Transcript are nurses prepared to meet the care needs of the largest us patient

2nd National Health Policy & Clinical Practice Conference
Westin Savannah Golf Harbor Resort & Spa
March 31-April 2, 2016
SPONSOR APPRECIATION
ARE NURSES PREPARED TO MEET THE
CARE NEEDS OF THE LARGEST US
PATIENT POPULATION?
DR. KIM KUEBLER DNP, APRN, ANP-BC
DIRECTOR MULTIPLE CHRONIC CONDITIONS RESOURCE CENTER
Disclaimer
Director: Multiple Chronic Conditions Resource Center
www.multiplechronicconditions.org
President: Advanced Disease Concepts LLC
The American Demographics
The United States is in the midst of a major
demographic shift.
In the next four decades, people aged 65 and
older will make up the largest percentage of
the population
Board on Mathematical Sciences and Their Applications · Division on Engineering and Physical Sciences
Committee on Population · Division of Behavioral and Social Sciences and Education, 2012
The American Demographics
The ratio of people aged 65 and older to people
aged 20-64 will rise by 80% up and until 2050
Board on Mathematical Sciences and Their Applications · Division on Engineering and Physical Sciences
Committee on Population · Division of Behavioral and Social Sciences and Education, 2012
US Aging Demographics
US Aging Demographics
The US Aging Population
The oldest of the 80 million
baby boomers reached
age 65 in 2011
Living longer with increased
disability
Institute of Medicine (IOM), 2012
Medicare Beneficiaries and Multiple
Chronic Conditions (MCC)


In patients 65 years and older, three out of four have MCC.
Two out of three Medicare beneficiaries have MCC.

People with MCC are at increased risk for mortality and
poorer day-to-day functioning.

MCC account for substantial health care costs in the United
States.

Approximately 66 percent of the total health care spending
is associated with care for the over one in four Americans
with MCC.
US Department of Health & Human Services (2015).
Source: Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chart book. Baltimore, MD. 2011.
An Aging World 2015: International
Population Reports

This month, the US Department of Health and Human Services, National
Institutes of Health, National Institutes of Aging, US Census Bureau and the
US Department of Commerce, Economics and Statistics Administration
released the An Aging World 2015: International Population Reports

America is identified in this report as the American Wealthhealth Paradox,
one of the wealthiest larger countries but not the healthiest. Smoking,
obesity and hypertension contribute to the increase in female mortality
over men. American men and women living in the poorer southern states
have lower health, life expectancy than elsewhere in the US.
He, W., Goodkind, D., & Kowal, P. (2016). An Aging World 2015: International Population
Reports. US Department of Commerce
Affordable Care Act
111TH CONGRESS
The Patient Protection and
Affordable Care Act
May, 2010
2d Session
COMPILATION OF PATIENT
PROTECTION AND AFFORDABLE
CARE ACT HEALTH-RELATED
PORTIONS OF THE HEALTH CARE
AND EDUCATION
RECONCILIATION ACT OF 2010
PREPARED BY THE
Office of the Legislative Counsel
FOR THE USE OF THE U.S. HOUSE OF
REPRESENTATIVES
ACA TITLE IV
TITLE IV—PREVENTION OF CHRONIC DISEASE
AND IMPROVING PUBLIC HEALTH
Affordable Care Act. 2010
Federal Initiatives Promoting Change
in Chronic Disease
Most Frequent use of Healthcare
Resources
CHRONIC EXACERBATIONS
Heart Failure
Chronic Obstructive Pulmonary Disease
POORLY MANAGED DISEASE and SYMPTOMS
CMS, 2010, IOM, 2010, US Department of HHS, 2010
Concomitant Conditions & Symptoms
Prolonged course of disease and disability from
MCCs is compromised further by concomitant
symptoms such as pain, depression, dyspnea
and fatigue among others…
Concomitant Conditions & Symptoms
If symptoms are under-treated, contribute to a
decrease in quality of life, increase in disease
exacerbations, frequent hospitalizations and
costly care for millions of Americans
Kuebler, 2014
Physician Shortage – US Crisis
Total physician demand is projected to grow by 17% - a
result of increased aging population
 In 2025, demand for physicians will exceed supply by
90,000
 Biggest demand will be for surgeons, especially those
who treat disease common to older people such as
cancer

