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Improving the Chain of Recovery for Acute Stroke in Your Community: Task Force Report

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December 12-13, 2002

Task Force Report
Professional Education

Patrick D. Lyden, M.D.
Task Force Chair
University of California at San Diego
Medical Center		   Thomas G. Kwiatkowski, M.D.
Long Island Jewish Medical Center
New Hyde Park, New Yorkl
 
Susan L. Hickenbottom, M.D., M.S.
Task Force Co-Chair
University of Michigan Health System
Ann Arbor		   Christopher A. Lewandowski, M.D.
Henry Ford Hospital
Detroit		  
 
Richard P. Atkinson, M.D.
University of California at Davis
Sacramento		   Colin C. Rorrie, Jr., Ph.D., C.A.E.
American College of Emergency Physicians
Irving, Texas		  
 
Lisa Davis, R.N., M.S.N.
National Institute of Neurological Disorders and Stroke
Bethesda		   Edward P. Sloan, M.D., M.P.H., F.A.C.E.P.
University of Illinois at Chicago		  
Jeremy Golding, M.D.
University of Massachusetts Memorial
Health Care System
Worcester		   Judith A. Spilker, R.N.
University of Cincinnati		  
Judith A. Hinchey, M.D.
New England Medical Center
Boston		   Robert E. Suter, D.O., M.H.A.
American College of Emergency Physicians
Irving, Texas		  
 
Kurt Kleinschmidt, M.D.
University of Texas Southwestern
Medical Center at Dallas		   Steven Warach, M.D., Ph.D.
National Institute of Neurological Disorders and Stroke
Bethesda		  

The objective of the Professional Education Task Force Report is to outline strategies to motivate physicians, other health care providers, and health care organizations to learn and apply the principles of acute stroke care. The report discusses current barriers to implementing recommendations for improved acute stroke care and suggests how to overcome them by using methods that engage the support of local and national organizations in the education process. It also discusses how to improve professional education for acute stroke care by effectively incorporating educational materials into continuing medical education (CME) programs, medical school and nursing school curricula, and residency programs.

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Principles of Adult Education

Learning is defined as the acquisition of knowledge that leads to a change in behavior (1). To modify the practices of health care providers responsible for delivering improved stroke care, the principles of adult education must be incorporated into stroke evaluation and management educational interventions. These principles are summarized in Table 1. Most importantly, adults must be motivated to learn. Motivation can result from varied forces, both internal and external. The vast majority of health care providers possess strong internal motivation to assimilate new information in order to improve the quality of care they provide to patients. This internal motivation to improve may be influenced by major life events or may arise from a perceived moral imperative to do what is best for the patient. From a more practical standpoint, this internal desire to learn must be strong enough to successfully compete with other time demands placed on people with already saturated schedules. On the other hand, external factors, including direct supervisors, health system administrators, insurance organizations, and regulatory agencies, can also be very powerful motivators. Pressures from these entities can often promote learning even when internal motivation is lacking.

In general, adults may not learn purely for the sake of learning; they do so because they have a relevant use for the knowledge or skill being sought (2). Adults also tend to prefer learning concepts and principles rather than facts, and they are better motivated to learn if they can quickly apply what they have learned (1,3). When new concepts are linked to existing knowledge and experiences, such as through a problem-oriented teaching approach, learning is enhanced. For example, case studies focus learning on a common point and provide opportunities for discussions (1). Adults prefer learning settings that involve straightforward information, a "how to" focus, and single-concept/single-theory courses (2). Conversely, information that is complex or conflicts with what is already held to be true is integrated more slowly into practice.

Moreover, adults prefer active, not passive, curricula that are focused on the learner. Thus they often prefer self-directed or self-designed learning projects over group learning experiences, although interaction with other learners is still deemed important. In group learning sessions, adults want instructors to facilitate learning, not to dominate the process (2). Finally, adults like feedback to evaluate their own performance (3). Negative feedback is accepted more readily if some positive feedback is also used. Adults tend to take "errors" or bad outcomes personally and thus are less likely to try new approaches (2). For health care providers, this may be particularly compounded by the current medico legal atmosphere.

