Nurse Practitioner/Physician Assistant Education and the Management of HCV
Johnson, Ruth W., Holman-Speight, Tracy, ABNF Journal
Abstract: In this article, the authors discuss the consequences of the 911 attack on the United States and the concomitant increase in the noted prevalence of Hepatitis C Virus due to the presence of the virus in the blood donors. The authors discuss the background and consequences of infection with the virus, epidemiology, impetus for curricula development, curricular outcomes, curricula modules, and HCV case management for nurse practitioners (NPs) and physician assistants (PAs).
Key Words: Nurse Practitioner Education, Physician Assistant Education, HCV Infection, Case Management of HCV.
The horrendous act of 911 brought Hepatitis C Virus (HCV) awareness to the forefront of public health concerns. Many of the courageous people on that day wanted to assist those less fortunate. These were the people who had terrible burns, broken bones, and severely punctured wounds. These were people who needed blood transfusions to possibly sustain life. Volunteers arrived at the hospitals in large numbers. A noble act for certain. However, a problem existed that was not anticipated. To the surprise of many health care workers, many of the donors unknowingly were infected with HCV. HCV very quickly and quietly has become a serious public health concern and problem.
HCV is one of the leading known causes of liver disease in the United States. Thirty-five thousand new cases occur annually; and the number of adults infected with HCV is projected to increase by fourfold. HCV is found in at least 1.8 percent of the population, and is the most common chronic bloodborne disease in the United States.
HCV is a virus of the Flaviviridae family. There are six HCV genotypes and more than 50 subtypes. These genotypes differ by as much as 31 - 34 percent based on their nucleotide sequences; whereas, subtypes differ by 23 to 23 percent based on a full-length genomic sequence comparisons. The lack of a vigorous T-lymphocyte response and the high propensity of the virus to mutate, appears to promote a high rate of chronic infection. The extensive heterogeneity of HCV has important diagnostic and clinical implications. Genotype 1 accounts for 70 - 75 percent of all HCV infections in the United States, and is associated with a lower response rate to treatment (National Institute of Health [NIH], 2002).
It is estimated according to the National Health and Nutrition Examination Survey (NHANES, 1994) that over 3.9 million Americans were infected with HCV. It has also been estimated that of this group, 2.7 million are chronically infected. This figure does not include members of the population who are incarcerated, homeless, or institutionalized. Because most members of the population with chronic HCV infection have yet to be diagnosed with chronic HCV, it has been projected (1990 - 2015) that in the next decade those infected are likely to seek medical attention. Currently, persons aged 40 -50 years have the highest prevalence of HCV infection, and in this group, the prevalence is highest (6.1 percent) in African Americans (NIH, 2002). Transmission primarily occurs through exposure to infected blood. This exposure includes injections from drug use, unsafe medical practices, occupational exposure to infected blood, and birth to an infected mother, sex with an infected person, high-risk sexual practices and intranasal cocaine use. Any persons having blood exposure related to blood transfusions or organ transplants prior to 1992 would benefit from HCV testing. The introduction of serosensitive tests virtually eliminated transmission of HCV from blood products and organ transplants (NIH, 2002). HCV seroprevalence rates (from 15 to 20 percent) have occurred in specific subpopulations, such as the homeless, incarcerated persons, injection drug users, and persons who were treated with hemophilia who were treated with clotting factors before 1992. The highest seroprevalence rates (70 percent to more than 90 percent) have been reported in the last two of these groups.
IMPETUS FOR CURRICULA DEVELOPMENT
Given the fact that HCV is a leading cause of liver disease in the United States, that African Americans have a higher prevalence of chronic HCV infection than whites (3.2 percent compared to 1.5 percent), and because African Americans have disproportionately higher rates of HCV infection, disease management strategies must be especially targeted to eliminate or minimize negative health outcomes. In a majority of nurse practitioner (NP) and physician assistant (PA) programs, curricula have very little time allocated for learning or discussion related to communicable disease. Generally, communicable diseases in NP and PA programs are limited to a discussion of Universal Precautions. Communicable diseases are usually compartmentalized and the lecture consists of very basic information. One strategy considered was the development of a highly technical program that would educate Nurse Practitioners (NPs) and Physician Assistants (PAs) about case management of the population diagnosed with HCV. Funding for the project, known as the Hope C Project, was obtained through the collaborative efforts of Integrated Systems Management, the Graduate Program for Nurse Practitioners, the program for Physician Assistants at Howard University and the Center for Healthcare Excellence at Morehouse University. These institutions also provided the impetus for curricula development and implementation.
