The future of cardiovascular nursing

(1)

The future of

cardiovascular nursing

Philip Moons, PhD, RN

Landskursus, Nyborg, November 2-3, 2011

Overview

Challenges for healthcare Impact on nursing Policy reports • Practice • Education • Leadership • Workforce Data Take home messages

Challenges for healthcare

• The aging population

• The boost of chronic conditions

• The plethora of technological innovations

• The increasing costs

The aging population

COMMUNICATION FROM THE EUROPEAN COMMISSION, 2005: Green Paper “Confronting demographic change: a new solidarity between the generations”

The aging population

COMMUNICATION FROM THE EUROPEAN COMMISSION, 2005: Green Paper “Confronting demographic change: a new solidarity between the generations”

The boost of chronic conditions

49% of Americans have a chronic condition

(2)

The boost of chronic conditions

• USA

http://mpkb.org/home/pathogenesis/epidemiology

The boost of chronic conditions

• Global

Yach et al., JAMA 2004

The plethora of technological

innovations

Remote monitoring of ICD

Implantable monitoring systems

Non-invasive imaging Hybrid approaches

The plethora of technological

innovations

Percutaneously implantable valve

±18000 euro 135000 DKK

CRT-D: Cardiac Resynchronization

Therapy Defibrillator

±21000 euro 156000 DKK

The increasing costs

(3)

The increasing costs

• Data van kosten

The increasing costs

15-20% increase per 10 year

Global problems but ….

….. regional differences

Future of nursing

• The Prime Minister’s Commission on the Future of Nursing and Midwifery in England

(4)

Future of nursing

• Robert Wood Johnson Foundation and the Institute of Medicine

Future of nursing

• Transforming practice

• Transforming education

• Transforming leadership

• Meeting the need for better data on the

healthcare workforce

Future of nursing

• Transforming practice

• Transforming education

• Transforming leadership

• Meeting the need for better data on the

healthcare workforce

Future of nursing:

Transforming practice

1. Remove scope-of-practice barriers: Advanced

practice nurses should be able to practice to

the full extent of their education and training.

2. Expand opportunities for nurses to lead and

diffuse collaborative improvement effort

3. Implement nurse residency programs

(5)

Special Eurobarometer 241, 2006

29% have experienced medical errors

Special Eurobarometer 241, 2006

Future of nursing:

Transforming practice

1. Remove scope-of-practice barriers: Advanced

practice nurses should be able to practice to

the full extent of their education and training.

2. Expand opportunities for nurses to lead and

diffuse collaborative improvement effort

3. Implement nurse residency programs

What is Advanced Practice Nursing?

RCT: Secondary prevention of

coronary heart disease: mortality

5% Follow-up by GP

Follow-up by GP + nurse specialist

(6)

RCT: Management of hypertension

and hyperlipidemia in diabetes

0 2

Target BP and lipid levels Reduction of cholesterol

Reduction of blood pressure

    Nurse clinic Usual care 1 3 Mortality

New et al., Diabetes Care 2003

Review: Secondary prevention of

coronary heart disease: behaviour

Campbell, Heart 2004

Nurse care Usual care

Nurses do make a difference!!

Outcomes

Death Disease Disability Discomfort Dissatisfaction Dollars

Epidemiological Quality of life Consumer Costs

paradigm perspective

Clinical outcomes Patient-oriented outcomes Consumer-related Economical

outcomes outcomes

Health Outcomes Institute, 1996

= A nurse

A nurse

What kind of nurse do we need?

APN

education

expe

rience

Associate nurse Primary nurse Specialized nurse By courtesy of G. Peeters

Level 1: Associate nurse

• Entry level of most nurses • Merely at executive level

• He/she can take up the care for a limited number of patients (3 pat.), but needs supervision of primary nurse

• Normally, an associate nurse evolves towards a primary nurse

(7)

Level 2: Primary nurse

• The primary nurse is a role model in nursing practice • He/she focusses on the executive level, as well as

coordination of care

• Can take up care independently for several patients ( 10 pat.)

