- Email: [email protected]
Palliative medicine nurse preceptorship at the Medical College of Wisconsin
SpeiialArlick
Palliative Medicine Nurse Preceptorship at the Medical College of Wisconsin Julie Criflie, RN, Cs, APNP, and David E. Weissman, MD L&vi&n o/HCncdq (IG., D.E. W), Palliatiw Medicin* hgram (D.E.lC). apmholr o/ Mrdiciw, MaiicaI Cd@ o/ Wisonuin, Mihauht, Wisconsin
This arti& dacdcs (I 3dq ntmr pwqbtonhip pdutnlion pmgnnn in unun pain nud pauiativ wwdicine at the Mtxiid Gd4tge of Wisconsin (MCW). The program include shills dcwlopmml, ottd acrisknw with p&awning e-3$h&d and didadic itqii, J&r institutional change ita th &&wry OJ health rmr srrvira Thr edutotion pugram is cmtmd amuad)ioc tmchng mada&: fxah, non@in symptms, hospice nuning po/assiad issues, and fmdhative care. Eualuatiow dokz jrom (I rwmt cohort of 2? IU)TPJ dmoRstmrc that leaming and pmorrnl +trUer were nrt to n high dqre oj sati$artion.
0 U.S. Cancer Pain Relief Committee. I!?96 J Pain Symptom Manage I !%;I
2:3f50-363.
There b a critical need for the availability of training programs for all health professionals in cancer pain and palliative medicine. In particular, experiential opportunities that provide opportunities for skills training, role mcdeling, and ongoing support are desperately needed to help change the manner in which dying patients and their families are cared for in the United States. Since 1991. lbe Palliative Care Program of the Medical College of Wisconsin has been developing a wide array of didactic and experiendal education programs for health professionals at all educational levels. A major AddnrunpiRlrqmcrnraDavidE.Wcissman.MD, Hetnamhgy onedogy DiGon. Fro&err Haspit& Ik?I,92l?DWSlW mcomin Awznue, Mihaukce. WI ci3226.WA. z4t-+ed&m February 28L8.1996.
emphasis has been to link the acadrmic mrdical center wilh the needs of community heahh care providers.’ In 19913. a nurse preceptorship progmm was begun to provide an experiential opportunity for community nurses wishing advanced rraining in pain managemenc and palliative care.’ This article describes dre educational objectives, contenr. and evaluation of this progmm. l+vceptorship
Descripion
The Palliative Medicine Nurse Preceptorship Program (NPP) is coordinated by the Palliative Medicine Program in the Division of Hematology/Oncology at the Medical College of Wisconsin. The program is designed as a S&y experiential learning opportunity for nurses seeking advanced training in cancer pain and palliative medicine. Numes appropriate for lhis program include lhose working in hospicr. home care, hospital, rv long-term 088139!24/%/$15.00
PII sosB.59924(%)%1844
care setting Nurses in education or supervi.. sory powocs and nutses who work in human immunodehcicncy virus (HIV) or oncology clinics are also appropriate. The NPP is approved for continuing education units by the Wiionsin Nutses Association. Educalion Gmlcnt The NPP included a prtit nmmenr survey, completed hy the uainee. tc assist the Erculty in determining the best use of axulable educalinualexpedencuAllhestarldlhc~ gram, uainees compiete a 28quesdon palliative care knovdedge survey, which is subsequently used as a major teaching tool. Faculty rwiew the survey in depth with the nainee, identifying knowledge gaps and attitude barrien and suggesting resources for further education. Education content is divided into five modules: pain assessment and management, management of rumpain symptoms, hospice care, professional issues/decision making, and palliative care. Trainees receive a list of learning objectives, learning activities, and key references for each module (Table 1). Fducational opportunities for all trainees include daily rounds with the Palliative Care Cottsuhation Service (inpatient and outputient);
attendance at weekly cmcer pain roundr; and completion of the teaching syilah~.~’ ‘Fhe sylk husco”lain%kqarlidesaodcascsllxlk5.Uec. cive op~ues include attendance at a multidisciplinary pain clinic (predominantly noncancer pain) and HIV or radiation oncology clinics. home visits with a hospice nurse or social worker; attendance at a hospice team meeting. or rounds with MC% hiucti consultahn service. Fxperiential learning includes direct patient consultations and written case studies. Participants are expected to develop a plan of care for patients seen on the Palliative Care Consultation Service that includes management of pain and any nonpain symptoms. together with identification of relevant psychosocial, ethical, and disposition issues. Fach participant is expected to pctform and discuss three pain -menu. including one observed pain -merit and/or a cr&iqued pain aacument using a simulated patient In addition, they are to perform an amessment and develop a management plan for at least twn nonpain symp tams. Case studies in the teaching syllabus combine problems of symptom management with decision making and disposition issues to
