YNEDT-02736; No of Pages 5 Nurse Education Today xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
The challenge of multimorbidity in nurse education: An international perspective☆ Claire A. Rushton a,⁎, Julie Green a, Tiny Jaarsma b, Pauline Walsh a, Anna Strömberg c,d, Umesh T. Kadam e a
School of Nursing and Midwifery, Keele University, England, UK Department of Social and Welfare Studies, University of Linköping, Sweden Department of Medical and Health Sciences, Linköping University, Sweden d Department of Cardiology, County Council of Östergötland, Sweden e Health Services Research Unit, Keele University, England, UK b c
a r t i c l e
i n f o
Article history: Received 14 November 2013 Received in revised form 2 May 2014 Accepted 21 May 2014 Available online xxxx Keywords: Multimorbidity Comorbidity Education Nursing Curriculum
s u m m a r y The rise in prevalence of chronic diseases has become a global healthcare priority and a system wide approach has been called for to manage this growing epidemic. Whilst healthcare reform to tackle the scale of chronic disease and other long term conditions is still in its infancy, there is an emerging recognition that in an ageing society, people often suffer from more than one chronic disease at the same time. Multimorbidity poses new and distinct challenges and was the focus of a global conference held by the Organization of Economic Cooperation and Development (OECD) in 2011. Health education was raised as requiring radical redesign to equip graduates with the appropriate skills to face the challenges ahead. We wanted to explore how different aspects of multimorbidity were addressed within pre-registration nurse education and held an international (United Kingdom–Sweden) nurse workshop in Linköping, Sweden in April 2013, which included nurse academics and clinicians. We also sent questionnaire surveys to final year student nurses from both countries. This paper explores the issues of multimorbidity from a patient, healthcare and nurse education perspective and presents the preliminary discussions from the workshop and students' survey. Crown Copyright © 2014 Published by Elsevier Ltd. All rights reserved.
Introduction Chronic diseases are the biggest cause of death worldwide with over 36 million people (63% of global deaths) dying of a chronic disease in 2008, a risk which is higher in women and undeveloped countries (WHO, 2011a). Nine million of these deaths were premature (before the age of 60) and potentially preventable (WHO, 2011b). Prevalence of chronic disease is high and increases with age, with over 15 million people in the UK suffering from one or more chronic diseases or other incurable conditions, a situation which is similar within the Swedish population (Coulter et al., 2013; Lennartsson and Heimerson, 2012). The cooccurrence of two or more diseases within one person at any one time is described as multimorbidity (van den Akker et al., 1998). Such multimorbidity further complicates the management of chronic disease and it is estimated that 23% of the population have multimorbidity, rising
☆ Funding: CR and JG were supported by an Erasmus Teaching Mobility 2012/UK Keele 0120859 Grant to undertake a teaching assignment at Linköping University, Sweden. ⁎ Corresponding author at: Health services Research Unit, Innovation Centre 1, Keele University, Staffordshire ST5 5BG, England. Tel.: +44 1782 733768; fax: + 44 1782 734302. E-mail address: [email protected] (C.A. Rushton).
to up to 80% in those over 80 years (van den Akker et al., 1998; Barnett et al., 2012). Indeed, one study in Sweden found nursing home residents to have an average of 17 coexisting chronic health problems (Akner, 2009). In the United States 65% of all healthcare utilisation is by people with multiple chronic conditions and two thirds of healthcare expenditure is on people with 5 or more conditions (Robert Wood Johnson Foundation and the Johns Hopkins Bloomberg School of Public Health, 2010). In the light of our ageing population, multimorbidity is set to become an international healthcare priority which requires a radical redesign, not only of health care service delivery, but also of research and the education of health care professionals (American Expert Panel, 2012; Barnett et al., 2012). By 2018 in terms of the UK example, the Department of Health (2012) forecasts a rise in the number of patients with multimorbidity to 2.9 million (53% increase over 10 years). In spite of the known increase with age, half of all those with multimorbidity are under the age of 65 years since, where there is socio-economic deprivation, such multimorbidity occurs up to 10–15 years earlier and is becoming the new normal of middle age in certain deprived areas (Mercer et al., 2011; Barnett et al., 2012; Smith et al., 2012). This is also reflected in a more than double death rate from non-communicable diseases in younger people in low-income countries than in high-income countries (WHO, 2011a). The prevalence of mental health issues is also a concern
http://dx.doi.org/10.1016/j.nedt.2014.05.006 0260-6917/Crown Copyright © 2014 Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Rushton, C.A., et al., The challenge of multimorbidity in nurse education: An international perspective, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.05.006
2
C.A. Rushton et al. / Nurse Education Today xxx (2014) xxx–xxx
since this increases in relation to the number of coexisting physical conditions that a patient suffers; indeed, 36% of those with multimorbidity present with both mental and physical health issues and proportions are known to be higher in women and the elderly (Marengoni et al., 2011; Barnett et al., 2012). Where multimorbidity includes this combination of both physical and mental health problems, research demonstrates that the negative impact on the quality of life of the patient is increased (Mercer et >al., 2012). Despite the insight that we have, little is known about the risk factors for multimorbidity and there is currently no scientific evidence base for the care for such patients (Marengoni et al., 2011; Smith et al., 2012). The Patient Context The patient with multimorbidity often reports a very different experience of their healthcare journey (Boyd et al., 2007). Patients are often faced with an increased mortality risk, greater symptom burden, limited physical and psychological functioning, reduced quality of life and, as a result, severely compromised health outcomes (Gott et al., 2006; Barnes et al., 2006; Kadam and Croft, 2007; Barnett et al., 2012). Multimorbidity gives rise to the need for more regular contact with health care professionals, but such patients frequently report receiving fragmented care from specialists who focus on treating one disease or condition (Coulter et al., 2013). The risk of errors in care is heightened as a result of a single disease focus and polypharmacy, adverse drug reactions and inconsistent monitoring are common (Smith et al., 2012). The patient with multimorbidity often has to balance numerous appointments with a variety of specialists which results in poor continuity of care and a ‘chaotic experience’ with duplication of services and difficulty accessing relevant urgent care (Fortin et al., 2007). Such problematic interactions with health care professionals leads to reports from patients of conflicting advice, disappointment with care, a lack of attention to personal preferences, poor communication and a lack of shared decision making. These issues can lead to reduced motivation and a lack of understanding which limits the patient's ability to engage in selfmanagement or to fully understand their conditions (Boyd et al., 2007; Fortin et al., 2007; Noel et al., 2007; Smith et al., 2012). Self-care is the cornerstone of chronic disease management (Department of Health, 2012) but often multimorbidity complicates the patient's ability to self-care since symptom recognition, appropriate lifestyle modifications and drug adherence are all more complex (Bayliss et al., 2003; Vogeli et al., 2007; Riegel et al., 2012). The Healthcare Context Over the past decade healthcare has become preoccupied with national and international, standardised guidelines and disease-specific policy (Rushton et al., 2011). In the light of the growing prevalence of multimorbidity, healthcare faces the challenge of developing new models of care that place the patient at the centre of care decisions and provide integrated services that meet their individual and complex health care needs. Our current healthcare delivery is based on a single disease framework and, internationally, systems are configured for individual diseases, which has serious limitations (Salisbury et al., 2011). Multimorbidity thus presents a major challenge to leaders on various levels in health care systems across the world (Barnett et al., 2012). Evidence demonstrates that this single disease approach to care is duplicative and inefficient, leading to services that fail to communicate with the patient and each other effectively or to provide integrated care. In the United Kingdom (UK), the King's Fund describes this as a ‘reactive, disease-focused, fragmented model of care’ rather than the holistic and patient-centred approach that would ensure that the patient and their needs were at the centre of the care delivery process (Coulter et al., 2013). This would require radical change; indeed The King's Fund (2013) reports that despite the lobbying of Members of Parliament (MPs) in the UK about this potential ‘crisis’ progress in
