Nurse Practitioners can Effectively Deliver Pain Coping Skills to Patients with Osteoarthritis

Transcription

1 Nurse Practitioners can Effectively Deliver Pain Coping Skills to Patients with Osteoarthritis PAT BRUCKENTHAL, PHD, APRN-BC, ANP, FAAN ASSOCIATE PROFESSOR STONY BROOK SCHOOL OF NURSING Acknowledgements Stony Brook University Joan Broderick, PhD (PI) Doerte Junhaenel, PhD Stefan Schneider, PhD Joseph Schwartz, PhD Alan Kaell, MD Elaine Gould, MD Christine Stamatos, DNP, ANP Stacey Vieritti Tursi, ANP Lauren Diot, ANP Duke University Francis Keefe, PhD David Caldwell, PhD Daphne McKee, PhD Shelby Reed, PhD Verena Knowles, ANP Mary Davidson, FNP Marjorie Thompson, FNP-S Funding: RO1 from NIAMS NIH award AR Background Arthritis affects 22% of population > ½ population (60%) diagnosed with OA by age 65 Interventions include analgesics, joint replacement, joint injections, exercise Pain Coping Skills Training (PCST) has demonstrated efficacy for OA Access to PCST is limited Nursing profession emphasis on self management and patient education 1

2 Purpose To determine whether NP s can treat OA patients with chronic pain of the knee/hip and achieve reductions in : Pain Physical function Psychological disability And increases in: Self efficacy Use of coping strategies QOL Secondary Purpose To develop a PCST model for NP s To test the effectiveness of PCST based on NP level of PSCT delivery competence METHODS Design: Multisite RCT (New York, Virginia, North Carolina) Setting: community primary care and rheumatology offices Subjects: (N=256) Physician confirmed OA of knee or hip (Kellergan-Lawrence grading system) Age 21 years or older Usual pain >/ 4 (0-10 rating scale) for at least 6 months Read, write, understand English Ability to attend 10 treatment sessions No expected joint replacement with in the next 2 years. Measures Arthritis Impact Measurement Scales (AIMS2):78 item, pain, mobility, function, self care α= Brief Pain Inventory (BPI): 4 items current, average, worst, least pain α=.89 Western Ontario and McMaster OA Index (WOMAC): 24 items pain, stiffness, physical function α= Coping Strategies Questionnaire (CSQ): 42 item engagement in coping strategies; coping self statements, praying, diverting attention α= Beck Depression Inventory (BDI): 21 item depressed mood α=.89 Arthritis Self Efficacy Scale: 8 item α=.92 Quality of Life Scale: 16 item α=.91 Brief Fatigue Inventory (BFI) : 4 items α=.86 End of day symptom diaries: IVR recordings for 7 days following each assessment period. Pain intensity, interference with physical, social, work activities, pain medication usage. Primary Outcome Measures Pain intensity Physical functioning Psychological distress Coping Catastrophizing Self efficacy Quality of Life 2

3 PCST Procedure 10 individual weekly session in provider office (up to 4 telephonic at NP discretion ) Four broad coping skills across minute sessions Relaxation response Attention diversion techniques Altering activity and rest patterns to increase activity levels Reducing negative pain related thoughts and emotions Sessions outlined in patient treatment manual Format review of home practice from previous session instruction of new coping skill guided practice of new skill home practice assignment NP training Initial 2 day PCST workshop at Duke Continues training at home site to reach competency Competency 3 (satisfactory) to 5 (excellent) on therapist performance rating (1=poor- 5= excellent) 2-3 pilot patients each All sessions audio-taped and 10% rated by co-investigators Inter-rater agreement 85% NP Therapist Performance Rating Tool Eight item behavior rating scale (1= poor, 5=Excellent) Based on CST delivery criteria and NP skill level Sample Performance Criteria: Stays on schedule with protocol or makes appropriate adjustments when indicated Applies CST protocol to participant s situation and current challenges Encourages participant s active involvement in the session Uses time effectively/appropriate pacing Demonstrates good interpersonal skills (warmth, concern, confidence, genuineness) NP Training Model SE Rating 1: Based on your reading and current knowledge of the skill, how confident are you that you can deliver the skill? SE Rating 2: Based on this modeling session, how confident are you that you can deliver the skill? SE Rating 3: If you were able to incorporate all of these things that worked into your session, how would you rate your confidence in delivering these skills? 3

4 NP Training results Hours of initial training range Types of training Formal 2 day face to face 1:1 workshop training 1:1 +video tape review Pilot patients range 1-3 Weekly supervision range 5-30 weeks Monthly supervision range 9-12 months Booster sessions = 1 NP Competency Ratings 45% patients received treatment from NP with 3 (satisfactory) rating 21% patients received treatment from NP with 4 (good) rating 34% patients received treatment from NP with 5 (excellent) rating Intervention Effects by NP rating 4

5 Main Trial Results RESULTS: Demographics Primary Outcome Measures 5

6 Patient Rating of Program Patient Ratings of Most Useful Coping Strategies DISCUSSION NP delivered PCST protocol produced significant improvements in a range of pain related variables compared to usual care. NP ratings of competence once proficient was not related to treatment outcome Ethnic background, education, level of distress and disability, were not different in terms of PCST effects NP led Intervention and findings concordant with IOM reports: The Future of Nursing :Leading Change, Advancing Health Nurses should practice to the full extend of their education and training Nurses should be full partners with physicians and other health professionals in redesigning health care. Relieving Pain in America: Blueprint for Transforming Prevention, Care, Education, and Research recommends promoting and enabling self management of pain 6

7 Implications/Future Directions A large cadre of trained APRN s could have a substantial impact on management of chronically painful diseases such as OA Determine the optimal dose of PCST Exploration of other treatment formats (technologically delivered) Implement and evaluate the effects of a APRN PCST program that will provide monitoring of intervention competence and usefulness in varied clinical settings. 7