Patient Education In Nursing and Innovative Roles
Role and Delivery of Patient Education In Health Care System and Nursing.
Roles And Delivery Of Patient Education Services
While it is well recognized that persons with diabetes must be educated in self-management, this task is immense and can be accomplished more effectively. For example, 1 in 10 acute hospital beds is occupied by patients with coexisting diabetes, frequently admitted for vascular complications.
An RCT of standard inpatient care for adults with diabetes with an intervention of a diabetes specialist nurse found a 3-day reduction of inpatient length of stay without any adverse impact on readmission rates and associated with improvements in diabetes knowledge and satisfaction with care, compared with those without such an intervention.
The intervention included education and management assistance for patients and case based feedback toward staff. Cost of the specialist nurse was easily offset by decrease in length of stay (Davies, Dixon, Curriet, Davis, & Peters, 2001).
In a similar RCT, a nursing care management system was designed to improve outcomes in patients with complicated and long standing diabetes, with one or more major medical comorbid conditions and HbAlc of more than 10%. Patients in the experimental group met with a nurse care manager to establish individual outcome goals, attended group sessions once a week for up to 4 weeks, and received phone calls to manage medications and self-care activities.
At 1 year, the mean decrease in HbAlc, total cholesterol, and LDL cholesterol were significantly greater in the intervention group compared with the usual care group and without increasing physician visits. Fortythree percent of these patients were able to achieve an HhAle of less than or equal to 75%-impressive because these patients were selected on the basis of lack of control (Taylor et al., 2003).
Two UK studies document effectiveness of specialist nurse led interventions to treat and control hypertension and hyperlipidemia in diabetes. In these settings, diabetes specialist nurses manage their own caseload, initiating and titrating drugs for glycemic control, and in this extended role saw patients with hypertension or hyperlipidemia in the diabetes center every 4 to 6 weeks for 30- to 45-minute appointments until biological targets were achieved.
At these visits, lifestyle modifications were reinforced and reviewed and medications adjusted. In this trial, significantly more subjects randomized to the specialist nurse-led clinic achieved target level than did those who received normal care (New et al., 2003).
Similar results were found by a different group of UK investigators using a hypertension nurse who emphasized need for tight blood pressure control, gave nonpharmacologic advice for healthy living, discussed problems with medication side effects, and initiated treatment changes (Denver, Barnard, Woolfson , & Earle, 2003).
Urinary incontinence is common and problematic, particularly for women. The nurse continence advisor role was established in England in 1974 and in Canada in 1995. These advisors follow a caseload of patients and provide consultation and educational services to generalist nurses (Skelly & Kenny, 1998),
Finally, a series of seven studies by Brooten et al. (2002) of transition care from hospital to home, delivered by advanced practice nurses (APNs) has shown excellent results. Patient education is a dominant part of this intervention. Groups chosen were vulnerable, high volume and high cost patient groups of women with high-risk pregnancies, women with unplanned cesarean births, and elders with cardiac medical and surgical diagnoses.
Transitional care consisted of patient and caregiver preparation for discharge including patient demonstration of basic knowledge and skills, take-home materials, and a series of home visits with daily APN telephone availability and physician backup. Groups with APN-provided transition care were hospitalized for less time and at less cost, reflecting early detection and intervention.
An RCT of a similar intervention to predominantly Latino and African American adolescent mothers, from the time of pregnancy through 2 years postpartum, showed lower total days of non birth related infant hospitalizations, fewer infants seen in ERs, and 15% lower repeat pregnancies than the control group.
Results were sustained for a year following program termination and clearly decreased the higher rates of morbidity and unintentional injuries and hospitalizations seen in children of adolescents compared with children of adult mothers.
The experimental group received preparation for mother hood classes and intense home visitation from public health nurses including training in self management skills, life planning and decision-making, handling emotions, and coping with stress and depression. The control group had traditional public health nursing (Koniak-Griffin et al., 2003).
Just as advanced practice nursing roles have always included a major emphasis on patient education, now a traditional teaching role-that of the Certified Diabetes Educator (CDE) is expanding into diabetes clinical management as well as encompassing patient education. In 2000, a new credential was launched-Board Certified-Advanced Diabetes Manager (BC-ADM).
It is available to nurses, dietitians, and pharmacy practitioners who hold an advanced clinically relevant degree and demonstrate skill including providing therapeutic problem solving, counseling, and regimen adjustment for patients with diabetes. In 2003, 300 individuals had earned this credential (Valentin, Kulnarni, & Hinnen, 2003),
Some countries such as Sweden have significantly developed nurse-led patient education and follow-up services. Between 1990 and 1998, nurse-led heart failure clinics opened in two thirds of all Swedish hospitals (Stromberg et al., 2003), asthma educators are also being introduced in US hospitals.
There is a fascinating description of a new role in transplantation, the family support counselor, whose responsibility is to provide bereavement support and unbiased education to enable families to make an informed decision about organ donation (Sade et al., 2002). The role resulted from division of the procurement coordinator position into five new positions including the bereavement counseling and education service.
A major focus was on helping families of potential donors understand brain death and transplantation. The concept of brain death is widely misunderstood, it is believed to be something less than “real” death.
The natural tendency to deny that death has occurred is reinforced by the belief that brain death is not really death, that there is hope even when death has been pronounced. Most hospitals are apparently not prepared to provide the lengthy support and specialized education now encompassed in this new role.
Remarkably, over a period of 4 years, the donation rate increased from 18.2 to 33.6 donors per million of population, while despite intensive educational efforts aimed at the general public, national rates remained virtually unchanged. The support service and aftercare program are not linked in any way to consent for donation and should not be.
Although documented only as a case study in South Carolina's organ procurement organization, the family support counselor role addresses a need. Other research (Dejong et al., 1998) has documented a low level of understanding of brain death, particularly among nondonor families.
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