such re-design remains slow and little progress has been made. Similarly, the Swedish Social Board of Welfare has issued several reports which highlight the need for new forms of care for those with multiple long term conditions. In addition, the Swedish Government has an ongoing initiative to improve the health and social care of the sickest elderly which emphasises enhanced collaboration, efficient resource usage and the delivery of care based on patient needs (Socialstyrelsen, 2013). Managing specific conditions rather than the patient is a situation which is intensified by the current Quality and Outcomes Framework (QOF) in general practice in the UK which incentivises the application of evidence based clinical guidelines, albeit often with a single disease focus. This serves to limit the focus of consultation to that of a specific condition (Chew-Graham et al., 2013; NHS Improvement, 2013) whereas the shift needs to be towards better integration of information and care for the patient with multimorbidity (Kadam, 2012). Much of the care for the multimorbid patient takes place within primary care; long term conditions account for 90% of National Health Service activity and 80% of consultations within general practice are with a patient with long term conditions (Mercer et >al., 2012). The goals of primary care should include the enhancement of patients' functional status, minimising symptoms, disability and pain and prolonging life through secondary prevention (American Expert Panel, 2012). Yet despite these admirable goals, many qualified health care professionals report that they feel inadequately prepared to effectively manage multimorbidity (Boyd et al., 2007) and there is a reliance on single disease clinical pathways and guidelines which have not been tested in a multimorbid context. Clinical evidence and guidelines most often focus on a single disease and most randomised controlled trials exclude the elderly and those with multiple conditions (Barnett et al., 2012). Guidelines overlook multimorbidity and fail to support health care professionals when there are several relevant but conflicting guidelines for the patient with multiple conditions (Marengoni et al., 2011; Barnett et al., 2012). The Nursing and Educational Context Nursing as a profession has developed along a single disease management trajectory with ever increasing disease targeted specialist roles in, for example, heart failure and diabetes. As well as developing a variety of career pathways for nurses, such specialism has been found to improve patient outcomes (Blue et al., 2001). However, without careful consideration of the patient's other existing diseases, specialism can be at the expense of holistic and patient-centred practice (Castledine, 2006). This may leave nurses less confident to deal with multimorbid patients' complex needs; indeed, evidence suggests that during nurse consultations relating to a specific condition, nurses tended to overlook or ‘block’ patient cues or fail to offer advice when issues beyond the condition that is discussed (Green et al., 2013), an issue which may be intensified in the context of the patient with multiple conditions. In the same way that specialism has begun to dominate healthcare delivery, the review of individual conditions is most often the focus of healthcare education, and there is extremely limited multimorbidity teaching. Despite the slow move of healthcare into the community setting education remains delivered in a mostly hospital centric environment and needs to include more ambulatory settings (Anderson, 2011). Current approaches to nurse education are said to be out-dated and at risk of ‘producing ill-equipped graduates given the challenges to be faced’ (OECD, 2011). Calls have been made for a shift in the focus of nurse education to improve the care of those with multiple long term conditions which may lead to a necessity to redesign the nursing curricula once again. Indeed, health professionals need to be trained differently; there needs to be a shift of emphasis to a focus on prevention (Hughes et al., 2012) and population health, with different measures of the quality of the health system, from specific diseases to
Please cite this article as: Rushton, C.A., et al., The challenge of multimorbidity in nurse education: An international perspective, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.05.006
C.A. Rushton et al. / Nurse Education Today xxx (2014) xxx–xxx
general health (OECD, 2011). Nurses are able to intervene at all levels of healthcare delivery (International Council of Nurses, 2010) and with the philosophical roots of nursing set in holism, they are well placed to embrace the developing multimorbidity challenges. However multimorbidity has yet to become fully recognised or integrated within current curricula. Issues such as those relating to older people, communication, chronic disease, disability, dependency and frailty are often included and whilst they are relevant within the multimorbid domain, they do not address the specific issues such as polypharmacy (Rushton and Kadam, 2011), competing treatments, self-care challenges, fragmented care and prioritisation of needs. If nurses are to address the multimorbid patient's needs, to properly implement patient centred care and shared decision making, then these issues require addition to the nursing curricula and supported by appropriate experiences within both clinical practice and simulated scenarios. These issues appear to be currently more readily addressed in some fields of nurse training such as learning disability, where client attachment ensures a longitudinal understanding of the variety of needs that the client is exposed to.
International Workshop An international (UK-Sweden) nurse workshop in Linköping, Sweden was undertaken in April, 2013 which included nurse academics and clinicians from two universities. During the workshop, a number of questions were addressed: (i) What do pre-registration student nurses need to know about multimorbidity? (ii) How are these needs addressed within the current preregistration nursing curricula? (iii) What are the current gaps in nursing education? The findings were presented at the Nurse Education Today Conference in September 2013 and include a number of similarities between these two countries despite quite different nurse education frameworks. Whilst both countries provide 3-year bachelor degrees in nursing at higher education institutes, Sweden provides a generic nursing course with specialisation at post registration level. This is in contrast to the UK where students elect to specialise in adult, child, mental health or learning disability nursing from the start of their course albeit approximately one third of the course is generic.
3
What do Nursing Students Need to Know? There was an agreement across the two countries that new registrant nurses needed clear definitions about multimorbidity and person centred care. They needed an understanding of the context of multimorbidity in terms of research, healthcare delivery, education, prevention and the impact on the health and well-being of the patient. New registrants needed good communication, problem solving and consultation skills with a clear understanding of issues relating to patient choice and shared decision making. Experience of inter-professional working was seen to be essential in improving the seamless care required by such ‘complex’ patients along with holistic health assessment approaches in the context of multimorbidity. Students needed to be aware of how to provide care for multimorbid patients and how to deal with conflicting evidence. The ability to effectively assess risk and prioritise health needs for patients was all seen as essential skills.
How are These Needs Addressed Currently and What are the Gaps? Nurse academics and clinicians from both universities felt that the development of inter-professional learning (IPL) within their programmes was the key to delivering multimorbidity education. In Sweden the first semester of their nursing course is delivered in IPL groups and this is repeated at different points throughout their education with the final clinical placement in the last semester being taken on a multi-professional student led ward. In the UK, inter-professional learning also forms part of the three year curriculum delivery and is provided in blocks throughout the three years. Problem and case based learning were also utilised by both universities and allows students to explore complex patients and direct their own learning needs. It was felt by both universities that the complexity of patients should build throughout the nursing course and include more multimorbidity examples. One suggestion at the UK university was for cases to be more longitudinal so that the complexity of the case could develop over time rather than multiple cases focused on single health entities. It was felt that topics such as polypharmacy, drug and condition interaction, risk factor recognition and management, population health and epidemiology needed better addressing and the UK university felt that multimorbidity would be better addressed as a theme within the nursing curricula. The provision of clinical practice placements that provide students with a longitudinal experience of the patient's journey, particularly in ambulatory settings, provided a challenge for both universities.
