four people of our members represented, speaking to you today. and thenthe remainder of the members are listed here for your information. and this is a picture of the initial in-personmeeting of our advisory panel and does not

have the entire complement included, but givesyou a flavor of the spectrum of people who were present at our particular meeting. so the evidence reviews; we took two approachesto this. and the first was a systematic evidence review, and then the second was actually lookingat the report mechanism for ninr and other nursing-specific research. i'll go back and just comment that our systematicevidence review was really focused on practice-based evidence, and so that particular evidencereview was somewhat limited in that it focused on whether or not there was evidence thatnurses who were competent in genetics and genomics made a difference in health outcomes,whereas the report mechanism looking for active

research was really focused more on what nurseswere doing in research that incorporated genetic and genomic concepts and sciences. so we had two webinars, as i mentioned. thefirst webinar was really to get people sort of understanding what the purpose of thisinitiative was, who were the other panel members that they'd be working with as they pursuedthis initiative, to overview what exactly we were going to try to achieve as an outcomeof this particular effort, and the strategies that we were going to use to achieve thatoutcome, and then what work had already been done to date. as i think jeanie mentioned,way back at our strategic implementation planning meeting in 2006, was when this idea presenteditself, and we continued to hold meetings,

and planning, and seek funding for this. andso there was quite a bit of work that had been done, including some of the evidencereviews by the time we actually convened our panel to actually begin work. the second webinar was to actually hear fromkey stakeholders. so in addition to our panel members, we probably needed to have some perspectivefrom key stakeholders that extended beyond the panel itself. and those included peoplefrom the nursing leadership, the consumer perspective, and the medical perspective.and by "medical," i mean the physician perspective of all of this kind of evidence and researchwork. we did review, in the second webinar, findingsfrom the systematic evidence review, and provided

people with the actual written overview ofthat review. and if you go to the jns manuscript, you can access that systematic evidence reviewas supplemental material in its final form. and then we had a long discussion with thepanel in regards to what additional preparatory materials they felt that they would need beforethe convened in person to actually do the bulk of the work associated with this effort. our first in-person meeting was held in juneof last year, and there were six key things that we really discussed. and the first wassort of models for establishing the research agenda, an overview of the actual evidencegaps, the scope of the research that would be -- needed to be addressed to cover theevidence gaps, to identify within that scope

of research what would be the key priorities,and then address specific research directions and funding considerations. after that particular -- after that particularmeeting and the draft of the research agenda, we sent the research out for a public commentperiod. and that public comment period is -- was in that intervening period betweenthe june 8th meeting and our second in-person meeting on september 20th. that particularmeeting, which was actually sponsored by the national institute of nursing research, wehad an opportunity to have a keynote address by dr. grady, who's the director of ninr.and we spent the bulk of the meeting, really, reviewing the details of the public comments;making revisions to the blueprint itself,

based on those public comments; planning forthe manuscript associated with the outcome of all of this work; and then the preliminarydiscussions of next steps, because just having the blueprint is not sufficient, and we reallyneed to then think about how to move that forward. if you are interested in seeing the publiccomments, which people had the opportunity to either comment in person and say who theywere; they could have very long comments or short comments. or they could put up theircomments and submit them anonymously. those are all still available for viewing, and you'rewelcome to go to the genome.gov website listed here. and this will be on the slides thatyou can access to actually see the comments

that people submitted, all of which we thoughtwere very thoughtful and very helpful in strengthening the blueprint to move it forward. so what does the blueprint actually beginto look like? basically, there were a number of things that the advisory panel concluded.and the first was that the focus of the research needed to produce clinically-relevant evidence that was along the translation sciencecontinuum, and that we needed to use multiple methodologies, multiple measurements thatbuild on existing work. most importantly was to frame the blueprintsso that it aligned with the national institute of nursing research strategic plan areas.and then we made some major sort of concept definitions, and the panel agreed that theclient should be consistent with the definition

that is in all of the competency documentsthat dr. jenkins already reviewed with you, which is the broadest possible definition.so the clients constitutes persons, families, communities, and/or populations. the other thing was that there should be twomajor research areas: focus on the client, and focus on the context in which health careis delivered, and that there were some cross-cutting themes that went across all of the blueprintrecommendations. so the focus on the context versus the clientis actually important because this is one area of research where we need to really focuson capacity building. we have to have increased capacity for nursing scientists, nursing faculty,for students as well, and perhaps most importantly,

the practicing nurse, regardless of what theirrole is, or their clinical specialty or their level of academic preparation. and there are a lot of environmental influencesin the context, all of which plays a role in all of the science that is recommended,and that includes health disparities, cost, some policy implications, and the public education,and that we need to have this evidence to guide practice. so at this point, i will turn this over forthis discussion on the focus on the context versus the client, with this beginning partof focus on the context being delivered by dr. bakos.