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Inadequacies of Previous Professional Education Efforts for Acute Stroke

Continuing education, in the form of meetings and journals, has been the time-honored method of transmitting new medical information to practicing medical professionals. To date, most of the professional education efforts aimed at improving acute stroke care have relied on this traditional approach. Unfortunately, studies have shown that most continuing medical education (CME) aimed at physicians, usually in the form of didactic lectures, results in little if any change in physician behavior and practice (4,5). CME can be made more effective, especially if it is combined with other techniques to promote behavioral change. New information about acute stroke management must be conveyed to all those in the medical community, but traditional CME needs to be altered to recognize the limitations of didactic lectures. Table 2 outlines techniques that have been tested and their relative effectiveness.

Furthermore, previous educational efforts for acute stroke care may not have been well targeted. Many national and local stroke education programs have focused primarily on postgraduate physician education, but have not distinguished between those already familiar with the latest strategies for diagnosis and management of acute stroke (e.g., neurologists or emergency medicine physicians) and those who may have less exposure to these aspects of stroke care (e.g., primary care providers). In addition, non-physician learners may have different needs. For example, much of the current nursing school curriculum is based on a "foundational concept" approach. Because such curricula are driven by a health-patterns model, nursing students are provided a foundation for providing care to patients with impairments in mobility, sensation, or communication. While this information clearly applies to a stroke patient, it is not often presented in the disease-focused model that drives continuing education. The portion of nursing school curricula that focuses on neurological diseases in general is limited, varying from 16 hours total for an associate's degree in nursing to 24-30 hours total for a bachelor's degree or advanced practice nursing specialties. As a result, nursing school graduates receive information about care needs of stroke patients indirectly at best. Continuing education efforts aimed at nurses should include information on disease-specific pathophysiology as an introduction to acute stroke care, as well as focusing on factors that have been found to effect change in clinical nursing practice (6) (table 3). Finally, some type of introductory instruction might be needed in undergraduate medical education or with others not as familiar with acute stroke care. Thus, a range of educational efforts is needed, and trying to create "one-size-fits-all" stroke courses may leave all attendees feeling dissatisfied, as educational expectations and needs are not met.

Finally, the content of previous acute stroke educational programs may have been too focused on thrombolysis to be of value to many learners. Because of variability in clinical resources, emphasis on this treatment only may distract learners from retaining stroke educational messages on the whole. Some physicians or other health care providers may have very infrequent opportunity to use thrombolysis, yet could still benefit from education about other aspects of acute stroke care.

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Environmental Barriers to Implementing Professional Education

Over the past decade, there has been an explosion in the number of individuals seeking emergency care nationwide. In 2000 there were 108 million emergency department visits, an increase of 17 percent over the number of visits in 1997. At the same time, many emergency departments are being closed. Furthermore, many locations are experiencing a significant decrease in the number of on-call specialists maintaining a full complement of privileges. Hospital crowding, declining financial resources for the provision of health care, and medico legal issues further complicate delivery of medical care.

The current national nursing shortage has increased the workload of emergency department and hospital nurses, and places limits on nurses' opportunities to leave the bedside to attend in-service continuing education events. The nursing shortage has also created a deficit of administrative support by limiting the number of hospital-based educators or clinical nurse specialists and others who have traditionally been responsible for presenting innovative practice information to the bedside nurse. In times of acute staff shortages, most hospital nursing leadership is focused on keeping beds open rather than on effecting behavioral change.

The impact of these difficulties on the ability of a health care system to undertake any specialized education initiatives related to stroke is evident. This environment would not be conducive to special initiatives that require focused activity or new approaches to learning.

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Improving Professional Education for Stroke

Improving the quality and increasing the impact of educational interventions for health care professionals is a worthy goal, as it should improve acute stroke care and outcomes for stroke patients in the long run. While the problem is complex, several steps can be taken to work toward this valuable goal.

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Incorporating Educational Theory into Practice

Whatever the method, target audience, or content of future educational programs for improving stroke care, the interventions will need to incorporate lessons learned from educational theory. In order to maximize the potential for success, new interventions will need to (a) elucidate and focus on health care provider motivation to learn, (b) be relevant to those taking care of stroke patients in clinical practice, (c) emphasize concepts and principles of stroke care, rather than reiterating facts, (d) involve participants in active learning, and (e) provide feedback to learners. External motivation to improve acute stroke care could be generated by garnering involvement of quality improvement divisions, marketing departments, or regional peer review organizations of local institutions. In addition, physicians and other health care professionals would be highly motivated to learn about acute stroke care if it were an emphasized part of the skill set needed in order to practice. Encouragement could come from employers (hospitals or medical groups), professional societies (American College of Emergency Physicians, American Academy of Neurology, etc), or certifying bodies through their various exams (U.S. Medical Licensing Exam; American Board of Emergency Medicine; American Board of Psychiatry and Neurology; American Board of Internal Medicine; American Board of Family Practitioners; neuroscience, critical care, or emergency nursing organizations; etc).