Table 1 Questionnaire surveys of nurse students. UK Age under 30 (%) Female (%) No prior health work experience (%) More multimorbidity training wanted (%) Terminology
Examples
Current course content
Sweden
66 90 89 75 46 55 92 94 • Multimorbidity, comorbidity and frailty used interchangeably. • Most described multimorbidity as the existence of more than one disease or condition. • Some students felt that the conditions had to be causative to be labelled with multimorbidity. • Most UK students in the mental health field suggested two psychiatric conditions whereas those in the other fields suggested two physiological conditions. • Most Swedish students suggested multiple physiological conditions. • Pathophysiology • Complex diseases • Organisation skills • Structured assessment frameworks (UK) • Multiple exposures to different clinical areas (UK) • Pain • IPL • Public health • Polypharmacy (Sweden) • Complex diseases (Sweden) • Psychiatry and geriatrics (Sweden)
Please cite this article as: Rushton, C.A., et al., The challenge of multimorbidity in nurse education: An international perspective, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.05.006
4
C.A. Rushton et al. / Nurse Education Today xxx (2014) xxx–xxx
Percentage
Table 2 Questionnaire surveys of UK nurse students: scenario responses.
UK nurse students
90 80 70 60 50 40 30 20 10 0
Knowledge Training Confidence
Single disease Disease pair Multiple disease Scenario Percentage of students who responded agree or strongly agree to their knowledge, training and confidence or each of the three scenarios (N = 74).
Student's Survey 74 UK students and 20 Swedish students responded to an electronic survey. The survey consisted of 10 questions which included demographic information and questions relating to the student understanding of multimorbidity. Students were asked to identify any current learning that they found helpful in understanding multimorbidity and were then presented with three scenarios (i) a single disease patient (ii) a patient with a disease pair and (iii) a patient with multiple diseases. They were asked whether they felt that they had the adequate knowledge, training and confidence to provide care for these patients. Finally students were asked if they felt that more training on multimorbidity was required in the nursing curriculum. There was a decrease in the number of students who responded agree or strongly agree to whether they felt that they had adequate knowledge, training and confidence from scenario 1 to scenario 3 as patients moved from single disease to more complex multimorbidity (Tables 1, 2 and 3).
Discussion Nursing requires an appropriately educated workforce that is fit for purpose given the challenges ahead. Whilst nurses have the opportunity for continuing professional development and further training what is learned in pre-registration training is critical to their current and future nursing practice. We found through our joint workshop that despite different nurse educational frameworks across the two countries, we share many of the same challenges in making sure that our respective Table 3 Questionnaire surveys of Sweden nurse students: scenario responses.
Percentage
Sweden nurse students 100 90 80 70 60 50 40 30 20 10 0
curricula are able to embrace the multimorbidity challenge. Strengths in some pedagogical approaches such as the widespread use of simulation and structured interprofessional learning were shared across the two universities as were challenges including the limited availability of community practice placements. Both sets of nursing students perceived their knowledge, training and confidence to reduce as the patients became more complex and nearly all would like more training in this area. It is clear that innovative strategies for nurse education need to be developed to address multimorbidity and these strategies need to be embedded within both curriculum design and delivery. Multimorbidity presents complex challenges and requires that nurse education moves from a focus on specific care pathways and content heavy delivery to equipping students with the skills for life-long learning that promotes high levels of problem solving within a constantly evolving healthcare system. The pedagogical theory of social constructivism, now embedded in the Keele Curriculum Model (Humphreys et al., 2013) provides a cyclical framework for learning through construction, collaboration and consolidation. This 6C model builds on the work of Bird (2007), placing patient-centred care at its core and sharing content and concepts with students through construction and collaboration and then reinforcing them by consolidation and competence. A multi-modal delivery framework that embraces new technologies is a key to successful delivery and promotes the learner centred approach required to address multimorbidity. Construction acknowledges that learning is a social process and that students need to build on their own unique prior experiences through reflection and interaction with new experiences. Simulated scenarios facilitated by collaboration in IPL and PBL as well as interaction with service users are all essential components. The Keele Active Virtual Environment (KAVE) is a physical room where students use 3D glasses and tracking technology to interact in real time with clinical scenarios and provides an innovative learning environment used to develop team leadership, management and communication skills (Humphreys and Bracegirdle, 2013; Richardson et al., 2013). Such innovations inspire students and create clinically realistic settings in which to develop confidence and competence. Consolidation is achieved through dialogue between students and their mentors, tutors and peers which is captured by the use and integration of an ePortfolio. Conclusion Through a joint workshop we were able to explore current approaches to multimorbidity in nursing education as well as identify key gaps that require addressing within nursing curricula. Despite different educational frameworks across the two countries, a core shared theme in meeting the challenge of multimorbidity was the high level of communication and problem solving skills required by nurses to properly deliver patient centred care to complex patients. Curricula design needs to embed approaches focused on the development of these skills and for life-long learning. Whilst nurse education must continuously strive to adapt to a changing landscape it has a lot to offer in paving the way for change. The nursing profession has undergone radical change over the past two decades with the growth of specialism but its foundations remain firmly rooted in holism and nurses are well placed to embrace the challenge of multimorbidity.
Knowledge Training
References
Confidence
Akner, G., 2009. Analysis of multimorbidity in individual elderly nursing home residents. Development of a multimorbidity matrix. Arch. Gerontol. Geriatr. 49, 413–419. American Expert Panel, 2012. guiding principles for the care of older adults with multimorbidity: an approach for clinicians. J. Am. Geriatr. Soc. http://dx.doi.org/10. 1111/j.1532-5415.2012.04188.x. Anderson, G., 2011. The latest disease burden challenge: people with multiple chronic conditions. Organization of Economic Cooperation and Development (OECD), 2011. Health Reform: Meeting the Challenge of Ageing and Multiple Morbidities. OECD Publishing. http://dx.doi.org/10.1787/9789264122314-en.
Single disease Disease pair Multiple disease Scenario Percentage of students who responded agree or strongly agree to their knowledge, training and confidence for each of the three scenarios (N = 20).