362
VoL 12 No. 6Lkembm 195%
Gtifie and Ikisman
provide a realistic problem solving challenge. Nurses have an opportunity IO learn and practice the use of a simple cognitive assessment scale and, using either real patient problems or written case studies, practice equianalgesic opioid dose conversions. Finally, reviewing paticms scctt on the consultation service, nurses work directly with inpatient discharge plannets to discuss issues related to hospice referral. These issues include finances, identificatior: of home caregiven, and level of nutsing support needed in the home. The inal aspect of the NPP involves a commitment to help trainees begin the process of changing the pattern of clinical practice in their own setting. Most nurses who enter the program have this as a stated goal. The faculty work with the trainee to identify specific goals of practice change (for example, start a pain assessment program), identify the barrien to change (for example, lack of administrative support); and help develop a strategy for beginning the change process (for example, formation of a pain assessment task force using a quality improvement model).
Program Evaluation Trainees complete a detailed 4lquestion evaluation of the NPP, including program content, whether or not program objectives and petsonal learning object&s were met, content organization ana relevance, and faculty teaching. All questions are rated using a l-4 scale where I = objectives met to a less than average degree, 2 = average degree, 3 = to a high degree, and -1 = to an exceptionally high degree. Narrative comments are encouraged. Since 1994,40 mtnes have patticipated in the NPP. Thii at-tide only presents evaluation information from the largest r:niform nurse cohort, 23 nurses who completed the NPP between Sep tember 1994 and January 1995. These muses were participants in a reg&tal progr~ to help institutionalize pain management practices within their respective practice settings.” Of the 23.15 worked iu acute care hospitals, 4 in ho+ pice agencies, 2 in long-term cam, 1 in an outpatient setting. and I muse wz irl an academic nutsing education position. AU 23 trainees had completed a Iday training program in pain management using rhe Role Model education format of the Wisconsin Cancer Pain Initiative.“J The opportunity
TDblr 2 A Sample of Narratin Co-nb AhouttbeNumeReeeptolahipRogRm
_
“The 3 dayswere a real stimulant” “It is helpful to seehow others have developedand function within estabtiihedprograms.to give ideas and sttppo” as we ty to meet our patient n:cds” “Thk wasa wonderful and valuableexperience” “So much content. so little rime” “I qainrd many more imighu into the goatsof palliation” “I ..ill -ccommendthis to &en” “I loved the entire experienceand hope to return” “Culture shock!-great experience” “My patients and 1 thank you for the excellent learning opportunity” “Feel vcly fortunatr to have this chanceto learn new information this way” “Clinical portion really ‘put it together’when combined wtth a lecture ponion”q
for these nurses subsequently to participate in the NPP was elective. based on the trainees’ desire for additional education and practicaJ experience in pain management and palliative care. There is ongoing evaluation of the impact of these trainees on their respective practice settings. Twenty program evaluation surveys were complete and available for review. The average score for questions asking about completion of stated program objectives tanged from 2.8 to 3.7 (Table 1). Average scores for questions rtlating to content organization, relevance, and meeting personal objectives ranged from 3.4 to 3.5. Average scores for questions regarding faculty teaching style and methods tanged from 3.4 to 3.8. Narrative comments were written in 15 of 20 surveys-all comments were positive. A sample of the narrative comments is presented in Table 2.
