Educating Tomorrow’s Nurses

November 2011Martha Ross

When Adrienne Franzese started her master’s degree studies at UCSF School of Nursing, she wanted to learn how to help people with mental illness cope with chronic pain.

Her interest grew during her first year of residency at Glide Health Services, a UCSF nurse practitioner-managed clinic in San Francisco’s tough Tenderloin neighborhood. As with the other 116 million Americans with chronic pain, the nearly 50 patients in Glide’s pain management program can’t rely on opioids as a permanent solution to end suffering. The drugs may lose their effectiveness as patients build tolerance. Addiction is a risk.

Plus, Glide’s patients present unique challenges. Many are poor, some are homeless, and they often have other health issues, including mental illness. Glide’s clinicians need to know as much as they can about a patient’s life outside the clinic, so that they can design an effective pain management plan. With that knowledge, they will typically employ a multimodal approach to pain management: medication plus non-pharmaceutical interventions such as physical therapy, stress reduction, support groups and counseling.

A new, two-quarter project planning course in the School of Nursing, Evidence-Based Practice for Advanced Practice Nurses, is giving Franzese the opportunity to test an idea to improve care. Her  project exemplifies the goals of the newly revised master’s curriculum at the School of Nursing.

Updated Curriculum Draws on Evidence-Based Needs

Franzese’s class is one of several that the School introduced last fall as part of an initiative to update the curriculum for master of science (MS) students. The purpose of the revision, led by a task force that included faculty, students and administrators, is to develop and implement an effective and efficient curriculum for future master’s-prepared students, so that they can provide high-quality, patient-centered care.

The curriculum revision takes place against a backdrop of major shifts in health care. Skyrocketing costs have forced the medical profession to pay greater attention to prevention and community-based care, often among diverse populations. Economics puts pressure on practitioners to watch the bottom line and employ methods that are proven to be efficient, beneficial and cost-effective.

Meanwhile, doctors continue to specialize, leaving nurses with growing responsibility for providing primary care, according to a 2010 report by the committee of the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine.

JoAnne Saxe “The new curriculum acknowledges that nurses are vital and central figures of any health care team,” says task force co-chair JoAnne Saxe, associate director of the School’s adult nurse practitioner master’s specialty program. Advances in technology and science provide opportunities to vastly improve care, and nurses need to know how to use the technology and translate evidence from research into practice, Saxe says.

More than ever, future nurses also must have the training to assume leadership roles in health care policy, whether it’s making the case for staff reassignments to cut patient wait times in an urgent care clinic or advocating changes on a national stage, task force members say.

Judy Martin-Holland “Nurses need a much broader sense of seeing how the systems work to get patients’ needs met,” says Judy Martin-Holland, the School’s associate dean for academic programs and diversity initiatives. “It’s broader than just diagnosing or treating or learning a certain set of tricks to keep in the game. It’s really taking more of a leadership role in assessing patient needs, and advocating for patients and improving care.”

The task force began its revisions in 2008 by studying other nursing programs and reports from various accrediting bodies. The new curriculum also reflects much of what is being promoted by professional organizations, including a report by the Carnegie Foundation for the Advancement of Teaching that was co-authored by Patricia Benner, a professor emerita in the School of Nursing.

Lynda Mackin Additionally, elements of the Institute of Medicine’s “Future of Nursing” report supported the case for change, particularly for faculty members who were initially hesitant, says Lynda Mackin, an associate clinical professor in the Department of Physiological Nursing.

A Careful, Ongoing Process for Change

The task force decided to focus on revising the MS core curriculum, not specialty courses. “When we did the assessment, we saw that the specialties have been doing an overall good job with being responsive to health care trends and professional role development,” Saxe says.

The core courses will provide a more solid background in skills that, Saxe says, have become essential to master’s-prepared nurses, including the ability to work in interdisciplinary teams, translate research into practice, adapt care to specific populations and demonstrate results.

A major addition to the curriculum is the Prologue, a one-week course held around the time of student orientation. It teaches fundamental skills that students need to succeed in their next two years of graduate work. It also brings students up to speed on the technology the School uses, such as library databases, a collaborative learning environment where students can view lectures online and electronically participate in discussion groups, and the UCSF Kanbar Center for Simulation, Clinical Skills and Telemedicine Education.

In addition, the Prologue gives students the chance to reflect on their individual strengths and challenges. “They might learn, ‘I’m a good writer,’ or ‘I’ve got some strong leadership skills, but I struggle with how to effectively communicate around times of conflict,’” Saxe says. As a summary of the students’ graduate program experience, there will be an Epilogue course, which is in development.

Task force members also wanted to make sure that master’s students received a solid foundation in research skills. The result is the two-part Advanced Scholarship in Research course, offered in the fall and winter quarters of the students’ first year.

Abbey Alkon Abbey Alkon, a professor in the Department of Family Health Care Nursing, described the way the revised curriculum also incorporates technology to make the large lecture course more interactive. Using handheld devices known as i>clickers, students can answer questions electronically, which allows Alkon to see their responses posted immediately on a projector screen. “The i>clickers are used to assess the students’ background knowledge and to review what they learned during the lecture,” she says.

And in keeping with the curriculum’s new emphasis on teaching students to demonstrate results, the curriculum itself will be subject to ongoing evaluation, task force members say. Students, faculty, staff, potential employers and other key stakeholders will have a role in providing input on what works and what doesn’t. Key to the evaluation is a quarterly “Connected Teaching” meeting, where faculty can share teaching successes and concerns and comment on the curriculum.

Translating Research and Education into Patient Care

As for Franzese, her idea is simple, but has potentially far-reaching implications. She will test a computerized flowchart, embedded in electronic clinic health records, that will display in one place vital data pertaining to each patient’s pain symptoms. Ideally, it will help clinicians quickly identify and address physical or psychological factors affecting patients’ pain levels.

Franzese spent her first two quarters analyzing research on pain management in clinical settings. This fall, she began creating the flowcharts. While these charts have been used successfully to help diabetes patients manage their condition, Franzese didn’t find literature showing they had been used for pain management.

She did find that data pertaining to patients’ mental and physical health are spread throughout patients’ files. Franzese’s idea is that the flowchart would allow nurse practitioners and doctors to easily spot trends – for example, noting that a patient’s back pain intensifies when he’s not physically active – and adjust treatment accordingly. As she tests out her idea, she will continue to work under the close supervision of a volunteer faculty facilitator. She’ll have the results of her project in December.

While the course asks that students aim to make small changes in a practice setting, Franzese hopes her idea will lead to significant relief for Glide’s pain patients, not least because Glide makes it easy for patients to access services that, the flowcharts suggest, could improve their condition.

“We’re dealing with an underserved population,” Franzese says. “There are so many medical issues going on with them, and their needs are not often met. What’s fantastic is that there is a wellness center in the Glide building that offers exercise classes, physical therapy and counseling.”

She also wonders whether the flowchart could prove to be a simple but effective strategy for other pain patients. She says, “The idea with this class is that you’re using evidence-based articles to develop a project to improve quality of care.”