Level 3: Specialized nurse

• A nurse who has developed a ‘unit-overarching’ expertise with respect to one or more patient populations

• He/she has a consultant and educational role towards patients, nurses en physicians of the entire hospital, and sometimes for professionals from other organisations

• Will contribute to the management of care at the unit, but also in the hospital at large

Level 4: Advanced Practice Nurse

• Nurse with Masters or PhD

• Nurse who, through profound clinical and scientific education, developed towards an Advanced Practice Nurse (APN)

Difference Specialized nurse - APN

• Specialized nurse - Specialisation

• Advanced Practice Nurse - Specialisation

Difference Specialized nurse - APN

• Advanced Practice Nurse - Specialisation - Expansion Kinesisten …. …. Ph ysiot her apist s Nurs es Ph ysicia ns

Difference Specialized nurse - APN

• Advanced Practice Nurse - Specialisation - Expansion Kinesisten …. …. Ph ysiot her apist s Ph ysicia ns Nurs es

(8)

Difference Specialized nurse - APN

• Advanced Practice Nurse - Specialisation - Expansion - Advancement Ar ts en Kinesisten …. …. Ph ysicia ns Nu rs es Ph ysiot her apist s

Hamric, Spross, Hanson, 2009

Difference Specialized nurse - APN

• Specialized nurse - Specialisation course - Postregistration course - Continuing education

• Advanced Practice Nurse - Master - Doctorate/PhD

APN roles

Clinical Nurse Specialist Nurse Practitioner

APN Case manager Nurse Anesthesist

Hamric, Spross, Hanson, 2009

Clinical Nurse Specialist

• A CNS is a registered nurse “who, through study and supervised practice at the graduate level (master’s or doctorate), has become expert in a defined area of knowledge and practice in a selected clinical area of nursing”

(ANA, 1980)

Direct care functions

Expert practitioner Role model Patient advocate

Indirect care functions

Change agent Resource person Clinical teacher Supervisor Innovator

Clinical Nurse Specialist

• 4 dimensions – Expert clinician – Consultant – Educator – Researcher • Specialisation can be:

– Population (pediatrics, geriatrics, obstetrics) – Setting (Intensive care, home care) – Disease or medical specialty (HIV, cardiology) – Type of care (rehabilitation)

(9)

Clinical Nurse Specialist

• Developed in hospitals, afterwards transferred towards other care environments

• First CNS were working in mental health care • Development is not unequivocal:

different emphases in role development • Typical for CNS: Working through nurses

– Staff education – Nurse mentorship – Leadership

Nurse Practitioner

• Focus on direct patient care • Substitution of physicians • Drivers:

– Shortage of physicians – Access of care – Costs

• Developed in primary care (primary care nurse practitioner) in the 1960s

• Afterwards transferred to hospitals (acute care nurse practitioner) in the 1970s

Nurse Practitioner

• Competencies:

– Strongly developed clinical skills (cfr. GP) • Added value:

– Care and cure

– More attention for prevention

• In some countries: prescription authority

Nurse Practitioner

• Potential/observed side effects – Migrates to medicine: Abandons nursing – Does not work with nursing teams – Difficult acceptance by nurses – Dependent from physicians

Roodbol, doctoral dissertation, 2005

Nurse Practitioner

Nurse practitioner No nurse practitioner Uncertain

Roodbol, doctoral dissertation, 2005

0 2 4 6 8 10 12 14 16 0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 5 4 RN= 1 MD 3 RN= 1 MD 2 RN= 1 MD 1 RN= 1 MD Ireland Iceland The Netherlands Luxembourg Switserland Sweden Norway Denmark Australia Canada Germany Czech Rep Austria Finland UK USA

Japan Spain France

Slovak Rep Belgium Italy Greece Portugal Hungary Poland Korea Turkey Mexico RN/1000 inhabitants MD/1000 inhabitants

Ratio RN-MD/1000 inhabitants

(10)

APN to complement physicians

Positive effects Negative effects No difference

Outcomes

outcomes outcomes

Patient outcomes of Advanced

Practice Nurses

Outcomes

outcomes outcomes

Positive effects Negative effects No difference

Patient outcomes of Advanced

Practice Nurses

APN to substitute physicians

Outcome: Nurses

• Traditional career of nurses:

