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Improving Pain and Palliative Care Competency among Non-Oncology Health Professionals
Pamela Bennett, RN, BSNPamela Bennett, RN, BSNPurdue Pharma, L.P.Purdue Pharma, L.P.
Maureen Lichtveld, MD, MPHMaureen Lichtveld, MD, MPHTulane University School of Public Health and Tropical MedicineTulane University School of Public Health and Tropical Medicine
Alison Smith, BA, BSN, RNAlison Smith, BA, BSN, RNC-ChangeC-Change
Thank you to many leaders and experts who have contributed to this body of work.
Thank you to Purdue Pharma, L. P. who generously provided
an unrestricted educational grant to C-Change that helped to fund the 4 pain and palliative care grant sites
and the CCCLI Pain Workshop.
The materials presented reflect the views and opinions of the individual presenters
Thank Yous, Disclosure, & Disclaimer
Workshop Objectives
By the end of this presentation, attendees will be able to …
• Describe the basic challenges and contemporary issues in pain and palliative care
• Appreciate how other sites have applied the competency-based method to achieve measurable outcomes
• Outline a competency-based approach for designing educational interventions – from planning thru implementation, and evaluation
• Identify sources for program curriculum, national standards, funding, advocacy, etc.
• Move forward with a prioritized list of next steps
Cancer Core Competency Initiative
Goal:Strengthen the basic cancer competency(knowledge, skills, and attitudes) of the non-oncology health workforce
Pain and Palliative Care: Issues and Challenges
ResearchResearchPracticePracticePolicyPolicy
Coalition Perspectives
• Your Challenges?
• Your Priorities?
Cancer Core Competency Initiative
Goal:Strengthen the basic cancer competency(knowledge, skills, and attitudes) of the non-oncology health workforce
Examples of Success
Pain & Palliative Care Grant Site Results
Examples of Success
Target audience:
• RNs and MAs practicing in rural, long term care facilities
Focus:
• Describe palliative and end of life care, and explain the role of hospice
Results:
• 40 participants
• 12% increase in knowledge from pre- to post-test scores
• Possible addition to Iowa nursing school curriculum
Unique Approach:
• Order sets for palliative/hospice care
• Scripts/ talking points for difficult conversations
Target Population:
• MD, RN, MSWs, and office staff in rural health, primary care clinics (mostly FQHCs)
Focus:
• Describe cancer-related symptoms, methods to screen for needs, and referral pathways and palliative care resources for patients.
Results:
• 90 participants
• 90% reported gaining new knowledge and skills to provide better patient care
Unique Approach:
• Interdisciplinary program
• Video with cancer patient perspectives
• Video with a standardized patient scenario
Examples of Success
Population:
• Native health workers, cancer survivors, and caregivers
Focus:
• Address culture-specific cancer pain
• Explain how cancer pain differs from other types of pain
• Perform a cancer pain assessment
• Differentiate pain and distressResults:
• 102 participants
• 120% improvement in confidence
• 7% increase in knowledge Unique Approach:
• Pre-Assessment with talking circles
• Patient symptom journal
• “Discomfort” Barometer
South Puget Intertribal
Planning Agency(SPIPA)
Examples of Success
Population:
• Medical students and pediatric residents
Focus:
• Recognize the barriers to effective pediatric pain management
• Perform a pediatric pain assessment
• Describe the pathophysiology of pain in children
• Manage pediatric-related pain and analgesic side effects
Preliminary Results:
• 310 participants to date
• 32% increase in knowledge
Unique Approach:
• Online, interactive course
Examples of Success
Institution
Enhanced visibility/ credibility
Provided foundation for future trainings
Community
Enhanced relationship with institution
Addressed needs Benefits of better
prepared/ increased workforce
Professional
Professional development
Learner
Increased knowledge
Increased confidence
Received tangible reference materials
Enhanced academic experience
Enhanced professional self-reflection
Program Benefits
Pilot Site Findings
UTILITY• Pilot sites found the cancer core competencies to be highly useful
FLEXIBILITY• Implementation of the competencies was feasible across cancer
core continuum, professional settings, and disciplines
Program Resources:C-Change Toolkit
Pilot Site ReportUniverstiy of Pittsburgh Medical Center
Pilot Site ReportMarshall University School of Medicine
Pilot Site ReportCalifornia University of Pennsylvania
School of Social Work
Pilot Site ReportAudrain Medical Center
Addressing the Cancer Workforce CrisisUsing a Competency-Based Approach
with Non-Oncology Professionals
Pilot Project Evaluation Report
July 2008
Summary Publications
Overview & “How to” GuidanceExamples
Order free copies or download: www.cancercorecompetency.org
Templates
Program Resources:Purdue Pharma L.P. Resource Guide
Information, resources, ideas and tools to help those suffering with pain:
• Pain scales, diaries, medication record and advocacy resources
• Tools to facilitate communication with providers
• Tips for living a healthier life• Financial resources• Caregiver tips• Useful websites
Toolkits may be ordered free of charge at www.IntheFaceofPain.com or by contacting Kimberley Tiller at 203-588-8538
Building a Competency-Based Pain and Palliative Care Educational Program
Why?