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Changing the Approach to Continuing Education

Traditional continuing education activities will need to be modified to include the above concepts. Several factors have been identified as most effective in preparing physicians and other health care providers for change and learning.

  • Providers must recognize the need to change.
  • Educational tools must provide interaction among learners with opportunities to practice the skills learned.
  • Education should use sequenced and multifaceted activities (7).

Thus, options for improved CME programs on stroke include the following:

  1. Provide material or data that raises awareness of gaps in knowledge or performance.
    Motivation to improve knowledge or performance can come from audit and feedback, benchmarking, registries, or any technique that demonstrates gaps between performance and guidelines. Behavior must first be measured before it can be successfully changed. Assessment of process and outcomes can be promoted locally. This may include the development of forms to collect specific information and allow feedback on compliance with the recommendations. Means to this end could include:
    • Developing web-based, interactive individual and system assessment tools for stroke. These tools could offer case studies with multiple choice answers and feedback, and downloadable model guidelines, orders, and pathways (both in PDF format and compatible with PDA's).
    • Developing tests of knowledge and assessment of clinical practice about stroke before didactic lectures.
    • Developing benchmarks of care so providers and systems can compare their practice to "best care."


  1. Provide interactive learning opportunities.
    "Interactive" continuing education, requiring some response from the receiver, has shown the best outcomes in studies of physician knowledge and practice patterns (8). Examples include workshops, small discussion groups, and individualized training sessions. More extensive use of personal computers, PDA's, and the Internet may revolutionize the field and make this a feasible and cost-effective evolution (9). Some interactive options include:
    • Live or video lectures with local/regional/national leaders who use an interactive approach, such as a case study review.
    • PDA-appropriate content about acute stroke management. This could include information such as decision trees for thrombolysis, blood pressure management, glucose issues, discharge medications for secondary stroke prevention, and atrial fibrillation anticoagulation issues.
    • A forum on the Internet for stroke-related management discussion through a moderated site (eg, via the American Academy of Neurology, the American College of Emergency Physicians, or the American Stroke Association).
    • Use of simulated stroke patients and mock "stroke codes."
    Self-assessment tools and interactive learning materials are under development or are available through many organizations, including the American Academy of Neurology, the American Stroke Association, and the Foundation for Education and Research in Neurological Emergencies.
  1. Provide sequenced and multimodal activities.
    Because health care providers learn in different ways and several factors are involved in changing behavior (10), the most successful teaching techniques include using a combination of the methods shown in table 2 (5).

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Targeting Multiple Audiences with Interventions Appropriate to Knowledge Level

As noted above, it is important to design multifaceted educational programs that include information targeted to learners from different disciplines and at different levels of training. Since medical students, nursing students, and medical residents are essentially a captive audience primed for learning, a major goal should be improving stroke-related curricula in medical and nursing schools and residency programs.

Stroke-related components of nursing school, medical school, and residency curricula should be evaluated for their currency and comprehensiveness. Because stroke is the third most common cause of death in the United States, physicians in all specialties are frequently confronted with patients at risk for stroke, or who are experiencing stroke symptoms. To address this medical need the American Academy of Neurology is preparing a neurology residency curriculum with input from all the specialty sections of the Academy. Implementation of this curriculum, with current stroke information, should be a priority. In addition, national organizations charged with overseeing undergraduate and graduate education for medicine, emergency medical services providers, physician assistants, etc, should incorporate stroke into their curricula.

Nursing education in stroke should be reviewed and updated as follows:

  • Undergraduate nursing education should be evaluated for content specifically relevant to stroke care across the health care continuum.
  • Continuing education for nurses needs to be developed to effectively integrate baseline nursing knowledge of stroke care management into the multidisciplinary stroke system approach. For example, continuing education strategies should include nursing participation in case-conference discussions with physicians and other stroke care providers.

Education for other personnel who care for stroke patients, including emergency medical services providers and physician assistants, should also be reviewed and updated. Home health providers and those who deliver services to residents in assisted living, nursing care, and other long-term facilities need specialized education in caring for a population where pre-stroke functional disability, cognitive impairment, and co-morbidities are common. This specialized education will help ensure that this high-risk population is properly evaluated for stroke symptoms and referred promptly to hospitals when appropriate.