Please cite this article as: Rushton, C.A., et al., The challenge of multimorbidity in nurse education: An international perspective, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.05.006
C.A. Rushton et al. / Nurse Education Today xxx (2014) xxx–xxx Barnes, S., Gott, M., Payne, S., Seamark, D., Parker, C., Gariballa, S., Small, N.A., 2006. Prevalence of symptoms in a community-based sample of heart failure patients. J. Pain Symptom Manag. 32, 208–216. Barnett, K., Mercer, S., Norbury, M., Watt, G., Wyke, S., Guthrie, B., 2012. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 380, 37–43. Bayliss, E., Steiner, J., Fernald, D., Crane, L., Main, D., 2003. Description of barriers to selfcare by persons with comorbid chronic diseases. Ann. Fam. Med. 1, 15–21. Bird, L., 2007. The 3 “C” design model for networked-collaborative e-learning: a tool for novice designers. Innov. Educ. Teach. Int. 44, 153–167. Blue, L., Lang, E., McMurray, J., Davie, A., McDonagh, T., Murdoch, R., Petrie, M., Connolly, E., Norrie, J., Round, C., Ford, I., Morrison, C., 2001. Randomised controlled trial of specialist nurse intervention in heart failure. Br. Med. J. 323, 715. Boyd, C., Boult, C., Shadmi, E., Leff, B., Brager, R., Dunbar, L., Wolff, J., Wegener, S., 2007. Guided care for multimorbid older adults. The Gerontologist 47, 697–704. Castledine, G., 2006. Generalist versus specialist nursing practice. Br. J. Nurs. 15, 347. Chew-Graham, C., Hunter, C., Langer, S., Stenhoff, A., Drinkwater, J., Guthrie, E., Salmon, P., 2013. How QOF is shaping primary care review consultations: a longitudinal qualitative study. BMC Fam. Pract. 14, 103–120. Coulter, A., Roberts, S., Dixon, A., 2013. Delivering Better Services for People with Longterm Conditions. The King's Fund, London, (2013). Department of Health, 2012. Long term conditions compendium of information. London, DH. Available at: https://www.gov.uk/government/publications/long-term-conditionscompendium-of-information-third-edition (Accessed on 9th October 2013). Fortin, M., Soubhi, H., Hudon, C., Bayliss, E.A., van den Akker, M., 2007. Multimorbidity's many challenges. 7 Br. Med. J. 334, 1016–1017. Gott, M., Barnes, S., Parker, C., Payne, S., Seamark, D., Gariballa, S., Small, N., 2006. Predictors of quality of life of older people with heart failure recruited from primary care. Age Ageing 35, 172–177. Green, J., McKinley, R., Jester, R., Pooler, A., 2013. Nurse-patient consultations in primary care — do patients disclose their concerns? J. Wound Care 22, 534–539. Hughes, P., Hancock, C., Cooper, K., 2012. Non-communicable diseases: calling healthcare educators to action. Nurse Educ. Today 32, 757–759. Humphreys, M., Wood, I., Johnson, C., Walsh, P., Witton, N., Green, J., Corkhill, S., 2013. The Keele curriculum model: a contemporary framework for designing an interprofessional technology enhanced nursing curriculum. Open J Nurs. 3, 358–362. Humphreys, M., Bracegirdle, L., 2013. Using a virtual learning environment within simulation to enhance inter-professional team working skills. Edulearn13 Proceedings, pp. 4263–4268. Kadam, U.T., Croft, P., 2007. Clinical multimorbidity and physical functioning in older adults: a record and health status linkage study in general practice. Fam. Pract. 24, 412–419. Kadam, U.T., 2012. Redesigning the general practice consultation to improve care for patients with multimorbidity. Br. Med. J. 345, e6202. Organization of Economic Cooperation and Development (OECD), 2011. Health Reform: Meeting the Challenge of Ageing and Multiple Morbidities. OECD Publishing,. http://dx.doi.org/10.1787/9789264122314-en. Lennartsson, C., Heimerson, I., 2012. Elderly people's health. Health in Sweden: The National Public Health Report 2012. Chapter 5. Scand. J. Public Health 40 (Suppl. 9), 95–120.
5
Marengoni, A., Angleman, S., Melis, R., Mangialasche, F., Karp, A., Garmen, A., Mainow, B., Fratiglioni, L., 2011. Aging with multimorbidity: a systematic review of literature. Ageing Res. Rev. 10, 430–439. Mercer, S., Gunn, J., Wyke, S., 2011. Improving the health of people with multimorbidity: the need for prospective cohort studies. J. Comorbidity 1, 4–7. Mercer, S.W., Gunn, J., Bower, P., Wyke, S., Guthrie, B., 2012. Managing Patients with Mental and Physical Multimorbidity. Br. Med. J. 345, e5559. NHS Improvement – Lung, 2013. Managing multimorbidity in practice … what lessons can be learnt from the care of people with COPD and co-morbidities?. Available at: http://www.improvement.nhs.uk/documents/COPD_MultiMorbidities.pdf (Accessed on 9th October 2013). Noel, P.H., Parchman, M., Williams, J., Cornell, J., Shuko, L., Zeber, J., Kazis, L., Lee, A., Pugh, J., 2007. The challenges of multimorbidity from the patient perspective. J. Gen. Intern. Med. 22 (Suppl. 3), 419–424. Riegel, B., Jaarsma, T., Strömberg, A., 2012. A middle range theory of self-care of chronic illness. Adv. Nurs. Sci. 35, 194–204. Robert Wood Johnson Foundation and the Johns Hopkins Bloomberg School of Public Health, 2010. Chronic care: making the case for ongoing care. Updated 2010, available at www.rwjf.org/files/research/50968chronic.care.chartbook.pdf. Rushton, C., Kadam, U.T., 2011. Polypharmacy in heart failure; a growing challenge. Br. J. Card. Nurs. 6, 214–220. Rushton, C., Satchithananda, D., Kadam, U.T., 2011. Co-morbidity in modern nursing: a closer look at heart failure. Br. J. Nurs. 20, 148–154. Salisbury, C., Johnson, L., Purdy, S., Valderas, J., Montgomery, A., 2011. Epidemiology and impact of multimorbidity in primary care. Br. J. Gen. Pract. 61, e12–e21. Socialstyrelsen, 2013. Health in Sweden 2012 — updated statistics. Accessed at: http:// www.socialstyrelsen.se/nyheter/2013februari/healthinsweden2012updatedstatistics (November 2013). Smith, M., Soubhi, H., Fortin, M., Hudon, C., O'Dowd, T., 2012. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. Br. Med. J. 345, e5205. The King's Fund, 2013. Long term conditions and multimorbidity. Accessed at: http:// www.kingsfund.org.uk/time-to-think-differently/trends/disease-and-disability/longterm-conditions-multi-morbidity (November 2013). Van den Akker, M., Buntinx, F., Metsemakers, J., Roos, S., Knottnerus, J., 1998. Multimorbidity in general practice prevalence, incidence, and determinants of cooccurring chronic and recurrent diseases. J. Clin. Epidemiol. 51, 367–375. Vogeli, C., Shields, A., Lee, T., Gibson, T.B., Marder, W.D., Weiss, K.B., Blumenthal, D., 2007. Multiple chronic conditions prevalence, health consequences and implications for quality, care management and costs. J. Gen. Intern. Med. 22, 391–395. World Health Organization (WHO), 2011a. Global status report on noncommunicable diseases. Accessed at http://www.who.int/nmh/publications/ncd_report_full_en.pdf (October 2013). World Health Organization (WHO), 2011b. Chronic disease and health promotion: region and country specific information sheets. Accessed at http://www.who. int/chp/chronic_disease_report/media/impact/en/index.html (October 2013).