…. in order to move up the career ladder, nurses need to move away from

the bedside…

• Interesting clinical career opportunities for nurses

Outcome: Organisation

• Characteristics of a Magnet Hospital – Working with clinically competent nurses

– Good nurse-physician relationships and communication – Nurse autonomy and accountability

– Supportive nurse manager/supervisor – Control over nurse practice environment – Support of education

– Adequate nurse staffing – Concern for patient is paramount

Outcome: Organisation

• Characteristics of a Magnet Hospital – Working with clinically competent nurses

– Good nurse-physician relationships and communication

– Nurse autonomy and accountability

– Supportive nurse manager/supervisor

– Control over nurse practice environment – Support of education

– Adequate nurse staffing

– Concern for patient is paramount

Conclusion

• A clear distinction between specialized nurses and Advanced Practice Nurses

• Advanced Practice Nurses provide a better quality of care …..

….. if the APN is complementary to physicians • Advanced Practice Nurses are important for patients,

(11)

And who will pay for this ???

RCT: Cost effectiveness of a Clinical

Nurse Specialist in rheumatoid arthritis

(van den Hout et al, Ann Rheum Dis 2003) Cost reduction of 324764 euro in 61 patients

Costs per patient over 2 years Clinical Nurse Specialist (n=61) Inpatient group (n=62) Day care group (n=61) Average total healthcare costs 8092€ 16581€ 13252€ Average total societal costs 11572€ 22448€ 16896€ 2.4 million DKK

Study: Economic evaluation of health

failure nurse management

(Stewart et al, Eur Heart J 2002) – Sensitivity analysis

• Reduction of hospital days with 10%

= cost reduction of £18 million

– Reduction in length of stay of readmissions:

• 50% reduction in hospital days results in a net benefit of £20 million/year.

Conclusion

• Advanced Practice Nurses provide a better quality of care

in a cost-effective way…..

….. if the APN is complementary to physicians • Advanced Practice Nurses are important for patients,

nurses and the organisation, and the health care budget

Take home messages

1. Developing and implementing the role of Advanced Practice Nursing is critical for improving clinical care to patients

(12)

Cardiology is becoming geriatrics

Typical heart failure patient

Cardiology is becoming geriatrics

Typical patient with aortic stenosis

Cardiology is becoming geriatrics

Typical patient with atrial fibrillation

 Pressures  Ejection fraction  Function of heart valves  Exercise capacity  Etc.

Cardiology toolbox

Cognition Gait IADL Vision Depression

Informal care giver burden

Pain Malnutrition Medication Pressure Ulcer Falls Housing  Cognition  Depression  Delirium  Dementia  Mobility  Nutrition  Vision  Pressure ulcer  Pain  Falls

 Activities of daily living  Living arrangement  Medication  Care givers  Etc

Geriatric toolbox

• Complex & heterogeneous

• Geriatric syndromes

• Beyond symptoms & complaints at admission

Diagnosis Insight in nature and severity of the functional and psycho-social consequences COMPREHENSIVE ASSESSMENT

Evaluation of ALL domains which might contribute to FRAILTY

Comprehensive Geriatric Assessment

Bernabei et al., 2000 Abellan et al., 2008

(13)

Comprehensive Geriatric Assessment:

Data transfer

Nursing Home Hospital Home Care 1st generation

• Collection of single domain instruments [e.g. MMSE, Lawton, …] • Individually validated

• Variance in selection of tools

• CGA is triggered by impression based on clinical expertise

2nd

generation

• Omni-comprehensive: allgeriatric domains

• Care setting-specific: residential, palliative, rehabilitation, home care • Reliability and validity tests on the entity of all domains and in every single

setting

3rd generation

• Exceeding care settings

• Standardization of clinical items, scoring, timeframes • Data transfer

Evolution in

Comprehensive Geriatric Assessment

Bernabei et al., 2008

interRAI Acute Care

• Since 2006 in RAI portfolio • 13 geriatric domains • 98 individual items • 4 assessment periods – Premorbid – Admission – Reassessment – Discharge • No total score • Outcome measurements

