Doctor Nurse

It was her mother's pragmatism that reeled her back in and shifted her focus to a career that, while not as romantic, has led to its own rewards. "I was always interested in science, even before I went to college. I wanted to either be an oceanographer or an archaeologist," Bruner says. "But I grew up without means, and my mother was very practical, and pointed out that I get sunburned and seasick, so . . . " she pursued a nursing degree at a local college.

Now Bruner is recognized as an international leader in cancer clinical trials and oncology nursing research, and has been ranked among the top 5 percent of all National Institutes of Health (NIH)–funded investigators since 2012. Last year, Emory's Nell Hodgson Woodruff School of Nursing was ranked No. 1 in NIH funding among US nursing schools, thanks in part to Bruner's work.

Bruner is one of what she describes as a "thimbleful" of PhD-level nurse researchers who are able to secure significant funding for evidence based research in what are often seen as the "soft sciences" of patient-reported outcomes and symptom assessment. Her titles include Robert W. Woodruff Chair in the School of Nursing; professor of radiation oncology in the School of Medicine; and associate director for outcomes research at Winship Cancer Institute. In 2015, President Barack Obama appointed her as one of five new members of the National Cancer Advisory Board, and in 2016 she was elected to the National Academy of Medicine, one of the highest honors in the field of medicine.

Bruner also is a principal investigator of the National Cancer Institute (NCI)–sponsored NRG Oncology National Community Oncology Research Program (NCORP) Research Base. She is the first and only nurse to lead an NCI national cooperative group, and leads studies in cancer prevention, control, screening, post-treatment surveillance, and cancer care delivery. Her breadth of research includes the microbiome and cancer-related symptoms, patient-reported outcomes, sexual function and sexuality after cancer treatment, and comparative effectiveness of radiation therapies.

"Only 1 percent of nurses in the US hold a doctoral degree," says School of Nursing Dean Linda McCauley. "When you consider that there are three million nurses in the US, that is a tiny little number, and that is counting nursing practice doctorates and academic PhDs. Deb is pretty special."

Bruner earned a PhD in nursing research from the University of Pennsylvania in 1999, nearly twenty years into her career as a nurse. McCauley, who recruited Bruner to Emory in 2011, would love to see more young nurses follow that example— ]on a slightly faster track.

"Deb is probably one of the best mentors that I've ever witnessed, and her mentorship is critical in building the next generation of nurse scientists. She has this incredible talent of inspiring young investigators to work very quickly and very hard, and that hard work results in rewards in terms of national recognition of their research," McCauley says. "She and I share a passion for helping nursing scientists move more quickly through their development as researchers and to become successful at a much younger age. Nursing has traditionally not done that. Nurses tend to enter research careers much later than in other disciplines, and to make that culture shift and to do it effectively is no small accomplishment."

Yet many of Bruner's research interests are grounded in the experiences she had early in her career. While working as a brand-new clinical nurse on a general floor of a Pennsylvania hospital, she met a patient who would steer her toward oncology nursing. The woman was in her fifties, and she was dying of lung cancer.

"She was alert when I walked in the door. She was sitting on the edge of the bed, gasping for breath, and she said, ‘Do you hear that sound?' I said yes, and she said, ‘I know what that is, it is the death rattle, and no one will sit with me.' I was so struck with that, I sat with her," says Bruner. "I began to realize how many doctors and nurses did what they had to do and quickly got out of that room. I really spent a lot of time with her until she died."

After that, Bruner continued to spend as much time as possible with cancer patients. When the hospital opened a cancer ward, she transferred to oncology nursing and never looked back. While working full time, she earned master's degrees in nursing oncology and nursing administration, driven by the need for evidence-based validation for treatment protocols.

At that time—in the late 1970s to mid- 1980s—patient-reported evidence was not widely considered, with no consistent, quantifiable standards or guidelines for symptom reporting.

"In the 1970s, clinicians began using symptom assessments, and that translated into a quality-of-life movement in medicine. We figured out that it is not just having the symptom that matters, but how much it impinges on the quality of your life," Bruner says.

Over the years, Bruner's work has informed the NCI's adverse-event reporting system, an important tool used to grade symptom toxicities associated with chemotherapy drugs, immunotherapies, precision medicine, radiation medicine, and surgery in cancer treatment—work that has made patient-reported outcomes as important as clinical outcomes in changing practice. She recently reported at the American Society for Radiation Oncology's annual meeting on a potentially "practice-changing trial" contrasting patient-reported outcomes between two radiation treatments.