Please cite this article as: Rushton, C.A., et al., The challenge of multimorbidity in nurse education: An international perspective, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.05.006
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
The challenge of multimorbidity in nurse education: An international perspective☆ Claire A. Rushton a,⁎, Julie Green a, Tiny Jaarsma b, Pauline Walsh a, Anna Strömberg c,d, Umesh T. Kadam e a
School of Nursing and Midwifery, Keele University, England, UK Department of Social and Welfare Studies, University of Linköping, Sweden Department of Medical and Health Sciences, Linköping University, Sweden d Department of Cardiology, County Council of Östergötland, Sweden e Health Services Research Unit, Keele University, England, UK b c
a r t i c l e
i n f o
Article history: Received 14 November 2013 Received in revised form 2 May 2014 Accepted 21 May 2014 Available online xxxx Keywords: Multimorbidity Comorbidity Education Nursing Curriculum
s u m m a r y The rise in prevalence of chronic diseases has become a global healthcare priority and a system wide approach has been called for to manage this growing epidemic. Whilst healthcare reform to tackle the scale of chronic disease and other long term conditions is still in its infancy, there is an emerging recognition that in an ageing society, people often suffer from more than one chronic disease at the same time. Multimorbidity poses new and distinct challenges and was the focus of a global conference held by the Organization of Economic Cooperation and Development (OECD) in 2011. Health education was raised as requiring radical redesign to equip graduates with the appropriate skills to face the challenges ahead. We wanted to explore how different aspects of multimorbidity were addressed within pre-registration nurse education and held an international (United Kingdom–Sweden) nurse workshop in Linköping, Sweden in April 2013, which included nurse academics and clinicians. We also sent questionnaire surveys to final year student nurses from both countries. This paper explores the issues of multimorbidity from a patient, healthcare and nurse education perspective and presents the preliminary discussions from the workshop and students' survey. Crown Copyright © 2014 Published by Elsevier Ltd. All rights reserved.
Introduction Chronic diseases are the biggest cause of death worldwide with over 36 million people (63% of global deaths) dying of a chronic disease in 2008, a risk which is higher in women and undeveloped countries (WHO, 2011a). Nine million of these deaths were premature (before the age of 60) and potentially preventable (WHO, 2011b). Prevalence of chronic disease is high and increases with age, with over 15 million people in the UK suffering from one or more chronic diseases or other incurable conditions, a situation which is similar within the Swedish population (Coulter et al., 2013; Lennartsson and Heimerson, 2012). The cooccurrence of two or more diseases within one person at any one time is described as multimorbidity (van den Akker et al., 1998). Such multimorbidity further complicates the management of chronic disease and it is estimated that 23% of the population have multimorbidity, rising
☆ Funding: CR and JG were supported by an Erasmus Teaching Mobility 2012/UK Keele 0120859 Grant to undertake a teaching assignment at Linköping University, Sweden. ⁎ Corresponding author at: Health services Research Unit, Innovation Centre 1, Keele University, Staffordshire ST5 5BG, England. Tel.: +44 1782 733768; fax: + 44 1782 734302. E-mail address: [email protected] (C.A. Rushton).
to up to 80% in those over 80 years (van den Akker et al., 1998; Barnett et al., 2012). Indeed, one study in Sweden found nursing home residents to have an average of 17 coexisting chronic health problems (Akner, 2009). In the United States 65% of all healthcare utilisation is by people with multiple chronic conditions and two thirds of healthcare expenditure is on people with 5 or more conditions (Robert Wood Johnson Foundation and the Johns Hopkins Bloomberg School of Public Health, 2010). In the light of our ageing population, multimorbidity is set to become an international healthcare priority which requires a radical redesign, not only of health care service delivery, but also of research and the education of health care professionals (American Expert Panel, 2012; Barnett et al., 2012). By 2018 in terms of the UK example, the Department of Health (2012) forecasts a rise in the number of patients with multimorbidity to 2.9 million (53% increase over 10 years). In spite of the known increase with age, half of all those with multimorbidity are under the age of 65 years since, where there is socio-economic deprivation, such multimorbidity occurs up to 10–15 years earlier and is becoming the new normal of middle age in certain deprived areas (Mercer et al., 2011; Barnett et al., 2012; Smith et al., 2012). This is also reflected in a more than double death rate from non-communicable diseases in younger people in low-income countries than in high-income countries (WHO, 2011a). The prevalence of mental health issues is also a concern
http://dx.doi.org/10.1016/j.nedt.2014.05.006 0260-6917/Crown Copyright © 2014 Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Rushton, C.A., et al., The challenge of multimorbidity in nurse education: An international perspective, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.05.006
2
C.A. Rushton et al. / Nurse Education Today xxx (2014) xxx–xxx
since this increases in relation to the number of coexisting physical conditions that a patient suffers; indeed, 36% of those with multimorbidity present with both mental and physical health issues and proportions are known to be higher in women and the elderly (Marengoni et al., 2011; Barnett et al., 2012). Where multimorbidity includes this combination of both physical and mental health problems, research demonstrates that the negative impact on the quality of life of the patient is increased (Mercer et >al., 2012). Despite the insight that we have, little is known about the risk factors for multimorbidity and there is currently no scientific evidence base for the care for such patients (Marengoni et al., 2011; Smith et al., 2012). The Patient Context The patient with multimorbidity often reports a very different experience of their healthcare journey (Boyd et al., 2007). Patients are often faced with an increased mortality risk, greater symptom burden, limited physical and psychological functioning, reduced quality of life and, as a result, severely compromised health outcomes (Gott et al., 2006; Barnes et al., 2006; Kadam and Croft, 2007; Barnett et al., 2012). Multimorbidity gives rise to the need for more regular contact with health care professionals, but such patients frequently report receiving fragmented care from specialists who focus on treating one disease or condition (Coulter et al., 2013). The risk of errors in care is heightened as a result of a single disease focus and polypharmacy, adverse drug reactions and inconsistent monitoring are common (Smith et al., 2012). The patient with multimorbidity often has to balance numerous appointments with a variety of specialists which results in poor continuity of care and a ‘chaotic experience’ with duplication of services and difficulty accessing relevant urgent care (Fortin et al., 2007). Such problematic interactions with health care professionals leads to reports from patients of conflicting advice, disappointment with care, a lack of attention to personal preferences, poor communication and a lack of shared decision making. These issues can lead to reduced motivation and a lack of understanding which limits the patient's ability to engage in selfmanagement or to fully understand their conditions (Boyd et al., 2007; Fortin et al., 2007; Noel et al., 2007; Smith et al., 2012). Self-care is the cornerstone of chronic disease management (Department of Health, 2012) but often multimorbidity complicates the patient's ability to self-care since symptom recognition, appropriate lifestyle modifications and drug adherence are all more complex (Bayliss et al., 2003; Vogeli et al., 2007; Riegel et al., 2012). The Healthcare Context Over the past decade healthcare has become preoccupied with national and international, standardised guidelines and disease-specific policy (Rushton et al., 2011). In the light of the growing prevalence of multimorbidity, healthcare faces the challenge of developing new models of care that place the patient at the centre of care decisions and provide integrated services that meet their individual and complex health care needs. Our current healthcare delivery is based on a single disease framework and, internationally, systems are configured for individual diseases, which has serious limitations (Salisbury et al., 2011). Multimorbidity thus presents a major challenge to leaders on various levels in health care systems across the world (Barnett et al., 2012). Evidence demonstrates that this single disease approach to care is duplicative and inefficient, leading to services that fail to communicate with the patient and each other effectively or to provide integrated care. In the United Kingdom (UK), the King's Fund describes this as a ‘reactive, disease-focused, fragmented model of care’ rather than the holistic and patient-centred approach that would ensure that the patient and their needs were at the centre of the care delivery process (Coulter et al., 2013). This would require radical change; indeed The King's Fund (2013) reports that despite the lobbying of Members of Parliament (MPs) in the UK about this potential ‘crisis’ progress in