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Expanding the Content of Acute Stroke Education

As noted above, new interventions for professional stroke education cannot focus only on the delivery of thrombolytic therapy. Additional aspects of stroke care that need to be addressed in educational interventions might include epidemiology, pathophysiology, stroke syndromes, emergency care and stabilization, evidence for or against other acute therapies (heparin, temperature or glucose control, etc), emerging therapies, diagnostic work up including CT interpretation, inpatient care, rehabilitation and recovery, quality of life issues, secondary prevention, systems of care, and quality improvement.

Moreover, there is a need for the development of consistent, easily accessible "model" guidelines on stroke management and prevention for local adaptation and use in quality improvement projects. A recent study pointed out the variability of advice given in national guidelines regarding stroke prevention (11). Validated guidelines for medical and nursing management of stroke patients should be developed using simple language and "how to" advice. These guidelines should be made available at all point-of-care sites. Local health care providers could adapt these guidelines to fit their needs and environment, and quality improvement measurements could be created from them. Hospitals and payers could then pursue quality improvement in stroke care for their communities, tying current knowledge about stroke management to easily measured hospital quality improvement projects. Potential measures might include anti thrombotic therapy use at discharge, proportion of ischemic strokes treated with thrombolytics, use of early swallowing assessments, and use of deep vein thrombosis prophylaxis in non-ambulatory stroke patients.

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Overcoming Other Barriers

Other chapters in this book will deal more fully with issues of implementing a systems approach for acute stroke care, navigating the current medico legal climate as it pertains to acute stroke care, and developing financial incentives for acute stroke care. However, it should be noted that these environmental barriers play a role in frustrating effective education. Behavioral change needs to occur within an organization, and organizational barriers to change must be removed for education to succeed. A fundamental way to begin to overcome organizational barriers at the local level is to form teams of health care professionals to encourage local implementation of guidelines (12). The use of local opinion leaders to deliver seminars has also been effective to encourage local change (13).

As noted above, national specialty organizations, advocacy groups, regulatory agencies, and others should be approached to aid in the development and implementation of these proposals, to gain institutional "buy-in" for acute stroke education and care, and also to provide external motivation for behavioral change among health care providers. Institutional motivation to bring about these changes will be key in a successful educational intervention. In addition to the desire to provide quality care, institutions can be motivated to provide or require professional education by ranking, certification, or regulation. These approaches have been used effectively in stimulating overall institutional performance as well as specifically for cardiac and trauma care (14-17). Ranking institutional performance is usually a function of a media outlet or advocacy group. This function is not usually a function of regulatory agencies, as these agencies view their role as delineating minimum performance or adherence to standards. Promotion of an institutional ranking system through stroke advocacy groups and/or a major magazine that would take an interest in this area could be pursued. Certification systems could also serve to motivate institutions. Development of stroke center identification, mostly through the efforts of the American Stroke Association, could provide further impetus to apply current stroke management knowledge at hospitals throughout the country. Guidelines for the establishment of a "primary stroke center" were published in the Journal of the American Medical Association in 2000 (18). A survey done in Southern California found that large numbers of hospitals believed they met these criteria, but when actually evaluated, a small percentage truly qualified (Kidwell CS, personal communication, 2002). In a competitive health care market, such efforts can be expected to attract sufficient attention to improve professional education and stroke care, and educational materials with practical advice on how to develop and maintain a stroke center will be useful in this process. Finally, regulation is an efficient, if onerous, method of promoting professional education, but there are currently no examples of nationwide professional education required by regulation. Efforts to increase recognition of stroke and to compel immediate transport of the patient to an emergency department might be successful, and a national stroke registry is in prototype testing. These approaches could be areas worthy of further exploration.

Finally, financial support will be needed to develop, implement, and evaluate professional education for stroke. Programs for needs assessment, validation of guidelines, measuring adherence to guidelines, and assessing the effectiveness of educational interventions will all need to be supported through national funding initiatives.

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Conclusions

The Professional Education Task Force members summarized their recommendations to the educational community as follows:

  • Develop comprehensive stroke curricula targeted at disciplines involved in providing stroke care.
  • Deliver professional education in a multi modal, interactive manner, consistent with the principles of adult education.
  • Increase funding for the development, implementation, and evaluation of professional education interventions.