Dish If US health care facilities are to advance the clinical care of dying patients, new training programs must be established to teach physicians and nurses critical knowledge and skills. Without question, nurses are the key members of the health care team to begin and carry forward the process of institutional change in pain and palliative care service delivery. As such, nurses have been targeted for a variety of special education progtams.w
Vol. 12 No. 6 L)rumber 19%
Pabtim MedicineNuns hwplodip
Community health professional education is a major component of the educational mission of the M C W Palliative Care Program, and considerable effort has been made since 1993 to recruit a network of Wisconsin nurses from various health care settings, working individually or as part of a larger team, who can act as institutional change agents. Key principles of this approach to community nurse education includes the following Use of multiple education formatsincluding lecture, small group, and experiential learning opportunities
l
l
l
incorporation of skills training, for example, pain assessment, care plan development, communication skills Availability of practical tools, for example, standards, policies
. Ongoing support including availability to respond to questions, provide encoumgemerit, and continue the process of skills development The preceptorship experience is. thus, but one aspect of nurse education. The NPP experience described here is a short, intensive, experiential immersion in pain and palliative medicine. It has clearly defined learning objectives and a wide variety of learning experiences. It can be utilized by muses seeking personal growth and by nurses wishing to become change agents for pabdtiw are service delivery. Evaluations from nurses participating in the program as future change agents indicate that they found the experience very worthwhile. As stated in the narrative comments, participants not only learned new knowledge and skills but benefited from the role modeling provided by the faculry-a key educational tool for assisting practice behavior change.‘” Future plans for the preceptorship experience include continued development of ways to teach and evaluate critical skills inclnJing pain and nonpain symptom assessment and management; seeking of ways to incorporate clinical bioethics into daily practice; and plac-
363
ing a greater emphasis on spiritual and cuftural awareness. The major problem with the current NPP is that it is extremely time and labor intensive-requiring one-one supervision for most of the S-day experience. A rns; ?r challenge for expansion of the program v&I be to develop the staffing and financial resources nectary to continue a high degree of interactive, experiential learning.
AChOWlt?~ The authors’ work is supported
by National
Cancer Institute Cancer Pain Fducation grant K25 CA57786 and a grant from the MAYLM Foundation.
1. Weissman DE, Palfiatiw medicine education at the Medical Cdlege of Wisconsin. Wise Med J 1995; 94305408. 2. Griffic J. Weissman DE. The development of a palliative care nurse preceptorship program for enhancing the palliative care expertise of commnnity nurses [abt]. J Cancer Educ 1994;9(suppl):lS.
3. Weissmm DE, Giffie J. The Palliatiw Care Consultation Service of the Medical College nf M+consin. J Pain Symptom Manage 1994;9:474-479. 4. Weissman DE, Abrxn DE, Haddox JD. et at. The eriucational role of cancer pain rounds. J Cancer Educ 1989;4:113-116. DE. Changing pain manage 5. GrifFte J. Weii mcnf prwtice patterns after education: yrporting insdwtional effnrts to improve outcomes of ana&GC treatment [ah]. J CancerEduc 1995;1O(suppl)15.
6. WeissmanDE, Dahl JL Beasfey JW. The Cancer Pain Role Model Pmgram of the W=nnsin Cancer Pain Initiative. J Pain +nptom Manage 1993829-35. 7. Weissman DE, DahlJL Update on the Cancer Pain Role Model Education Program. J Pain Symp tom Manage 1995;10292-297.
8. Ferrell BB, Cram M. Birchey XJ. et al. Ths pain resource approach
nurse training program: a unique to pain management. J Pain Symptom
Manage 1995;8:54+558. 9. Ferrell BR. Dean GE, Grant M. Colurzi P. An institutional commitment to pain management. J Clin Oncol 1995;19:2158-2165. 10. Greco PJ. Eisenberg JM. Changing physicians’ practices. New Engl J Med 1995;329:127l-1274.