such re-design remains slow and little progress has been made. Similarly, the Swedish Social Board of Welfare has issued several reports which highlight the need for new forms of care for those with multiple long term conditions. In addition, the Swedish Government has an ongoing initiative to improve the health and social care of the sickest elderly which emphasises enhanced collaboration, efficient resource usage and the delivery of care based on patient needs (Socialstyrelsen, 2013). Managing specific conditions rather than the patient is a situation which is intensified by the current Quality and Outcomes Framework (QOF) in general practice in the UK which incentivises the application of evidence based clinical guidelines, albeit often with a single disease focus. This serves to limit the focus of consultation to that of a specific condition (Chew-Graham et al., 2013; NHS Improvement, 2013) whereas the shift needs to be towards better integration of information and care for the patient with multimorbidity (Kadam, 2012). Much of the care for the multimorbid patient takes place within primary care; long term conditions account for 90% of National Health Service activity and 80% of consultations within general practice are with a patient with long term conditions (Mercer et >al., 2012). The goals of primary care should include the enhancement of patients' functional status, minimising symptoms, disability and pain and prolonging life through secondary prevention (American Expert Panel, 2012). Yet despite these admirable goals, many qualified health care professionals report that they feel inadequately prepared to effectively manage multimorbidity (Boyd et al., 2007) and there is a reliance on single disease clinical pathways and guidelines which have not been tested in a multimorbid context. Clinical evidence and guidelines most often focus on a single disease and most randomised controlled trials exclude the elderly and those with multiple conditions (Barnett et al., 2012). Guidelines overlook multimorbidity and fail to support health care professionals when there are several relevant but conflicting guidelines for the patient with multiple conditions (Marengoni et al., 2011; Barnett et al., 2012). The Nursing and Educational Context Nursing as a profession has developed along a single disease management trajectory with ever increasing disease targeted specialist roles in, for example, heart failure and diabetes. As well as developing a variety of career pathways for nurses, such specialism has been found to improve patient outcomes (Blue et al., 2001). However, without careful consideration of the patient's other existing diseases, specialism can be at the expense of holistic and patient-centred practice (Castledine, 2006). This may leave nurses less confident to deal with multimorbid patients' complex needs; indeed, evidence suggests that during nurse consultations relating to a specific condition, nurses tended to overlook or ‘block’ patient cues or fail to offer advice when issues beyond the condition that is discussed (Green et al., 2013), an issue which may be intensified in the context of the patient with multiple conditions. In the same way that specialism has begun to dominate healthcare delivery, the review of individual conditions is most often the focus of healthcare education, and there is extremely limited multimorbidity teaching. Despite the slow move of healthcare into the community setting education remains delivered in a mostly hospital centric environment and needs to include more ambulatory settings (Anderson, 2011). Current approaches to nurse education are said to be out-dated and at risk of ‘producing ill-equipped graduates given the challenges to be faced’ (OECD, 2011). Calls have been made for a shift in the focus of nurse education to improve the care of those with multiple long term conditions which may lead to a necessity to redesign the nursing curricula once again. Indeed, health professionals need to be trained differently; there needs to be a shift of emphasis to a focus on prevention (Hughes et al., 2012) and population health, with different measures of the quality of the health system, from specific diseases to
Please cite this article as: Rushton, C.A., et al., The challenge of multimorbidity in nurse education: An international perspective, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.05.006
C.A. Rushton et al. / Nurse Education Today xxx (2014) xxx–xxx
general health (OECD, 2011). Nurses are able to intervene at all levels of healthcare delivery (International Council of Nurses, 2010) and with the philosophical roots of nursing set in holism, they are well placed to embrace the developing multimorbidity challenges. However multimorbidity has yet to become fully recognised or integrated within current curricula. Issues such as those relating to older people, communication, chronic disease, disability, dependency and frailty are often included and whilst they are relevant within the multimorbid domain, they do not address the specific issues such as polypharmacy (Rushton and Kadam, 2011), competing treatments, self-care challenges, fragmented care and prioritisation of needs. If nurses are to address the multimorbid patient's needs, to properly implement patient centred care and shared decision making, then these issues require addition to the nursing curricula and supported by appropriate experiences within both clinical practice and simulated scenarios. These issues appear to be currently more readily addressed in some fields of nurse training such as learning disability, where client attachment ensures a longitudinal understanding of the variety of needs that the client is exposed to.
International Workshop An international (UK-Sweden) nurse workshop in Linköping, Sweden was undertaken in April, 2013 which included nurse academics and clinicians from two universities. During the workshop, a number of questions were addressed: (i) What do pre-registration student nurses need to know about multimorbidity? (ii) How are these needs addressed within the current preregistration nursing curricula? (iii) What are the current gaps in nursing education? The findings were presented at the Nurse Education Today Conference in September 2013 and include a number of similarities between these two countries despite quite different nurse education frameworks. Whilst both countries provide 3-year bachelor degrees in nursing at higher education institutes, Sweden provides a generic nursing course with specialisation at post registration level. This is in contrast to the UK where students elect to specialise in adult, child, mental health or learning disability nursing from the start of their course albeit approximately one third of the course is generic.
3
What do Nursing Students Need to Know? There was an agreement across the two countries that new registrant nurses needed clear definitions about multimorbidity and person centred care. They needed an understanding of the context of multimorbidity in terms of research, healthcare delivery, education, prevention and the impact on the health and well-being of the patient. New registrants needed good communication, problem solving and consultation skills with a clear understanding of issues relating to patient choice and shared decision making. Experience of inter-professional working was seen to be essential in improving the seamless care required by such ‘complex’ patients along with holistic health assessment approaches in the context of multimorbidity. Students needed to be aware of how to provide care for multimorbid patients and how to deal with conflicting evidence. The ability to effectively assess risk and prioritise health needs for patients was all seen as essential skills.
How are These Needs Addressed Currently and What are the Gaps? Nurse academics and clinicians from both universities felt that the development of inter-professional learning (IPL) within their programmes was the key to delivering multimorbidity education. In Sweden the first semester of their nursing course is delivered in IPL groups and this is repeated at different points throughout their education with the final clinical placement in the last semester being taken on a multi-professional student led ward. In the UK, inter-professional learning also forms part of the three year curriculum delivery and is provided in blocks throughout the three years. Problem and case based learning were also utilised by both universities and allows students to explore complex patients and direct their own learning needs. It was felt by both universities that the complexity of patients should build throughout the nursing course and include more multimorbidity examples. One suggestion at the UK university was for cases to be more longitudinal so that the complexity of the case could develop over time rather than multiple cases focused on single health entities. It was felt that topics such as polypharmacy, drug and condition interaction, risk factor recognition and management, population health and epidemiology needed better addressing and the UK university felt that multimorbidity would be better addressed as a theme within the nursing curricula. The provision of clinical practice placements that provide students with a longitudinal experience of the patient's journey, particularly in ambulatory settings, provided a challenge for both universities.