– Clinical Assessment Protocols: trigger (potential) domains at risk – Scales:

quantify functional evolution over time

interRAI software in different countries

Take home messages

2. Cardiovascular nurses should become familiar with Comprehensive Geriatric Assessment

(14)

Measuring outcomes

Effects of structured education

World Congress of Cardiology 2012, submitted

Effects of structured education

Variable

Intercept

Education (vs no prior education)

Age Educational level Disease complexity Standardized estimate p-value 0.031 0.31 <0.001 0.02 0.790 0.35 <0.001 0.17 0.001 No difference Small difference Moderate difference Large difference Cohen’sd

Effects of structured education

Acta Cardiologica, 2009

Effects of structured education

44% 71% 0 10 20 30 40 50 60 70 80 90 100 With APN Without APN Year 2000

Outcome assessment

Outcomes

outcomes outcomes

(15)

Take home messages

3. Cardiovascular nurses should systematically measure the outcomes of their care

Effects of structured education

World Congress of Cardiology 2012, submitted

Patient education by using technology

WEB 2.0

Patient education by using technology

• Effectiveness of games on knowledge

Patient education by using technology

• Effectiveness of games on self-management

Take home messages

4. Cardiovascular nurses should develop and use technologies to improve care

(16)

Specific issues in cardiovascular care

Specific issues in cardiovascular care:

e.g. sexual counselling

• 33% of patients with coronary artery disease have fear of sexual intercourse

• Patients with moderate or severe impairment of left ventricular ejection fraction have a significant increase of erectile dysfunction

• Men on beta blockers are 3.13 times more likely to report erectile dysfunction

Kazemi-Saleh et al, J Sex Med, 2007

Baumhäkel et al, Int J Clin Pract, 2007

Cook et al, Am J Cardiol, 2007

Specific issues in cardiovascular care:

e.g. sexual counselling

• Sexual functioning may be impaired due to: – heart failure

– cardiac medication

– psychological barriers

Specific issues in cardiovascular care:

e.g. sexual counselling

• Erectile dysfunction (ED) is a predictor of acute coronary syndromes

• ED developed on an average of 3 years on beforehand

• Moderate-to-severe, but not mild ED is calculated to increase the 10 year relative risk of developing coronary arterial disease by 65% and stroke by 43%

Montorsi, Eur Urol, 2003

Ponholzer, Eur Urol, 2005

Specific issues in cardiovascular care:

e.g. sexual counselling

• ED is a warning sign of vascular disease

• A man with ED and no cardiac symptoms is a cardiac or vascular patient until proved otherwise

• Aggressive risk reduction may prevent subsequent (cardio)vascular events

Jackson, J Sex Med, 2006

Specific issues in cardiovascular care:

e.g. sexual counselling

• Ask routinely

– “It is quite normal for some men with cardiovascular disease to experience problems at some stage with getting an erection. Is this a problem you’ve experienced? If so, is it something you would like to do something about?”

– “Some men may have sexual difficulties after bypass surgery, a heart attack or from medication - have you experienced any problems?”

(17)

Specific issues in cardiovascular care:

e.g. sexual counselling

Goossens et al, Int J Clin Pract, 2011 (0-32)

(0-20) (0-20)

(0-16)

Take home messages

5. Cardiovascular nurses should identify issues in which they can make a difference, e.g. sexual counselling

Future of nursing

• Transforming practice

• Transforming education

• Transforming leadership

• Meeting the need for better data on the

healthcare workforce

Future of nursing:

Transforming education

1. Increase the proportion of nurses with a

baccalaureate degree to 80 percent by 2020

2. Double the number of nurses with a doctorate

by 2020

3. Ensure that nurses engage in lifelong learning

Nursing education in Europe 2011

First cycle 2deand 3ecycle Country Professional edu. University College University Master and PhD