alexis bakos:so thank you. so, as kathy stated [spelled phonetically], we will now focus on the contextin which health care is delivered. and this first contextual category is technology development,which involves incorporating new technologies, applications, and the policy and guidelinesto support the applications, as well as ethical considerations of technological development. technology development also encompasses genomicbioinformatics, as well as translation, dissemination, and implementation of information. the useof genomic information and technology is no longer dependent on referral to a geneticsspecialist that has transitioned into non-specialty health care delivery.

we need to be cognizant of the use of technologyand information delivery, provider performance improvement, as well as resources that supportgenomic research, such as best practices and nursing outcomes. next slide, please. informatics support systems and environmentalinfluences are additional contextual categories to consider. nurses should be poised to becomethe point-of-care decision support for clients, help facilitate cross-generational sharingof genomic data, and assist in the management, analysis, and interpretation of genomic information.nursing should help broker common formats for data storage and use to facilitate researchprocesses and outcomes, as well as standardize terminology and taxonomy. environmental influencescan have an important impact on the progress

needed to be made. the development of evidence based guidelines,economic factors such as nursing's impact on cost effectiveness, regulatory gaps orvariability across states, as well as the impact of the affordable care act's coverageof preventive services, such as breast cancer, genetic testing and counseling for women athigh risk, are all examples of environmental influences next slide, please. as the largest and most trusted health careprofession, nurses must be competent in genomics to provide safe, cost-effective, quality healthcare. we know that a broad segment of nurses and nursing faculty have limited genomic competency.consequently, we need to train future nursing

scientists and nursing faculty, as well aseducate advance practice nurses and research nurse coordinators in genomics. as part ofthe capacity building, we must promote innovative use of biorepositories, and advance the useof bioethics to support this growth. the full spectrum of the nursing workforce, from nursingleadership to those entering pre-licensure programs, must be trained in genomics to supportgenomic translation, research, and practice. finally, there are broader influences thatcut across almost all of the research topic areas within this rubric of contextual. andwe need to look at health disparities and its impact on ultimately achieving healthequity, as well as factors such as the disproportionate occurrence of disease in the population, andgenomic misinformation that sometimes occurs

among ethnic minority communities is importantto consider. regarding costs, it is important to address the strategic comparative of measuringthe impact of competencies on cost, quality, and outcomes of care. also, we know that researchshould inform policy and that policy becomes the context of funds so that is quite an iterativeprocess. and, finally, it's important that we focus on improving the overall health literacyof the public, and, specifically, their genomic literacy as well. i would like to now turn the presentationover to dr. ann cashion, who will discuss research focus on the client. ann cashion:thank you. we will divide the research focus

on the client into two categories. primarily,one is called health promotion and disease prevention. the second category is named "advancingthe quality of life." i'll go through the specific nursing research categories specificto those topics at this time. so when we're looking at genetics, we usually-- many nurses actually just start looking at risk assessment. a lot of nurses want tobe able to predict who will actually be at risk for certain diseases, or certain conditionsor disorders. so risk assessment is an important elementof nursing research. and we can be looking at that in terms of the biologic plausibility,which is looking at actual pathways that are involved or mechanisms that are involved.if you're -- many people [unintelligible]

about biomarkers, such as specific genes orproteins that would actually indicate someone's at risk. so those are involved in risk assessment. we also look at comprehensive screening opportunitiesthat we could use in order to determine groups of populations who would be at risk. componentsof risk assessment can also include family history. the surgeon general's family historieswebsite has been used by many nurse educators to help nursing students become familiar withthe effect family history could have on their own genetic history or their potential outcome. and we can also look at risk-specific healthcare decision-making. again, that's an issue that's becoming increasingly focused on; decision-makingis getting a lot of focus on the national

level. and nurses have been concerned abouthow individuals make decisions regarding genetic testing for many years. and they have beensome of the first to really start doing research in that area. so another category under health promotionand disease prevention is communication. again, we come back to risk communication, and that'sin terms of what do they speak with the patient about, what do they want to know about, andwhat the families should know in terms of genetics of the actual patient. informed consent is becoming an increasinglydiscussed area as we move into whole genome sequencing and our ability to actually locatespecific mutations that may not have been