Table 1 Questionnaire surveys of nurse students. UK Age under 30 (%) Female (%) No prior health work experience (%) More multimorbidity training wanted (%) Terminology
Examples
Current course content
Sweden
66 90 89 75 46 55 92 94 • Multimorbidity, comorbidity and frailty used interchangeably. • Most described multimorbidity as the existence of more than one disease or condition. • Some students felt that the conditions had to be causative to be labelled with multimorbidity. • Most UK students in the mental health field suggested two psychiatric conditions whereas those in the other fields suggested two physiological conditions. • Most Swedish students suggested multiple physiological conditions. • Pathophysiology • Complex diseases • Organisation skills • Structured assessment frameworks (UK) • Multiple exposures to different clinical areas (UK) • Pain • IPL • Public health • Polypharmacy (Sweden) • Complex diseases (Sweden) • Psychiatry and geriatrics (Sweden)
Please cite this article as: Rushton, C.A., et al., The challenge of multimorbidity in nurse education: An international perspective, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.05.006
4
C.A. Rushton et al. / Nurse Education Today xxx (2014) xxx–xxx
Percentage
Table 2 Questionnaire surveys of UK nurse students: scenario responses.
UK nurse students
90 80 70 60 50 40 30 20 10 0
Knowledge Training Confidence
Single disease Disease pair Multiple disease Scenario Percentage of students who responded agree or strongly agree to their knowledge, training and confidence or each of the three scenarios (N = 74).
Student's Survey 74 UK students and 20 Swedish students responded to an electronic survey. The survey consisted of 10 questions which included demographic information and questions relating to the student understanding of multimorbidity. Students were asked to identify any current learning that they found helpful in understanding multimorbidity and were then presented with three scenarios (i) a single disease patient (ii) a patient with a disease pair and (iii) a patient with multiple diseases. They were asked whether they felt that they had the adequate knowledge, training and confidence to provide care for these patients. Finally students were asked if they felt that more training on multimorbidity was required in the nursing curriculum. There was a decrease in the number of students who responded agree or strongly agree to whether they felt that they had adequate knowledge, training and confidence from scenario 1 to scenario 3 as patients moved from single disease to more complex multimorbidity (Tables 1, 2 and 3).
Discussion Nursing requires an appropriately educated workforce that is fit for purpose given the challenges ahead. Whilst nurses have the opportunity for continuing professional development and further training what is learned in pre-registration training is critical to their current and future nursing practice. We found through our joint workshop that despite different nurse educational frameworks across the two countries, we share many of the same challenges in making sure that our respective Table 3 Questionnaire surveys of Sweden nurse students: scenario responses.
Percentage
Sweden nurse students 100 90 80 70 60 50 40 30 20 10 0
curricula are able to embrace the multimorbidity challenge. Strengths in some pedagogical approaches such as the widespread use of simulation and structured interprofessional learning were shared across the two universities as were challenges including the limited availability of community practice placements. Both sets of nursing students perceived their knowledge, training and confidence to reduce as the patients became more complex and nearly all would like more training in this area. It is clear that innovative strategies for nurse education need to be developed to address multimorbidity and these strategies need to be embedded within both curriculum design and delivery. Multimorbidity presents complex challenges and requires that nurse education moves from a focus on specific care pathways and content heavy delivery to equipping students with the skills for life-long learning that promotes high levels of problem solving within a constantly evolving healthcare system. The pedagogical theory of social constructivism, now embedded in the Keele Curriculum Model (Humphreys et al., 2013) provides a cyclical framework for learning through construction, collaboration and consolidation. This 6C model builds on the work of Bird (2007), placing patient-centred care at its core and sharing content and concepts with students through construction and collaboration and then reinforcing them by consolidation and competence. A multi-modal delivery framework that embraces new technologies is a key to successful delivery and promotes the learner centred approach required to address multimorbidity. Construction acknowledges that learning is a social process and that students need to build on their own unique prior experiences through reflection and interaction with new experiences. Simulated scenarios facilitated by collaboration in IPL and PBL as well as interaction with service users are all essential components. The Keele Active Virtual Environment (KAVE) is a physical room where students use 3D glasses and tracking technology to interact in real time with clinical scenarios and provides an innovative learning environment used to develop team leadership, management and communication skills (Humphreys and Bracegirdle, 2013; Richardson et al., 2013). Such innovations inspire students and create clinically realistic settings in which to develop confidence and competence. Consolidation is achieved through dialogue between students and their mentors, tutors and peers which is captured by the use and integration of an ePortfolio. Conclusion Through a joint workshop we were able to explore current approaches to multimorbidity in nursing education as well as identify key gaps that require addressing within nursing curricula. Despite different educational frameworks across the two countries, a core shared theme in meeting the challenge of multimorbidity was the high level of communication and problem solving skills required by nurses to properly deliver patient centred care to complex patients. Curricula design needs to embed approaches focused on the development of these skills and for life-long learning. Whilst nurse education must continuously strive to adapt to a changing landscape it has a lot to offer in paving the way for change. The nursing profession has undergone radical change over the past two decades with the growth of specialism but its foundations remain firmly rooted in holism and nurses are well placed to embrace the challenge of multimorbidity.
Knowledge Training
References
Confidence
Akner, G., 2009. Analysis of multimorbidity in individual elderly nursing home residents. Development of a multimorbidity matrix. Arch. Gerontol. Geriatr. 49, 413–419. American Expert Panel, 2012. guiding principles for the care of older adults with multimorbidity: an approach for clinicians. J. Am. Geriatr. Soc. http://dx.doi.org/10. 1111/j.1532-5415.2012.04188.x. Anderson, G., 2011. The latest disease burden challenge: people with multiple chronic conditions. Organization of Economic Cooperation and Development (OECD), 2011. Health Reform: Meeting the Challenge of Ageing and Multiple Morbidities. OECD Publishing. http://dx.doi.org/10.1787/9789264122314-en.
Single disease Disease pair Multiple disease Scenario Percentage of students who responded agree or strongly agree to their knowledge, training and confidence for each of the three scenarios (N = 20).