The operational methodology, agreed to by selected faculty members representing each program, for the curriculum would include the comprehensive case management services provided by the NPs and PAs in community settings. A survey conducted by the Project Manager indicated that the NP and PA programs in the local area supported the need for a comprehensive curriculum on HCV. The survey also indicated that most gastroenterologists and hepatologists welcomed the assistance of the NP and PAs in HCV case management.
It was acknowledged that the chronic nature of the disease required NPs and Pas who could take the time to spend with the patient. The illness and the patient's response to the illness relegated that constant, consistent care was needed.
It was determined by the faculty team that the developed program would follow valid educational principles in determining curricular outcomes. The outcomes would be measurable and would indicate to the faculty team if the curriculum was effective in its delivery of content related to HCV.
The following curricular outcomes were noted as critical to the success of the programs:
1. Have a comprehensive understanding of HCV infection process.
2. Identify the impact of HCV on the various health disparities.
3. Identify important components of health assessment, clinical screening and diagnostic evaluations related to HCV infection.
4. Discuss principles of community health related to caring for persons with HCV.
5. Identify cultural, psychological and spiritual implications related to HCV infection.
6. Identify criteria for treatment and treatment options related to HCV infection.
7. Journalize essential data findings for future research.
Educational modules were selected as the method for instruction. The traditional lectures were presented by power point as well as lecture. The benefit of the modules was twofold. First, the educational modules allowed for independent interactive activity and the opportunity for exercises of critical thinking. Each module was formulated to include educational objectives, expected outcomes. Teaching/learning strategies, critical questions, and case studies were included. A total of eleven modules were developed and each module covered specific content.
Curricular modules included in the programs were the following:
1. HCV Course Overview
2. HCV and Health Disparities
3. Epidemiology and Risk Factors
4. Pathophysiology Related to HCV
5. Health Assessment and Screening
6. Treatment Options for HCV Infection
7. Case Management Model
8. Functional Literacy Issues
9. Culture and HCV
10. Principles of Community Health, Depression, Diagnosis and Treatment
Module refinement was conducted after session evaluations. Modules were either combined or condensed as needed. Information related to HCV was updated frequently as required by new research information. The more technical part of the content proved to be challenging for the NPs and PAs. There were many questions related to pathophysiology that were quite complex. A hepatologist was requested to join the team representing the Howard University faculty. The team consisted of the hepatologist, who spoke about the disease process, a psychiatrist, who lectured on depression as a result of having a chronic illness, the director of the PA program, who is a medical doctor, whose lectures were concentrated on the need for client/patient teaching, and a nurse clinical specialist, chair of the NP program whose lectures were on the cultural dimensions and implications of chronic illnesses. Classes were usually scheduled from 9-5 p.m. with sufficient breaks so that all participants could take of personal matters, check their e-mails, phone calls, etc.. The educational sessions occurred in Atlanta, Georgia.
IMPLICATIONS FOR FUTURE RESEARCH
The implications for future research as the NPs and PAs worked in the community became evident. Implications for future research involved four areas. The four areas identified are:
1. Biogenetic variables related to pharmacological therapy.
2. Cultural variances related to treatment.
3. Educational strategies for client instruction.
4. Gender differences related to treatment response.
All of the NPs and PAs reported a marked improvement with the pharmacological use of a particular medication in African Americans. Some clients/patients reported the use of folk medicine as a remedy for HCV and questioned the use of the remedy along with western medication. These phenomena occur mainly in the south and the southwest.
Educational strategies became a challenge for everyone as the NPs and the PAs interacted with their clients/patients. Some client/patient groups were quite knowledgeable about HCV, and the sessions turned into one where the PAs had to rethink their approaches to client/patient education and redefine the purpose of the group meetings. Gender differences related to sexual response when taking medication for HCV was of importance to the men who participated in the project. Female concern relative to sexual functioning has not emerged as an area of concern. All NP and PA participants are asked to maintain ajournai to document areas of interests, concerns and any unusual occurrences.
It is anticipated that as the Hope C Project continues to implement its educational program, continue with its community efforts, and the treatment of clients with HCV that other areas will emerge and these areas may indicate the need for future research. The promise from this futuristic activity can take this educational project to another level.
HCV CASE MANAGEMENT
An integral component of the Hope C Project is the infrastructure created by the nurse practitioners (NPs) and the physician assistants (PAs). The organization outlay imports mid-level practitioners into established clinical settings. The uniqueness of the NPs/PAs role is one that allows gastroenterologists and primary care physicians the ability to focus on the cumbersome treatment of Hepatitis C (HCV), and begin to treat their patients with HCV.