Palliative Medicine Nurse Preceptorship at the Medical College of Wisconsin Julie Criflie, RN, Cs, APNP, and David E. Weissman, MD L&vi&n o/HCncdq (IG., D.E. W), Palliatiw Medicin* hgram (D.E.lC). apmholr o/ Mrdiciw, MaiicaI Cd@ o/ Wisonuin, Mihauht, Wisconsin
This arti& dacdcs (I 3dq ntmr pwqbtonhip pdutnlion pmgnnn in unun pain nud pauiativ wwdicine at the Mtxiid Gd4tge of Wisconsin (MCW). The program include shills dcwlopmml, ottd acrisknw with p&awning e-3$h&d and didadic itqii, J&r institutional change ita th &&wry OJ health rmr srrvira Thr edutotion pugram is cmtmd amuad)ioc tmchng mada&: fxah, non@in symptms, hospice nuning po/assiad issues, and fmdhative care. Eualuatiow dokz jrom (I rwmt cohort of 2? IU)TPJ dmoRstmrc that leaming and pmorrnl +trUer were nrt to n high dqre oj sati$artion.
0 U.S. Cancer Pain Relief Committee. I!?96 J Pain Symptom Manage I !%;I
2:3f50-363.
There b a critical need for the availability of training programs for all health professionals in cancer pain and palliative medicine. In particular, experiential opportunities that provide opportunities for skills training, role mcdeling, and ongoing support are desperately needed to help change the manner in which dying patients and their families are cared for in the United States. Since 1991. lbe Palliative Care Program of the Medical College of Wisconsin has been developing a wide array of didactic and experiendal education programs for health professionals at all educational levels. A major AddnrunpiRlrqmcrnraDavidE.Wcissman.MD, Hetnamhgy onedogy DiGon. Fro&err Haspit& Ik?I,92l?DWSlW mcomin Awznue, Mihaukce. WI ci3226.WA. z4t-+ed&m February 28L8.1996.
emphasis has been to link the acadrmic mrdical center wilh the needs of community heahh care providers.’ In 19913. a nurse preceptorship progmm was begun to provide an experiential opportunity for community nurses wishing advanced rraining in pain managemenc and palliative care.’ This article describes dre educational objectives, contenr. and evaluation of this progmm. l+vceptorship
Descripion
The Palliative Medicine Nurse Preceptorship Program (NPP) is coordinated by the Palliative Medicine Program in the Division of Hematology/Oncology at the Medical College of Wisconsin. The program is designed as a S&y experiential learning opportunity for nurses seeking advanced training in cancer pain and palliative medicine. Numes appropriate for lhis program include lhose working in hospicr. home care, hospital, rv long-term 088139!24/%/$15.00
PII sosB.59924(%)%1844
care setting Nurses in education or supervi.. sory powocs and nutses who work in human immunodehcicncy virus (HIV) or oncology clinics are also appropriate. The NPP is approved for continuing education units by the Wiionsin Nutses Association. Educalion Gmlcnt The NPP included a prtit nmmenr survey, completed hy the uainee. tc assist the Erculty in determining the best use of axulable educalinualexpedencuAllhestarldlhc~ gram, uainees compiete a 28quesdon palliative care knovdedge survey, which is subsequently used as a major teaching tool. Faculty rwiew the survey in depth with the nainee, identifying knowledge gaps and attitude barrien and suggesting resources for further education. Education content is divided into five modules: pain assessment and management, management of rumpain symptoms, hospice care, professional issues/decision making, and palliative care. Trainees receive a list of learning objectives, learning activities, and key references for each module (Table 1). Fducational opportunities for all trainees include daily rounds with the Palliative Care Cottsuhation Service (inpatient and outputient);
attendance at weekly cmcer pain roundr; and completion of the teaching syilah~.~’ ‘Fhe sylk husco”lain%kqarlidesaodcascsllxlk5.Uec. cive op~ues include attendance at a multidisciplinary pain clinic (predominantly noncancer pain) and HIV or radiation oncology clinics. home visits with a hospice nurse or social worker; attendance at a hospice team meeting. or rounds with MC% hiucti consultahn service. Fxperiential learning includes direct patient consultations and written case studies. Participants are expected to develop a plan of care for patients seen on the Palliative Care Consultation Service that includes management of pain and any nonpain symptoms. together with identification of relevant psychosocial, ethical, and disposition issues. Fach participant is expected to pctform and discuss three pain -menu. including one observed pain -merit and/or a cr&iqued pain aacument using a simulated patient In addition, they are to perform an amessment and develop a management plan for at least twn nonpain symp tams. Case studies in the teaching syllabus combine problems of symptom management with decision making and disposition issues to