The Challenge and Rationale for a Competency-Based Approach
Scope of the Workforce Supply
• Demand for oncologists is expected to exceed supply by 25%-30% by 2020 (ASCO, 2007).
• The social work labor force is older than most professions, with nearly 30% of licensed social workers over age 55 (NASW, 2006).
• By 2020 the projected gap between supply and demand for RNs will be 340,000 (three times larger than ever experienced in the U.S.).
• By 2020, more RNs will be in their 60s than in their 20s (Auerbach & Buerhaus & Staiger, 2007).
• The average age of a public health worker is 47; many public health agencies currently face a 20% vacancy rate (APHA, 2008)
• Cancer registrar vacancies remain difficult to fill in some regions of the country and demand for registrars is estimated to grow 10% in the next 15 years (NCRA, 2006)
• The proportion of minorities in the population outstrips their representation among health professionals by several fold (IOM, 2004).
Scope of the Public Demand
• Cancer is the second most common cause of death by disease claiming the lives of more than half a million people per year (ACS, 2007)
• Cancer rates are expected to increase as baby boomers age (CDC, 2000)
• The lifetime probability of developing cancer is 1 in every 2 men and 1 in every 3 women (NCI, 2005)
• Five-year cancer survival rates have risen to 64% for adults (CDC, 2005)
Who?
Defining learners / audience
Discipline, Scope of Practice
Who?
• Physician• Nurse• Social Worker• Pharmacist• Public Health Worker• Nursing Assistant• Lay Health Worker• Multi-disciplinary team
Implications for Program Design
• Levels of education / training• Areas of expertise• Scope of practice• Roles and responsibilities• Interactions• Interdependence
Exercise 1
WHO? Who is your target audience?
Physician, Nurse, Social Worker, Pharmacist, Public Health Worker, Nursing Assistant, Lay Health Worker?
What?
Defining the targeted competency improvement
Bloom’s Taxonomy
Verb describeslevel of
independence
KNOWLEDGE
COMPREHENSION
APPLICATION
ANALYSIS
SYNTHESIS
EVALUATION
Anatomy of a Competency Statement
Competency statements define what a professional should know or do:
Define palliative and end-of-life care
Targeted cancer contentLevel of complexity and/or independence
Within context:Scope of PracticeLevel of Expertise
Role and Responsibilities
AdministrationAmbulatory Clinics Academics
Acute Care Clinics Cancer Centers
Home Health Agencies Professional Societies
Advocacy Organizations
Domain IContinuum of Care
Prevention / Early DetectionTreatment / Survivorship
Palliative Care
Domain IIBasic Cancer Science Etiology / Epidemiology
Clinical Trials Cancer Surveillance
Domain IIICommunication & Collaboration
Interdisciplinary CarePsychosocial CommunicationCross-Cultural Communication
Grieving
Work Setting
Dis
cip
lin
e
Competency Standards
Allied Health MedicineNursingPharmacyPublic HealthResearchSocial Work
StudentsResidents/FellowsField FacultyPracticing Professionals
Breadth & Depth of the Competency Statement
Palliative and End of Life CareCompetency Statements
General
• Define palliative and end of life care
• Assess that resources for palliative and end of life care and insurance coverage are consistent with current recommendations
• Refer patients to community palliative and end of life support resources
• Explain the role of hospice care
• Manage symptoms of the cancer patient
• Incorporate end of life comfort strategies for the dying patient
Palliative and End of Life CareCompetency Statements
Pain management
• Explain how cancer pain differs from other types of pain
• Describe the methods used to diagnose cancer pain throughout the progression of the disease
• Differentiate between acute and chronic pain symptoms
• Describe the characteristics used to assess cancer pain: frequency, intensity and site
• Perform a cancer pain assessment
• Explain the different treatment options for cancer pain
• Perform a pain-related history taken during a physical exam
• Manage cancer-related pain and analgesic side effects
Exercise 2
WHAT? What should the professional know or be able to do?