part of the initial research study. and thequestion is, "how much of this information does the patient or subject want to know?and what is our responsibility as researchers to give that information?" so communicationis a large area. direct-to-consumer marketing and testing has also been studied by somenursing researchers. decision support; again, we talk about informedconsent. the match of the value to the preferences with the decisions, and that comes in, again,into discussing whether or not the subject or patient involved in the study has to betold certain information or not. risk perception and accuracy is a concern if we talk aboutclinical utility and personal utility; personal utility meaning, does it actually affect -- doesit actually -- does the individual want that

information? and clinical utility would bewhether or not the individual can use that information to make clinical decisions. nextslide, please. thank you. so advancing quality of life; thatis divided into family and symptom management on this particular slide. with family, welook at family context. and nurses are very interested in that area of research. ethicalissues: we have funded many studies in that as well. health care provider communicationwith families is another area. under symptom management, again, we have foundwhen we were developing this blueprint, that it was very difficult to put some of thesetopic areas only in one specific research category. so you will see there's a few ofthem do cross categories. so under symptom

management, you have the biologic plausibility.again, the clinical utility, person utility. pharmacogenomics is a booming area of researchwhen we try to decide if a specific mutation makes you more or less likely to respond tomedication or therapies, particularly in the cancer or oncology area. and i've already discussed decision making,and then evidence based effectiveness of approaches is something that is particularly pertinentto the clinical study at this particular time. on this slide, we look at disease states,and also client self-management. in disease states, we work enough that frequently nursesdo look at specific genetics within a disease state, whether it's diabetes, or obesity,or cystic fibrosis. so we are looking at genomic-based

interventions that can reduce morbidity andmortality in this area. gene/environment interactions: more of a molecular -- this is more on themolecular biology level. and epigenetics is certainly becoming more prominent in someof the research that's going on. pharmacogenomics; i've discussed that. andthen evidence-based effectiveness of the treatments and support. again, oncology is the leadingthe way in this, where we're actually seeing treatments based on specific genotype andfollowing -- and changing treatments based on the genotype of the tumor or the individual. under client and self-management, we lookat collecting and conveying information that informs self-management. again, we talkedabout family history, lifestyle behaviors.

certain genotypes have been associated withparticular lifestyles. and so that may become a bigger factor over -- in the future. environmental exposure and protection areoccupational areas. and the synergy of the client and the provider expectations. andthen personal utility, which i have discussed. and that's basically whether or not it's importantto the individual what their genetic make-up is. next slide, please. so our next steps. we want to further refinethe blueprint. and so ninr has been working on an initiative to potentially have a workshopin the future and look at drilling down even more in these particular areas. that is beingdiscussed at this time.

infrastructure is looking at designing, andimplementing, and evaluating the clinical and educational infrastructure to supportgenomic capacity and competency. and that involves some of what dr. bakos has discussedearlier, that there would be actually educational settings that can teach this information.we need research labs where nurse scientists have access to the technologies and equipmentin order to do this type of research. and then we also need hospitals and clinical settingsthat support nurses who are providing this type of clinical management. measurement is an issue that needs to be addressedin terms of trying to have consistent nurses and evaluation of the measures across studiesand across clinical settings. so building

this capacity is in the forefront right now.some of you may have been aware of initiatives that are called "big data initiatives." theseinitiatives have been ongoing in some other disciplines outside of health care for a numberof years, but it is extremely important in health care. based on the amount of data thatwe get from our genetic research studies, and trying to incorporate that amount of datawith clinical data, and then come up with some type of algorithm or modeling that wouldhelp us include care of our patients. so big data and database infrastructure is very importantat this point in time. and funding: funding is always usually a questionand a concern as well. we have agencies such as hrsa who's typically focused on workforcecapacity and building that. ninr and all of

nih, because many of the institutes here atnih do fund nurses, but we provide funding for genetic research. and then also foundationsare available to fun this type of research, whether it's the robert wood johnson, the[unintelligible] organizations such as oncology nursing society or sigma theta tau. so thereare many opportunities for funding, some small and some larger. next slide, please. so, in conclusion, genomics underlies allhealth care and is fundamental to nursing practice. nursing research in genomics willhelp establish the evidence base needed to facilitate the translation of genomics intopractice to improve health care. and the blueprint for genomic nursing science provides the initialplatform to accelerate research addressing

the critical gaps. i'll hand this back over to dr. jenkins atthis time. thank you. jean jenkins:so i now have a lawnmower going by the window, so you'll hear some background noise, i'mafraid. i will open it up for questions. there was one comment that i wanted to share withthe group, from joanna spaos [spelled phonetically], that says, "i would add one more categoryto the genetic and genomic influences across the continuum. and that is transition to adulthealth care." so thank you for that consideration. i know a couple of you said that it was hardto hear at times on the microphone, and i'm sorry. we do our best to make sure that thesound's clear. but hopefully it'll come out