362
VoL 12 No. 6Lkembm 195%
Gtifie and Ikisman
provide a realistic problem solving challenge. Nurses have an opportunity IO learn and practice the use of a simple cognitive assessment scale and, using either real patient problems or written case studies, practice equianalgesic opioid dose conversions. Finally, reviewing paticms scctt on the consultation service, nurses work directly with inpatient discharge plannets to discuss issues related to hospice referral. These issues include finances, identificatior: of home caregiven, and level of nutsing support needed in the home. The inal aspect of the NPP involves a commitment to help trainees begin the process of changing the pattern of clinical practice in their own setting. Most nurses who enter the program have this as a stated goal. The faculty work with the trainee to identify specific goals of practice change (for example, start a pain assessment program), identify the barrien to change (for example, lack of administrative support); and help develop a strategy for beginning the change process (for example, formation of a pain assessment task force using a quality improvement model).
Program Evaluation Trainees complete a detailed 4lquestion evaluation of the NPP, including program content, whether or not program objectives and petsonal learning object&s were met, content organization ana relevance, and faculty teaching. All questions are rated using a l-4 scale where I = objectives met to a less than average degree, 2 = average degree, 3 = to a high degree, and -1 = to an exceptionally high degree. Narrative comments are encouraged. Since 1994,40 mtnes have patticipated in the NPP. Thii at-tide only presents evaluation information from the largest r:niform nurse cohort, 23 nurses who completed the NPP between Sep tember 1994 and January 1995. These muses were participants in a reg&tal progr~ to help institutionalize pain management practices within their respective practice settings.” Of the 23.15 worked iu acute care hospitals, 4 in ho+ pice agencies, 2 in long-term cam, 1 in an outpatient setting. and I muse wz irl an academic nutsing education position. AU 23 trainees had completed a Iday training program in pain management using rhe Role Model education format of the Wisconsin Cancer Pain Initiative.“J The opportunity
TDblr 2 A Sample of Narratin Co-nb AhouttbeNumeReeeptolahipRogRm
_
“The 3 dayswere a real stimulant” “It is helpful to seehow others have developedand function within estabtiihedprograms.to give ideas and sttppo” as we ty to meet our patient n:cds” “Thk wasa wonderful and valuableexperience” “So much content. so little rime” “I qainrd many more imighu into the goatsof palliation” “I ..ill -ccommendthis to &en” “I loved the entire experienceand hope to return” “Culture shock!-great experience” “My patients and 1 thank you for the excellent learning opportunity” “Feel vcly fortunatr to have this chanceto learn new information this way” “Clinical portion really ‘put it together’when combined wtth a lecture ponion”q
for these nurses subsequently to participate in the NPP was elective. based on the trainees’ desire for additional education and practicaJ experience in pain management and palliative care. There is ongoing evaluation of the impact of these trainees on their respective practice settings. Twenty program evaluation surveys were complete and available for review. The average score for questions asking about completion of stated program objectives tanged from 2.8 to 3.7 (Table 1). Average scores for questions rtlating to content organization, relevance, and meeting personal objectives ranged from 3.4 to 3.5. Average scores for questions regarding faculty teaching style and methods tanged from 3.4 to 3.8. Narrative comments were written in 15 of 20 surveys-all comments were positive. A sample of the narrative comments is presented in Table 2.