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REFERENCES

  1. Douglas K, Hosokawa M, and Lawler F. A Practical Guide to Clinical Teaching in Medicine. New York, Pringer Publishing Company, 1988.
  2. Zemke R, and Zemke S. 30 things we know for sure about adult learning. Training 1988; 25(7): pp. 57-61.
  3. Whitman N, and Lawrence P. Surgical Teaching: Practice Makes Perfect. Salt Lake City, University of Utah, 1991.
  4. Davis DA, Thomson MA, Oxman AD, et al. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA 1992;268: pp. 1111-1117.
  5. Davis DA, Thomson MA, Oxman AD, et al. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274: pp. 700-705.
  6. Clarke HF. Using research to make a difference in clinical nursing practice: the Nightingale legacy. Child Health 2000, International Pediatric Nursing Conference 1995 (http://classweb.gmu.edu/rfeeg/ichna/clarke.html).
  7. Mazmanian PE, and Davis DA. Continuing medical education and the physician as a learner: guide to the evidence. JAMA 2002;288: pp. 1057-1060.
  8. Davis DA, O'Brien MA, Freemantle N, et al. Impact of formal continuing medical education. Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999;282: pp. 867-874.
  9. Wiecha J, and Barrie N. Collaborative online learning: a new approach to distance CME. Acad Med 2002;77(9): pp. 928-929.
  10. Allery LA, Owen PA, and Robling MR. Why general practitioners and consultants change their clinical practice: a critical incident study. BMJU 1997;314: pp. 870-879.
  11. Hart RG, and Bailey RD. An assessment of guidelines for the prevention of ischemic stroke. Neurology 2002;59: pp. 977-982.
  12. Cameron C, and Naylor CD. No impact from active dissemination of the Ottawa ankle rules: further evidence of the need for local implementation of practice guidelines. CMAJ 1999;160: pp. 1165-1168.
  13. Gifford DR, Holloway RG, Frankel MR, et al. Improving adherence to dementia guidelines through education and opinion leaders. A randomized, controlled trial. Ann Intern Med 1999;131: pp. 237-244.
  14. Dannenberg AL, Salive ME, Forston SR, et al. Board certification among preventive medicine residency graduates. Am J Prev Med 1994;10(5): pp. 251-258.
  15. Gunn IP. Regulation of health care professions. Part 2: Validation of continued competence. Clinical Forum for Nurse Anesthetists 1999;10(3): pp. 135-141.
  16. Livingood WC, and Auld ME. The credentialing of a population-based health profession: lessons learned from health education certification. J Public Health Manag Pract 2001;7(4): pp. 38-45.
  17. Parboosingh J. Credentialing physicians: challenges for continuing medical education. J Contin Educ Health Prof 2000;20(3): pp. 188-190.
  18. Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for the establishment of primary stroke center. The Brain Attack Coalition. JAMA 2000;283(3): pp. 102-109.

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Table 1. Principles of adult education

Adult students:

  • must be motivated to learn
  • need a relevant use for the knowledge or skill being sought
  • prefer learning concepts and principles rather than facts
  • prefer an active curriculum that is learner-based
  • like to receive feedback on their performance

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Table 2. Strategies for changing physician behavior*

Most effective strategies

  • Reminders (at point of need/services)
  • Patient-mediated strategies
  • Outreach visits
  • Encouragement from opinion leaders
  • Multiple, sequenced interventions sustained over time

Moderately effective strategies

  • Audit and feedback
  • Educational material

Least effective strategies

  • Formal CME conferences or activities

* Adapted from Davis et al, 1995 (5).

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Table 3. Factors found to effect change in clinical nursing practice*

Most effective strategies

  • Well-timed education sessions with clinical application of care-specific interventions
  • Demonstrations of obvious advantage to patients and positive patient outcomes
  • Availability of clearly written agency policy and procedures manuals
  • Access to opinions and support of other professionals
  • Efforts to bring about changes that are compatible with nursing values
  • Availability of simple-to-understand and easy-to-implement guidelines
  • Promotion of changes that can be tested and evaluated, that quickly demonstrate results, and that are accompanied by effective plans for implementation

Barriers to change

  • Perceived lack of authority to institute changes
  • Lack of physician and other administrative support
  • Efforts to mandate change without proper training
  • Absence of credible justification for change

* Adapted from Clarke, 1995 (6).

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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

Last updated July 15, 2008