Please cite this article as: Rushton, C.A., et al., The challenge of multimorbidity in nurse education: An international perspective, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.05.006
C.A. Rushton et al. / Nurse Education Today xxx (2014) xxx–xxx Barnes, S., Gott, M., Payne, S., Seamark, D., Parker, C., Gariballa, S., Small, N.A., 2006. Prevalence of symptoms in a community-based sample of heart failure patients. J. Pain Symptom Manag. 32, 208–216. Barnett, K., Mercer, S., Norbury, M., Watt, G., Wyke, S., Guthrie, B., 2012. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 380, 37–43. Bayliss, E., Steiner, J., Fernald, D., Crane, L., Main, D., 2003. Description of barriers to selfcare by persons with comorbid chronic diseases. Ann. Fam. Med. 1, 15–21. Bird, L., 2007. The 3 “C” design model for networked-collaborative e-learning: a tool for novice designers. Innov. Educ. Teach. Int. 44, 153–167. Blue, L., Lang, E., McMurray, J., Davie, A., McDonagh, T., Murdoch, R., Petrie, M., Connolly, E., Norrie, J., Round, C., Ford, I., Morrison, C., 2001. Randomised controlled trial of specialist nurse intervention in heart failure. Br. Med. J. 323, 715. Boyd, C., Boult, C., Shadmi, E., Leff, B., Brager, R., Dunbar, L., Wolff, J., Wegener, S., 2007. Guided care for multimorbid older adults. The Gerontologist 47, 697–704. Castledine, G., 2006. Generalist versus specialist nursing practice. Br. J. Nurs. 15, 347. Chew-Graham, C., Hunter, C., Langer, S., Stenhoff, A., Drinkwater, J., Guthrie, E., Salmon, P., 2013. How QOF is shaping primary care review consultations: a longitudinal qualitative study. BMC Fam. Pract. 14, 103–120. Coulter, A., Roberts, S., Dixon, A., 2013. Delivering Better Services for People with Longterm Conditions. The King's Fund, London, (2013). Department of Health, 2012. Long term conditions compendium of information. London, DH. Available at: https://www.gov.uk/government/publications/long-term-conditionscompendium-of-information-third-edition (Accessed on 9th October 2013). Fortin, M., Soubhi, H., Hudon, C., Bayliss, E.A., van den Akker, M., 2007. Multimorbidity's many challenges. 7 Br. Med. J. 334, 1016–1017. Gott, M., Barnes, S., Parker, C., Payne, S., Seamark, D., Gariballa, S., Small, N., 2006. Predictors of quality of life of older people with heart failure recruited from primary care. Age Ageing 35, 172–177. Green, J., McKinley, R., Jester, R., Pooler, A., 2013. Nurse-patient consultations in primary care — do patients disclose their concerns? J. Wound Care 22, 534–539. Hughes, P., Hancock, C., Cooper, K., 2012. Non-communicable diseases: calling healthcare educators to action. Nurse Educ. Today 32, 757–759. Humphreys, M., Wood, I., Johnson, C., Walsh, P., Witton, N., Green, J., Corkhill, S., 2013. The Keele curriculum model: a contemporary framework for designing an interprofessional technology enhanced nursing curriculum. Open J Nurs. 3, 358–362. Humphreys, M., Bracegirdle, L., 2013. Using a virtual learning environment within simulation to enhance inter-professional team working skills. Edulearn13 Proceedings, pp. 4263–4268. Kadam, U.T., Croft, P., 2007. Clinical multimorbidity and physical functioning in older adults: a record and health status linkage study in general practice. Fam. Pract. 24, 412–419. Kadam, U.T., 2012. Redesigning the general practice consultation to improve care for patients with multimorbidity. Br. Med. J. 345, e6202. Organization of Economic Cooperation and Development (OECD), 2011. Health Reform: Meeting the Challenge of Ageing and Multiple Morbidities. OECD Publishing,. http://dx.doi.org/10.1787/9789264122314-en. Lennartsson, C., Heimerson, I., 2012. Elderly people's health. Health in Sweden: The National Public Health Report 2012. Chapter 5. Scand. J. Public Health 40 (Suppl. 9), 95–120.
5
Marengoni, A., Angleman, S., Melis, R., Mangialasche, F., Karp, A., Garmen, A., Mainow, B., Fratiglioni, L., 2011. Aging with multimorbidity: a systematic review of literature. Ageing Res. Rev. 10, 430–439. Mercer, S., Gunn, J., Wyke, S., 2011. Improving the health of people with multimorbidity: the need for prospective cohort studies. J. Comorbidity 1, 4–7. Mercer, S.W., Gunn, J., Bower, P., Wyke, S., Guthrie, B., 2012. Managing Patients with Mental and Physical Multimorbidity. Br. Med. J. 345, e5559. NHS Improvement – Lung, 2013. Managing multimorbidity in practice … what lessons can be learnt from the care of people with COPD and co-morbidities?. Available at: http://www.improvement.nhs.uk/documents/COPD_MultiMorbidities.pdf (Accessed on 9th October 2013). Noel, P.H., Parchman, M., Williams, J., Cornell, J., Shuko, L., Zeber, J., Kazis, L., Lee, A., Pugh, J., 2007. The challenges of multimorbidity from the patient perspective. J. Gen. Intern. Med. 22 (Suppl. 3), 419–424. Riegel, B., Jaarsma, T., Strömberg, A., 2012. A middle range theory of self-care of chronic illness. Adv. Nurs. Sci. 35, 194–204. Robert Wood Johnson Foundation and the Johns Hopkins Bloomberg School of Public Health, 2010. Chronic care: making the case for ongoing care. Updated 2010, available at www.rwjf.org/files/research/50968chronic.care.chartbook.pdf. Rushton, C., Kadam, U.T., 2011. Polypharmacy in heart failure; a growing challenge. Br. J. Card. Nurs. 6, 214–220. Rushton, C., Satchithananda, D., Kadam, U.T., 2011. Co-morbidity in modern nursing: a closer look at heart failure. Br. J. Nurs. 20, 148–154. Salisbury, C., Johnson, L., Purdy, S., Valderas, J., Montgomery, A., 2011. Epidemiology and impact of multimorbidity in primary care. Br. J. Gen. Pract. 61, e12–e21. Socialstyrelsen, 2013. Health in Sweden 2012 — updated statistics. Accessed at: http:// www.socialstyrelsen.se/nyheter/2013februari/healthinsweden2012updatedstatistics (November 2013). Smith, M., Soubhi, H., Fortin, M., Hudon, C., O'Dowd, T., 2012. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. Br. Med. J. 345, e5205. The King's Fund, 2013. Long term conditions and multimorbidity. Accessed at: http:// www.kingsfund.org.uk/time-to-think-differently/trends/disease-and-disability/longterm-conditions-multi-morbidity (November 2013). Van den Akker, M., Buntinx, F., Metsemakers, J., Roos, S., Knottnerus, J., 1998. Multimorbidity in general practice prevalence, incidence, and determinants of cooccurring chronic and recurrent diseases. J. Clin. Epidemiol. 51, 367–375. Vogeli, C., Shields, A., Lee, T., Gibson, T.B., Marder, W.D., Weiss, K.B., Blumenthal, D., 2007. Multiple chronic conditions prevalence, health consequences and implications for quality, care management and costs. J. Gen. Intern. Med. 22, 391–395. World Health Organization (WHO), 2011a. Global status report on noncommunicable diseases. Accessed at http://www.who.int/nmh/publications/ncd_report_full_en.pdf (October 2013). World Health Organization (WHO), 2011b. Chronic disease and health promotion: region and country specific information sheets. Accessed at http://www.who. int/chp/chronic_disease_report/media/impact/en/index.html (October 2013).
Please cite this article as: Rushton, C.A., et al., The challenge of multimorbidity in nurse education: An international perspective, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.05.006