Iceland Bachelor – 4j MA, PhD

Ireland Bachelor – 4j MA, PhD

Malta Bachelor – 4j

Italy Bachelor – 3j MA, PhD

Norway Bachelor – 3j MA, PhD

Spain *2009 Bachelor – 4j MA, PhD

Sweden Bachelor – 3j MA, PhD

UK Bachelor – 3j MA, PhD

Greece Bachelor – 4j Bachelor – 4j MA, PhD

Portugal Bachelor – 4j Bachelor – 4j MA, PhD

Luxemburg *2010 Bachelor – 4j MA, PhD

Finland Bachelor – 3,5j MA, PhD

Denmark Bachelor – 3,5j MA, PhD

France *2009 Bachelor – 3 j MA, PhD

Switserland *2006 Diploma - 3j Bachelor – 4j

F: Only bachelor – 4j

MA, PhD

Austria * 2008 Diploma – 3j Bachelor – 3j Bachelor – 3j MA, PhD

Netherlands Diploma - 4j Bachelor – 4j MA, PhD

Belgium Diploma - 3j Bachelor – 3j MA, PhD

Germany *2004/2010 Diploma - 3j Bachelor – 3j MA, PhD

Sources: Spitzer en Perrenoud, 2006; Robinson & Griffiths, 2007; SIDIIEF, 2011

By courtesy of W. Sermeus

Nursing education in Europe 2011

MA, PhD

(18)

Nursing education in Europe 2011

First cycle 2de

and 3e cycle Country Professional edu. University College University Master and PhD

MA, PhD

Nursing education in Europe 2011

MA, PhD

Nursing education in Europe 2011

MA, PhD

By courtesy of W. Sermeus SIDIIEF, 2011

Nursing education needed for the

future

MA, PhD

Nursing education needed for the

future

Development

Time

Level of nursing education

(19)

Nursing education needed for the

future

First cycle 2de and 3e

cycle Country Professional edu. University College University Master and PhD

MA, PhD

Clinical Master education

Advanced Practice Nursing curriculum

PhD prepared nurses

• Developing new interventions • Evaluating effectiveness of

nursing interventions

• Advancing new concepts of care • ……..

Contributes largely to the maturity of the nursing discipline

Take home messages

5. Cardiovascular nurses should identify issues in which they can make a difference, e.g. sexual counselling 6. Establish clinical Master education – Increase number

of PhD prepared nurses

Future of nursing

• Transforming practice

• Transforming education

• Transforming leadership

• Meeting the need for better data on the

healthcare workforce

Future of nursing:

Transforming leadership

1. Prepare and enable nurses to lead change to

advance health

(20)

Nurse leadership

Macro

Meso

Micro

Nurse leadership should be involved in

“Health-in-all”

• Integrated approach of health and other policies • Health-in-all policy addresses the effects on health

across all policies such as agriculture, education, environment, fiscal policies, housing and transport. • It seeks to improve health and at the same time

contribute to the well-being and the wealth of the nation through structures, mechanisms and actions planned and managed mainly by sectors other than health. • Health-in-all policies are a top priority for the WHO and

the EU.

Nurse leadership should be involved in

“Health-in-all”

• Smoking ban in public places • Advertisement for sigarettes

• Side-walks, pedestrian overpasses, bike/walk trails to promote safe physical activity

• Subsidized export of whole (fatty) milk of French farmers to Swedish schools

• ……….

IMPACT OF NURSING ON THE SYSTEM

Nurse leadership should be involved in

“Health-in-all”

Healthy Communities Public Health Land Use & Planning Agriculture & Food Councils Transport-ation Parks & Recreation Public Safety Economic Development Housing

Take home messages

5. Cardiovascular nurses should identify issues in which they can make a difference, e.g. sexual counselling 6. Establish clinical Master education – Increase number of

PhD prepared nurses

7. Nurse leadership should be involved in “health-in-all” policy

Future of nursing

• Transforming practice

• Transforming education

• Transforming leadership

• Meeting the need for better data on the

healthcare workforce

(21)

Future of nursing:

Data on workforce

1. Build an infrastructure for the collection and

analysis of interprofessional health care

workforce data

Data on health care workforce

• Denmark renowned for extensive and complete databases

Take home messages

5. Cardiovascular nurses should identify issues in which they can make a difference, e.g. sexual counselling 6. Establish clinical Master education – Increase number of

PhD prepared nurses

7. Nurse leadership should be involved in “health-in-all” policy