Association American Medical Colleges (March, 2015)
Nursing Education Findings
Kuebler, K. (2012). Implications for palliative care nursing education.
Clinical Scholars Review
Kuebler, K. et al., (2014). A systematic review: A Collaborative
partnership on evaluating graduate nursing education in chronic
symptomatic disease. Clinical Scholars Review
Kuebler, K (2014). National graduate nursing survey: Chronic disease,
symptoms and self-management. Journal of Palliative Medicine
Kuebler, K. et al., (2015) National graduate nursing survey on chronic
disease, symptoms and self management. Clinical Scholars Review
Undergraduate Nursing
To compare baccalaureate nursing students’ selfperceived knowledge with objective test knowledge in
the management of chronic diseases and associated
symptoms.
Kuebler, 2012
Undergraduate Nursing
Senior RN students in two undergraduate programs:
Faith-based program in the NE (n=54)
State-based program in the SE (n=36)
Undergraduate Nursing: Self
Knowledge
Validated self-perceived knowledge survey evaluated
three domains:

Knowledge level of prevalent chronic disease states;

Management of chronic disease;

Use of optimal symptom management
Likert scale 1=lowest level of knowledge 4=greatest level
Undergraduate Nursing – Self
Knowledge

Highest score from self-rated knowledge survey for
chronic disease was Diabetes Mellitus – both cohorts

Both cohorts scored highest on Assessment for disease
management, and equally identified Referral as the
lowest score

SE cohort scored highest on Depression NE cohort
scored highest on Dyspnea
Undergraduate Nursing – Self
Knowledge
Both cohorts scored the lowest on Cachexia
The overall mean score from the self-rated knowledge
survey for the SE was 2.722 (Mdn=2.715) and for the NE,
2.602 (Mdn=2.610)
Overall, mean score between the SE and NE was
statistically significant at .120 (p<.01)
Undergraduate Nursing – Self
Knowledge
Both groups then completed a psychometrically sound
45-item objective examination of chronic disease,
symptom and self management.
Both cohorts scored similarly: SE 21.7 and NE 21.4
The SE and NE scored a mean score of less than 50%
Scatter Plot for Objective Knowledge Scores SE
30
25
Score
20
15
10
5
0
0
5
10
15
20
Students
25
30
35
40
Scatter Plot for Objective Knowledge Scores NE
30
25
Score
20
15
10
5
0
0
10
20
30
Students
40
50
60
National Graduate Nursing Survey
Evaluate differences between undergraduate and
graduate self-perceived knowledge when compared
with actual knowledge in a graduate nursing population
(Masters and Doctoral).
Kuebler, 2014
National Graduate Nursing Survey
Three consecutive emails went out to over 800 nursing
programs, chairs or administrators – contact information
came from the American Association of Colleges of
Nursing.
Graduate program designees were asked to encourage
student participation in this national project – a link to
Survey Monkey was embedded in the email
Kuebler, 2014
National Graduate Nursing Survey

Survey was collected from May 1, 2013 through March
1, 2014

Student participation was voluntary and anonymous

Students completed self-knowledge survey and then
completed the 45-item quantitative objective
examination on chronic conditions, symptoms and self
management
Kuebler, 2014
National Graduate Nursing Survey

250 students completed the demographic information
and 121 completed the survey and examination

Majority of students were from the SE (31.40%) and the
Midwest (28.10%), followed by the NE (19.01%)

87.60% of the respondents utilize Advance Directives in
their practice
Kuebler, 2014
National Graduate Nursing Survey

Graduate nurses rated Diabetes Mellitus management
as their highest level of knowledge (3.2)

Obesity, Cardiovascular Disease* and COPD were
equally rated (3.0)

Stroke, Alzheimer's and End-Staged Renal Disease were
equally rated (2.7)

Lowest scores were Cancer (2.41) and HIV/AIDS (2.13)
Kuebler, 2014
National Graduate Nursing Survey

Highest rated score was Management (3.14)and
Evaluation (3.04)

Followed by Self-Management (2.98), Referrals (2.94),
Follow-up Care (2.91)

Lowest scores were on Intervention/Therapies (2.84)
and Diagnostics (2.77)
Kuebler, 2014
National Graduate Nursing Survey

Dyspnea received the highest score for symptoms
(2.92)

Depression (2.82), Fatigue (2.77), Dysphagia (2.69)

Respondents were more comfortable managing NonMalignant Pain (2.58) vs. Malignant Pain (2.39)

Cachexia was rated the lowest (2.35)
Self Knowledge Survey: Chronic Disease
Subjects
CV
Cancer
Stroke
COPD
Diabetes
Obesity
ESRD
HIV
AIDS
SE BSN
Students
2.56
2.56
2.56
2.86
3.06
3.05
2.42
2.65
NE BSN
Students
2.72
2.49
2.63
2.59
3.13
2.91
2.52
2.37
National
Graduate
Students
3.0
2.13
2.8
3.0
3.2
3.0
2.7
2.13
ALZ
2.7
ed on self-management practices
Self Knowledge Survey: Chronic Disease
Management
Subjects
Assessment
Evaluation
Diagnosis
Therapy
Followup
Referral
SE BSN
Students
3.08
2.86
2.47
2.81
2.78
2.50
NE BSN
Students
2.96
2.91
2.31
2.81
2.46
2.17
National
Graduate
Students
3.14
3.04
2.77
2.84
2.91
2.94
SM
2.98
Self Knowledge Survey: Symptoms
Subjects
Non
Malig Pain
Malignant
Pain
Dyspnea
Dysphagia
Depression
Insomnia
Fatigue
Cachexia
SE BSN
Students
2.53
2.65
2.89
2.81
2.94
2.72
2.97
2.14
NE BSN
Students
2.63
2.44
2.93
2.67
2.76
2.48
2.72
1.67
National
Graduate
Students
2.58
2.39
2.92
2.69
2.82
2.73
2.77
2.35
Graduate Nurses Knowledge