"The major question was that we had these two treatments, and one of them was cheaper and shorter," Bruner says. "If you have no difference in survival, and the patients say there is no difference in symptoms, why wouldn't you treat with the shorter, cheaper treatment, which would also be more convenient for the patient? It is the patient reports that actually count in this regard."

Understanding how treatments influence patients' lives financially and emotionally, by examining living environments and family dynamics, is an important focus of Bruner's research on cancer treatments. McCauley says research like Bruner's takes into account the realities patients face in their lives, something that is not always accounted for in clinical trials.

"What I love about nurse scientists is they take the most trusted relationship with patients, and they take that trust into research studies. As nurses, we really can see things we believe other health professionals don't ever get to see because of the level of trust patients give us. It is really exciting that nurses can study some of this and layer on this human experience," McCauley says.

Although she has long been away from clinical nursing, Bruner says her research is driven by the desire to improve the practice of oncology care and nursing as a whole.

"Most nurses go into nursing because they love people, and they realize at some point they have to make a decision whether to pursue clinical care or research. When my mentees ask me about this, I say that there are many, many nurses—in fact, most nurses—who can give good clinical care," she says. "There are less than a handful of nurses with PhDs who can teach and do research. Of those, there is a thimbleful who are funded and can do research well. So, when I try to think about the best resource I can be to the field and the profession, the best thing I can use my talent for is mentorship of a much needed research workforce in nursing."

Walter Curran, executive director of Winship Cancer Institute, has worked with Bruner for many years as a group chairman and a principal investigator of NRG Oncology. He calls her a major leader in research that examines cancer treatment outcomes from the patient perspective.

"She leads one of four national research groups and is the first researcher leading a group to come from a nursing background. It is a different perspective, and she has not been afraid to apply novel tools to that research," Curran says. "Other people have taken the patient approach, but it is also about the quality of her research, the quality of ideas, and the rigor with which it is applied."

Bruner says her career path changed direction when she understood that asa researcher, she could not only care for individual patients, she could gather and analyze evidence to improve the treatment experience and outcomes for many.

"The more research I did, the more I realized nurses needed more training in research," she says.

Bruner was working at Fox Chase Cancer Center in Philadelphia when she decided to pursue a PhD in nursing research at the University of Pennsylvania, with the encouragement of her mentor, Gerald Hanks, then chair of radiation oncology at Fox Chase. "I wish I could say I had a woman and a nurse as a mentor, but it was a male physician who just opened tremendous doors in research for me. As a good mentor does, he gave me not only advice, he gave me opportunity," Bruner says. "There are still very few women in my position. We cannot leave it just for women to mentor women. We need men to mentor women, and I credit much of my career to good mentorship."

Canhua Xiao, assistant professor at the School of Nursing, came to Emory as a postdoctoral fellow to work with Bruner, who was her PhD adviser at the University of Pennsylvania. She says Bruner was instrumental in helping her to hone her research interests, which include studying fatigue and the role of antiinflammatory signaling in patients with head and neck cancer. Bruner also has helped guide her and other nurse researchers through the complex task of securing research funding.

"It is very hard to get funded at this stage, and she has provided guidance on how, logistically, we can conduct studies in ways that attract funding," says Xiao, who, as a postdoctoral fellow under Bruner, earned a four-year NIH K99/R00 Pathway to Independence award to study the role of pro- and anti-inflammatory signaling in fatigue in head and neck cancer patients.

This year, while still completing the R00 study, Xiao became the recipient of a $1.5 million NIH/National Institute of Nursing Research R01 grant to study epigenetic mechanisms of inflammation and fatigue in head and neck cancer patients.

"Mentorship is really important for scientific development and learning the way of communicating with other scientists, how to make a team work, how to conduct the research project in a very scientifically rigorous way,"Xiao says. "These are some of the things you can't learn from a textbook or from your education. You learn them from the senior faculty."

As the first director of faculty mentoring at the School of Nursing and associate director for mentorship, education, and training at Winship, Bruner means to pass on the same kind of wisdom and guidance she was fortunate to receive.

"I would like to be one-half as good a mentor as [Hanks] was to me," she says. "I would like women to be able to say, ‘I was mentored by a woman and nurse,' and I would like physicians to be able to say they were mentored by a woman and a nurse."