Dish If US health care facilities are to advance the clinical care of dying patients, new training programs must be established to teach physicians and nurses critical knowledge and skills. Without question, nurses are the key members of the health care team to begin and carry forward the process of institutional change in pain and palliative care service delivery. As such, nurses have been targeted for a variety of special education progtams.w
Vol. 12 No. 6 L)rumber 19%
Pabtim MedicineNuns hwplodip
Community health professional education is a major component of the educational mission of the M C W Palliative Care Program, and considerable effort has been made since 1993 to recruit a network of Wisconsin nurses from various health care settings, working individually or as part of a larger team, who can act as institutional change agents. Key principles of this approach to community nurse education includes the following Use of multiple education formatsincluding lecture, small group, and experiential learning opportunities
l
l
l
incorporation of skills training, for example, pain assessment, care plan development, communication skills Availability of practical tools, for example, standards, policies
. Ongoing support including availability to respond to questions, provide encoumgemerit, and continue the process of skills development The preceptorship experience is. thus, but one aspect of nurse education. The NPP experience described here is a short, intensive, experiential immersion in pain and palliative medicine. It has clearly defined learning objectives and a wide variety of learning experiences. It can be utilized by muses seeking personal growth and by nurses wishing to become change agents for pabdtiw are service delivery. Evaluations from nurses participating in the program as future change agents indicate that they found the experience very worthwhile. As stated in the narrative comments, participants not only learned new knowledge and skills but benefited from the role modeling provided by the faculry-a key educational tool for assisting practice behavior change.‘” Future plans for the preceptorship experience include continued development of ways to teach and evaluate critical skills inclnJing pain and nonpain symptom assessment and management; seeking of ways to incorporate clinical bioethics into daily practice; and plac-
363
ing a greater emphasis on spiritual and cuftural awareness. The major problem with the current NPP is that it is extremely time and labor intensive-requiring one-one supervision for most of the S-day experience. A rns; ?r challenge for expansion of the program v&I be to develop the staffing and financial resources nectary to continue a high degree of interactive, experiential learning.
AChOWlt?~ The authors’ work is supported
by National
Cancer Institute Cancer Pain Fducation grant K25 CA57786 and a grant from the MAYLM Foundation.
1. Weissman DE, Palfiatiw medicine education at the Medical Cdlege of Wisconsin. Wise Med J 1995; 94305408. 2. Griffic J. Weissman DE. The development of a palliative care nurse preceptorship program for enhancing the palliative care expertise of commnnity nurses [abt]. J Cancer Educ 1994;9(suppl):lS.
3. Weissmm DE, Giffie J. The Palliatiw Care Consultation Service of the Medical College nf M+consin. J Pain Symptom Manage 1994;9:474-479. 4. Weissman DE, Abrxn DE, Haddox JD. et at. The eriucational role of cancer pain rounds. J Cancer Educ 1989;4:113-116. DE. Changing pain manage 5. GrifFte J. Weii mcnf prwtice patterns after education: yrporting insdwtional effnrts to improve outcomes of ana&GC treatment [ah]. J CancerEduc 1995;1O(suppl)15.
6. WeissmanDE, Dahl JL Beasfey JW. The Cancer Pain Role Model Pmgram of the W=nnsin Cancer Pain Initiative. J Pain +nptom Manage 1993829-35. 7. Weissman DE, DahlJL Update on the Cancer Pain Role Model Education Program. J Pain Symp tom Manage 1995;10292-297.
8. Ferrell BB, Cram M. Birchey XJ. et al. Ths pain resource approach
nurse training program: a unique to pain management. J Pain Symptom
Manage 1995;8:54+558. 9. Ferrell BR. Dean GE, Grant M. Colurzi P. An institutional commitment to pain management. J Clin Oncol 1995;19:2158-2165. 10. Greco PJ. Eisenberg JM. Changing physicians’ practices. New Engl J Med 1995;329:127l-1274.