clearer on the archived version, and perhapsyou can listen to that. this is just the blueprint for genomic nursingscience. as you're aware, the journal of nursing scholarship, march 2013, had the genomic specialissue. and a reminder that all the articles are open access, including this article thatwe just presented information about. if you have any questions, please submit them.and, kathy, if you can go to the last slide. just a reminder that the webinar series canbe revisited. they were presented by both nursing and medical expert authors of themanuscripts. an archived video and slides from each webinar are available at this genome.govwebsite. so i'll open it up for questions. any comments or questions? and as we wait,i'll open up all the authors from this paper

to see if there are any general comments thatany of you wish to make. kathy. kathleen calzone:
i think my only commentabout the blueprint is we think it's a very useful tool for anybody in any setting, asyou're beginning to think about nursing research and incorporating genomics, that it can providea platform for your thinking, and provides a way to begin to identify areas where thepanel of experts has identified clear gaps in the evidence. so there are lots of opportunitiesto utilize this in your thinking and how you can move forward. jean jenkins:alexis, would you like to share any last-minute

thoughts? alexis bakos:
only that i'd like to thankann for mentioning looking at broad array of possible funding opportunities that arewithin the national institutes of health, specifically ninr, but also to please lookat the funding opportunities that will be issued probably in the fall of the year -- latefall, early winter of the year from the division of nursing, from hrsa. there will -- we'vehad, in the past, funding opportunities that are focused on intra-professional educationas well as intra-professional practice. and hopefully we can weave, specifically, somegenomic areas of focus into that. but the bottom line is that those are twofunding opportunities that would be perfect

for this, and so i hope that those of youwho are participating in the webinar will, you know, go to the division of nursing website,or send me an email so that i can put you on the hrsa division of nursing listserv,and you will get that information as soon as it is released to the public. but evenif you choose not to be part of the hrsa division of nursing listserv, i want to definitelyencourage you to check back in late fall or early winter of the year for those upcomingfunding opportunities announcements. jean jenkins:thanks, alexis. there was -- ann cashion:i would like to just say -- jean jenkins:go ahead, ann.

ann cashion:yes. i was just wanting to add that nurses have been shown to be excellent interdisciplinaryleaders. and so leading a team that is conducting genetic research is definitely within thescope of what nurses are able to do. i have found that to be the case a lot of times becausewe actually have some foundational knowledge about diseases, in general. and then we areusually very good communicators and collaborators. and that can translate into an excellent teammember. to do genetic research in the health care setting, you can't be involved in justone discipline because it takes a whole team. we need a molecular biologist, you need astatistician, you need usually access to patients. so it is definitely a team science. that'sall. thank you.

jean jenkins:thank you. there was a question that i'll put to the team. "are you planning somethingsimilar with proteomics and metabolomics?" ann cashion:i'm not sure what is meant by "similar." alexis bakos:
hello, this is alexis. i wouldthink that our present opportunities that might be issued -- i'm sure would be broadenough that it would encompass something like metabolomics or proteomics. so i don't thinkthat that will probably be a problem. we can't usually get for -- i think that ifyou -- at least, like, i know in terms of -- for hrsa, that we will make it broad enoughthat i think that it should be possible for you to submit an application or response sothat they can [unintelligible].

jean jenkins:
and i think on behalf of theblueprint discussion, yes, we talked about genomics, but indeed, the other componentsof dna, metabolomics, proteomics, any kind of -omic would probably be able to be replacedwithin our recommendations and still need the research in terms of finding out if genomicnursing competency made a difference to patient outcomes using that information and care. i'd also like to read this comment. "thisblueprint and presentation has given me many ideas for my bsn completion students to pursueand thinking about topics for their research projects. thanks to all of you for your foresightand hard work. we all need blueprints to guide our work, and this has been well-planned andexecuted."

any other comments from the team or participants?can you still hear me okay? female speaker:
no, you're fading out there. jean jenkins:okay. it's a lost audio connection for a moment. i said, are there any last comments or questionsfrom the team or from the attendees? okay. we will close off the webinar a littleearly today. we appreciate everyone's close attention to the journal of nursing scholarshipseries. and we welcome any further comments from you once you have your students or othersview the webinars, and if there are any questions that come up, please feel free to email dr.kathy calzone or myself, jean jenkins, at nih.gov. we'd be happy to hear from you. thankyou.

female speaker:
thank you.