The educational curriculum allows the novice mid-level practitioner to the expert mid-level practitioner the ability to strategize a clear concept of how the affects of case management can lead to optimal changes in the treatment of HCV. An area of major concern for the Hope C team of NPs/PAs is the outreach efforts made to the public. Past research suggests that African American males between the ages of 39 50 years are among the highest prevalence of persons affected by the Hepatitis C virus. It is known that there are approximately four million Americans suffering from HCV, and this does not include the incarcerated, mentally ill, and homeless populations. With this knowledge, the NPs/PAs need to implement strategic plans within the framework of existing organizations to perform the necessary outreach in the communities where the prevalence of the disease and the organizational structure of case management may not exist. Community health becomes a concern of equal intensity as in the realm of case management.
Case management for the mid-level practitioner is unique in that there is an opportunity to treat HCV, as well as become an integral component/specialist in the management of the disease in relation to the individual patient. The case manager strategically engages an infected person in the management of the HCV disease entity by allowing them to become active in their own management care of the disease. The combination of interferon and ribaviran therapy is the standard treatment for HCV and can present a patient with many challenges before any signs of reward are achieved. Prior to treating HCV, the patient must undergo a series of tests to determine the status of the virus. The patient will be required to undergo serology tests, an abdominal sonogram and in many cases, a liver biopsy. The patient should also be evaluated by a mental health provider because of the known side effects of treatment, in particular, depression. This is done to provide safety measures for the patient prior to the initiation of treatment. Although each clinical practice differs, clinicians need to competently assess and monitor their patients based on clinical judgment, if no prior history of mental illness is noted. This preliminary work-up can present for the patient as a hardship, and in some instances can be a barrier to treatment. The idea of so many doctor visits for some patients such as the working, who won't take time off from work, to the un-insured patient who can't afford the medicine, to the dependent patient relying on the "system" to see that they get their appointment, can become problematic in treating this disease.
Physicians have been very receptive to the idea of midlevel practitioners case managing their patients. In Project Hope C, the NPs/PAs do not "take" patients from the physician of origin; nor do the NPs and PAs claim the client/patient as their own.
The treatment for HCV is labor intense both for the patient and the provider. Physicians are able to co-manage their patient with the NP/PA without regard to feeling that they may lose their patient if they were to send them to a "hepatology specialist" in primary care situations. This working relationship allows for total patient management of HCV in which the patient is the center of attention.
A major role for the NP/PA is to then develop viable strategies with patients to help them on their treatment regimen. Any obstacle presented to a patient can prove overbearing, and thus the patient may not consider treatment and/or discontinue treatment. It is highly recommended that obstacle (i.e., environmental stressor, co-morbid diseases, etc.) presented by the patient be validated and assessed prior to the start of treatment, and throughout the treatment to reduce the possibility of any interruptions of treatment.
There were many lessons learned as a result of implementing the curriculum. Regardless of the preparation of the NPs and PAs, there was a need to implement a comprehensive curriculum. The benefit of this activity was that everyone began from the same knowledge base. Because some of the NPs and PAs were advanced in their experience with HCV patients, current information based on research results were essential as an addition to the curriculum. This information always generated a great deal of discussion between the NPs, PAs and the lecturers for the course. The benefit was that all of the participants contributions were listened to very attentively.
The NPs/PAs case Managers provide consistent collaborative, supportive medical case management for the patient. The NPs and PAs are responsible for total care and answering questions of the patients seen. The case managers' allegiance to the physician is one that builds upon trust and respect for the quality of care provided to the patient. The quality of the relationship between the NP and PA has had a direct impact on the patient with HCV. The patients learn that the NP, the PA and the physician are collaborative and consult each other regarding the care of the patient. The NPs/PAs are the first line of resource for the patient with HCV. Patients have been reported to send thank you cards, flowers, and other small tokens of appreciation. In the words of one patient, "I was so afraid in the beginning. Thank you for helping me get through my hardest times. This has all been worth it."
National Institute of Health. (2002).
National Health and Nutrition Examination Survey. (1994).
Ruth W. Johnson, EdD, RN, CS, FAAN and Tracy Holman-Speight, MSN, RN, FNP
Ruth W. Johnson, EdD, RN, CS, FAAN, is chair and associate professor in the Department of Nursing at Fayetteville State University. Dr. Johnson may be reached at: firstname.lastname@example.org. Tracy Holman-Speight, MSN, RN, FNP, is lead supervisory nurse practitioner for Project Hope C.…
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Publication information: Article title: Nurse Practitioner/Physician Assistant Education and the Management of HCV. Contributors: Johnson, Ruth W. - Author, Holman-Speight, Tracy - Author. Journal title: ABNF Journal. Volume: 16. Issue: 3 Publication date: May/June 2005. Page number: 60+. © Not available. Provided by ProQuest LLC. All Rights Reserved.