Prevention and management

What Canadians are saying

Rising statistics for chronic diseases demonstrate that the purely clinical “repair” model is not working. The Canadian Institute for Health Information (2009) reports that:

• nearly 49 per cent of Canadians with one or two chronic conditions report they “rarely or never” talked to their physician about specific measures they could take to improve their health;

• of patients with one or more of the seven chronic conditions recognized in Canada, 40 per cent say they had received no treatment plan with their primary care provider in the past year; and

• one-quarter of Canadians with diabetes, heart disease, high blood pressure or a history of stroke say their weight was not checked on an annual basis.

Why is this issue important to nurses?

The increasing prevalence of chronic disease in Canada will affect the work of many nurses — whether they work in institutions or in the community. More effective prevention strategies need to be developed, as well as more follow-up and support to individuals and their families to help them manage their conditions. Canadian nurses need to re-evaluate their role and training to ensure that they are well-prepared to address these challenges.

RNs and NPs in Canada are working with Canadians to prevent and manage chronic diseases. They are:

• working across sectors: alongside policy-makers, engineers, environmentalists, fitness experts, food safety authorities, nutritionists and community health organizations;

• supporting health promotion and coordinating cases for high-need clients;

• promoting disease problem-solving and health decision-making;

• enhancing skills required for self-management;

• using a social justice lens and focusing on social determinants of health such as housing, income support and access to healthy food and recreation;

• influencing the environment in which people live; and

• supporting healthy behaviours (health literacy, healthy choices easier, effective programs).

The two biggest challenges in chronic disease are preventing the disease in the first place, and managing the condition effectively when it arises. Both of these are long-term challenges that are best addressed through an effective and ongoing relationship between the health-care provider and the patient, based on mutual respect, trust and appropriate interventions. The primary care setting is where this long-term relationship is most often established and where interventions occur. Secondary and tertiary levels of care provide opportunities for treatment and shorter interventions at moments when the patient might be highly receptive (usually associated with the onset or worsening of a condition).

As members of interprofessional collaborative teams, nurses have important roles to play in the prevention and management of chronic diseases:

• Nurses are usually the first — and most consistent — point of contact for patients.

• Nurses are often in the best position to gather information about a patient’s family, as well as social, cultural and economic factors that might be important to developing an intervention.

• Nurses are frequently in a position to use their skills in health education, helping patients develop prevention and management strategies appropriate for their personal and family situations that also make the best use of community resources.

• Nurses are skilled at assessment, ongoing care, education and family support.

• Nurses play an important advocating role for people living with chronic diseases.

Nursing innovation

In 2007, NPs opened a clinic in Sudbury, Ontario — the first of its kind in Canada — where, along with the surrounding area, an estimated 30,000 people were without a regular health-care provider.

The team of NPs and other health-care professionals are providing comprehensive primary care to several thousand patients (Heale & Butcher, 2010) who would otherwise receive care through emergency departments or walk-in clinics. NPs at this clinic provide physical assessments; treat common illnesses and injuries; order lab tests, X-rays and other diagnostic tests; prescribe medications; and monitor patients with chronic illness (Young, 2009).

A 2009 study showed that patients managed their chronic disease better when an NP was involved in their care (Russell et al., 2009). A study of patients with hypertension and diabetes mellitus showed better health outcomes among patients whose care was managed by an NP and physician team than by a physician alone (Litaker et al., 2003).

The nurse-led Women’s Healthy Heart Initiative at the McGill University Health Centre in Montreal, Quebec, improves access to care for women at high risk for heart disease. Nurses with advanced training in cardiac care work alongside a team of cardiologists, an exercise trainer and a dietitian to offer patients a comprehensive heart disease assessment, risk care strategies, treatment plan and intense follow-up to support the prevention and management of cardiovascular disease. Some women coming to the clinic had previously undiagnosed or inadequately treated hypertension, high cholesterol or other chronic health problems. Most were not managing their heart disease risk factors effectively. Patient feedback has been favourable, particularly with respect to the nurse-led approach and focus on lifestyle issues (Wray, 2010).

The primary care RNs and NPs at the New Canadian Clinics in Burnaby and Surrey, British Columbia, work with physicians and other team members to address the health needs of immigrants who have chronic diseases. An estimated 70 per cent of immigrants to the Burnaby area clinic develop diabetes (Woods, 2008). The nurses work to ensure early identification and management of diabetes and other health concerns by initiating screening, counseling and medical referrals. These nurses and their team members provide primary health-care services to approximately 1,000 new immigrants and coordinate referrals to other community resources to help the immigrants adapt to life in Canada (T. Armstrong, personal communication, November 30, 2010).

The Complex Chronic Disease Management Clinic in Calgary, Alberta, strives to improve disease management and reduce hospital readmissions through an integrated approach to care. Nurses, physicians and pharmacists are part of an interdisciplinary team working to address medical, social, lifestyle and other factors that affect health outcomes. Results at the end of a first-year pilot project in 2009, which compared hospital admissions and lengths of stay during a 90-day pre-intervention period with a 90-day post-intervention period, showed that the total number of hospital admissions was reduced by 24 per cent and the total number of bed days (length of stay) by 51 per cent (Conly et al., 2009).

Led by an RN, the Institute for Healthy Living and Chronic Disease Prevention, a collaborative research centre based at the University of British Columbia, Okanagan, encourages and supports research related to promoting health based on determinants of healthy behaviour, lifestyles and preventing chronic disease by addressing risk factors such as smoking. Current areas of research include tobacco reduction, active living, promoting well-being, healthy eating and aging and health (The University of British Columbia, 2011).

What can nurses do about this issue?

• Ensure that the patient, the patient’s family and other health professionals understand the diagnosis, the treatment and where to obtain more information on the chronic disease.

• Listen to the patient’s wisdom and collaborate with them — they are the ones living with the disease.

• Work with community members and patients to ensure that appropriate services are available both in institutions and in the community. If appropriate community services are not available, the nurse’s role becomes that of facilitator and advocate.

• Consider the social determinants of health (e.g., income, employment, education, geographic isolation, social exclusion) in the assessment and treatment of clients with a chronic disease.

• Become aware of complementary practices available for patients to deal with existing chronic diseases or to prevent them. Determine the complementary practices your patients are using (if any), and assess the impact they may have on other treatments.

• Advocate for increased investment in health promotion and preventive care. Support the development of an integrated approach to chronic disease prevention that focuses on common major risk factors, and that integrates primary, secondary and tertiary prevention, health promotion, and related programs across sectors and disciplines.