Choose a competency statement:VERB + CONTENTLevel of complexity and/or independence + targeted cancer content
How?
Developing the learning activity
Adult Learning Principles
• Adult learning environments are designed to minimize dependence and maximize independence.
• Adult instructional strategies adapt to the learners’ previous experiences including skills and content.
• Faculty in adult learning settings function as both instructors and facilitators.
Educational Activity Design
Verb
Describe
Instructional Design
LearnerAssessment
Dialogue Short Answer
Apply Case Study Role Play
Synthesize Table Top Essay Question
Evaluate Peer Review StandardizedPatients
Competency to Curriculum
Curriculum Resources
See resources list:
• Best practice guidelines
• Professional education
• Clinical practice tools
• Patient Education
• Advocacy Materials
• Grant Funding
• e-News
• National Conferences
Clinical Practice Tools
Exercise 3
HOW? How should we design the educational activity to achieve the desired competency?
Match the competency with:
Adult learning principles
Knowledge or skill format
Tools for changing practice
So What?
Evaluating Impact
INPUTS OUTPUTS OUTCOMES
Program resources
Activities Participation Short Medium Long-term
Efforts on the part of the program or intervention staff
Changes in practice, care delivery system, patient outcomes
Changes in the learner’s knowledge, skills, and attitudes
The logic model assures that all of the program resources directly support the achievement of the desired competency outcome.
Planning, Implementation & Evaluation Tools
Logic Model
Evaluation Measures
Short Term Medium Term Long Term
Learner •Attendance in pain CE program
Pre/Post Test % improvement:• Knowledge• Skills• Attitude – Intent to change
•Change in practice as observed or thru documentation audits and f/u tests
•Utilization levels of order sets or resource materials
•Sustained knowledge and skills per repeat competency testing
•Sustained resource utilization
Program / System
•Support for competency program planning and implementation
•Consultations •Referrals/Admissions•Average Length of
Stay (ALOS) in hospice
•Pain drug utilization • Institutional policy
changes r/t clinical standards and tools
•Sustained consultations, referrals, admissions
• Increasing hospice ALOS
Patient Impact
• Patient use of resources (pain journal, support group svcs, medication adherence)
• Improved quality of life measures
•Patient / Family satisfaction r/t pain
Exercise 4
SO WHAT? How will we know if competency has been improved?
Develop measures:
Short term learner knowledge, skills, and attitudes
Medium and Long Term program and patient outcomes
Now What?
Taking the next steps toward program implementation
Sustain Efforts
Through Sharing
Implement & Manage
with Attention to Details
Evaluate and Interpret
Data
Define Audience & Topic Area
Refine Competency
Focus
Build a Balanced
Leadership Team
Develop Logic Model & Validation Template
IMPLEMENT
EVALUATE PLAN
PLAN
Complete Needs Assessment & Interpret Findings
Plan Implement Evaluate
Key Aspects of Planning
Leadership and faculty
• Coalition members, cancer center experts
Needs assessment
• SPIPA talking circles
Incentives and program promotion
• CEs, gas card, food, free registration, job requirement
Resources and partnerships
• Iowa – long term care facilities, school of nursing
• Florida – AHEC, cancer centers, university
Exercise 5
WHAT NEXT? What additional issues will need to be explored to prepare for implementation?
Leadership and faculty
Learner needs assessment
Incentives and program promotion
Resources and partnerships
Validation Template
Logic Model
Map for Next Steps
WHO?
WHAT?
HOW?
SO WHAT?
WHAT NEXT?
INPUTS OUTPUTS OUTCOMES
Program resources
Activities Participation Short Medium Long-term
Curriculum Validation Template
Tools for Success
Summary
• Effective method to address the cancer workforce shortage and achieving improved pain and palliative care competency
• Applicable in a variety of professional disciplines and settings
• Provides numerous resources for competency-based program development
www.cancercorecompetency.org
kcox@c-changetogether.org
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