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