Knowledge of Pathophysiology, Symptoms and SelfManagement, collective score 70%.

Recognize Dyspnea as a cardinal symptom of HF

Knowledge on use of Beta-Blockade in management of
HF

Identify pertinent laboratory findings for acute
respiratory failure
Graduate Nurses Knowledge

Effects of malignancy on patient-centered outcomes

Identify specific diagnostics to determine renal failure
severity

Results on the immune system with a low CD4 count
below 200/uL

Implementing cognitive assessment in confused
patients
Graduate Nurses Knowledge

Use of anticonvulsants and antidepressants as adjuvant
analgesics for neuropathic pain

Evaluate depression in patients living with malignancy

Recognize antidepressant that does not have sexual
alterations or anticholinergic effects
Impetus for Systematic Review
The federal initiatives and the demands of an aging
society prompted an:
Evaluation and analysis of the academic preparation of
graduate nurses who provide care and services to the
escalating population of patients living with
symptomatic chronic disease
A Collaborative Partnership: Design
9 Doctoral faculty members were recruited from 5
Universities:

Georgia Southern University

Sacred Heart University

University of South Carolina

Armstrong Atlantic State University

South University
Systematic Review Protocol: Design

PI developed a Protocol to guide the Systematic Review
(reducing bias)

All faculty members reviewed the protocol and the PIO
question and objectives to guide the search – conference
call

Specific SEARCH TERMS were agreed upon by the faculty
and assignments were made based upon the various
databases
Systematic Review Protocol: Design
QUESTION:
What is the available evidence that suggests the inclusion
of chronic disease, symptom and self-care
management content within graduate nursing
curriculum?
Systematic Review Protocol: Methods
STRATEGY:

Performed a comprehensive review of the existing literature
(not older than 8 years*)

Comparative studies of any design comparing curriculums

Primary studies selected by specific search terms –or current
national initiatives on MCC and federally recognized
measurements.

Agreed upon by the collaborative
Systematic Review Protocol: Methods
This systematic review initially sought to find evidence from:
1.
Randomized Controlled Trials
2.
Meta-analysis or systematic review’s
3.
Non randomized clinical trials
4.
Qualitative studies
Systematic Review Protocol: Methods
EXCLUSIONS:

Oncology related evidence

Undergraduate nursing education or curriculum

Observational studies

Case studies and case reports*
Systematic Review Protocol: Methods
DATABASES:
The data bases reviewed included:
PubMed, Cochrane Collaboration, Medline and Cinahl
Systematic Review Protocol: Methods
SEARCH TERMS:
Root Search Terms: Graduate Nursing Education OR Curriculum AND:

Chronic Disease: Congestive Heart Failure, Chronic Obstructive
Pulmonary Disease, Stroke, Diabetes Mellitus Type 2; Obesity;
Hypertension ; Arthritis, Dementia and/or

Symptomatic Chronic Disease and/or Symptoms (Include all of
these symptoms: Non-malignant Pain; Dyspnea; Edema;
Depression; Anxiety; Insomnia; Fatigue, Cachexia) and/or
Systematic Review Protocol: Methods

Chronic Disease Exacerbations (included hospital re-admission
rates, physical activity, activities of daily living, quality of life, self
management, disease management) and/or

Graduate Nursing Competencies in symptomatic chronic disease,
knowledge, clinical practice

Advanced Practice Nurse, certification
Results
Due to the lack of evidence in two of the databases
(Cochrane, Medline) – search terms were modified to
exhaust the systematic review.
Support from 3 university based librarians
Results
Each faculty group submitted their review to the PI after
comparing the selected literature to the search terms
established in the Protocol.
Initially, 105 publications were identified by the
collaborative
Quality Control
Two faculty separately reviewed the 105 publications by
referring to the protocol’s search terms - this yielded 38
papers (150->38)
A second review of 38 papers was independently
preformed by 2 faculty and narrowed to 10 papers
based upon protocol criteria
Quality Control
Four faculty members critically reviewed the 10
publications and populated a literature matrix - this
underwent peer review and was agreed upon by the 9
faculty members.
Results
Of these 10 publications common themes were identified and
correlated with the protocol’s search terms:

Chronic Disease/ Gerontological Nursing

Palliative Care /End of life Care

Symptom Management

Self Care Management

Nursing Theory (NEW)
Quality Control
2 faculty members independently preformed a third
review of the10 publications by using the final matrix,
protocol search terms and the identified themes
From this second review 4 publications were deleted
Deleted Publications

Palliative and End of Life Care theme: 3 publications
were deleted due to the primary focus on the End-ofLife Nursing Education Consortium (ELNEC)

1 publication from the UK with a primary focus on
faculty education on dementia was deleted
National Graduate Clinical Faculty
Survey
Based upon undergraduate and graduate nursing student
findings Graduate Faculty evaluation is currently ongoing
How does the Graduate Clinical Faculty compare in
perceived knowledge and actual knowledge in the
management of the most common chronic conditions?
Preliminary Data: National Graduate
Clinical Faculty Survey
This is what we are going to find out.
---------- Forwarded message ---------From:
Date: Thu, Aug 13, 2015 at 1:41 PM
Subject: survey
To: XYZF#%
I remember looking at the survey that you wanted me and XZ#$ to
complete and I didn't know the answers to any of the questions and I
was going to have to look them up so I didn't because of the time it
would take. Do you want me to answer them blindly? I'm not sure of
the purpose of the survey.
National Graduate Clinical Faculty

Target graduate clinical faculty from 800 US nursing
programs

Survey Monkey

No identifiers or influence on employment

Gain an understanding of basic knowledge on chronic
condition management
National Graduate Clinical Faculty
To Date:
83 respondents:
PhD (n= 28.92), DNP (n= 37.35) MN (n= 33.73) Faculty
72 are Nurse Practitioners
7 Clinical Nurse Specialist
4 Clinical Nurse Leader
National Graduate Clinical Faculty
Knowledgeable:
Cardiovascular
Diabetes
COPD
Stroke
Obesity
Least Knowledgeable:
Cancer
End Stage Renal Disease
HIV/AIDS
Alzheimer's
National Graduate Clinical Faculty
Knowledgeable:
Least Knowledgeable:
Assessment
Diagnostics
Evaluation
Interventions/Therapies
Referrals
Follow-Up Care
National Graduate Clinical Faculty
Knowledgeable:
Least Knowledgeable:
Dyspnea
Cachexia
Depression
Malignant and NonMalignant Pain
Insomnia
Fatigue
Dementia
National Graduate Clinical Faculty
CARDIOVASCULAR:
 Recognize dyspnea as cardinal symptom of HF
 Use and implementation of Ace Inhibitors for management
of HF
 Understand physiological effects from Beta Blockade
 Identify Black Box Warning on Beta Blockers
 Recognize Ejection Fraction of <40% to diagnose HF
 Are not familiar with JNC-8 Guidelines for Hypertension
Management
National Graduate Clinical Faculty
Chronic Obstructive Pulmonary Disease:
 Recognize symptoms that identify onset of COPD
exacerbation
 Identify how to prevent exacerbation in COPD patients
 Implementation of appropriate medication use in
patients with Moderate COPD
 Recognize GERD as common concomitant condition
with COPD
National Graduate Clinical Faculty
Cancer:

Contributing symptoms from a diagnosis of malignancy

Treatment in patients with pleural effusion

Somatic pain in patients with bone metastasis

When to implement or integrate palliative care

Confuse somatic pain with neuropathic pain

Prescribe breakthrough pain medication
National Graduate Clinical Faculty
Dementia and Confusion:

Associated symptoms from dehydration and use of
anticholinergic medications

Manage drug induced-delirium

Cognitive Assessment in patients who are confused
National Graduate Clinical Faculty
Self-Management:
Purpose and use of self-management in chronic
conditions
Findings
There is a lack of consistency in how chronic disease,
symptoms and self-management are included and
how much time is allocated to this content in current
graduate nursing curricula.
There is no standardized approach on how best to
integrate this content
Implications
Based upon the current and growing aging
demographics and Federal initiatives there is a need to:

Develop standardized methods and specific content for
inclusion into nursing curriculum;

Evaluation of methods to determine if content is
effective, and to;

Ensure that faculty are maintaining ongoing education
and implement the use of current guidelines in didactic
and clinical education and PRACTICE
Implications
The escalating population of aging Americans with MCCs,
the dramatic shortage of physician’s in primary care and
specialty practice requires prompt attention
Are We Prepared to Meet the Health Care Demands of
America’s Largest, Fastest Growing and Most Costly
Patient Population?
WHAT DO WE DO IF NOT TO MAKE LIFE
BETTER FOR OTHERS