April Joy Steele, RN,BScN,BSc. Psych,MN,NP-C,DNP (student) The Elephant in the Clinic Room, An Advanced Practice Nursing Education Intervention April Joy Steele, RN,BScN,BSc. Psych,MN,NP-C,DNP (student)

Hypertension Background Background: Health care providers often do not intensify treatments when clearly warranted, a phenomenon known as therapeutic or clinical inertia (TI or CI). Limited information is available on educational interventions to ameliorate knowledge-to-action gaps in TI/CI.

Objectives To evaluate the efficacy of an educational intervention compared to usual care among practicing primary care providers in rural Northern Alberta treating known adult hypertension. To explore the possible dissemination and refinement of study outcomes to translate this information to a variety of chronic disease management primary care practices.

  According to the Theory of Planned Behavior behaviour is influenced by three elements: Attitude: That the behavior will be beneficial to the individual. For example, Provider feels that assertively optimizing hypertension treatment is best practice. Subjective norms: The belief that other people think that the behavior is acceptable. (For example, Providers believe prescribing colleagues support using assertive optimization strategies to address uncontrolled hypertension. Perceived ability: The belief that one has the skills and capability to change behavior. (For example, Providers believes they are able to access and use clinical strategies to avoid clinical inertia and optimize hypertension management.  

Knowing and Doing Ulrich (2013). Ulrich, K. (2013). The burden of hypertension. Eurointervention Journal, 9. Ulrich (2013).

Methodology Single-blind, parallel-group, randomized clinical trial. Inclusion criteria included primary care nurse practitioners and physicians in rural Alberta primary care practice actively involved in managing hypertension patients. Participants to be exposed to 12 simulated case-scenarios (6 cases at baseline, and 6 cases post-randomization to usual care vs. educational intervention) of suboptimal control of known adult hypertension (Saposnik, Sempere, Prefasi, et al.,2017). The educational intervention will use a colour coded priority system to facilitate decisions, allowing subjects to recognize must act scenarios requiring hypertension treatment escalation. Differences between groups will assess possible decision fatigue (Tierney,2011). Current Canadian hypertension guidelines will be used exclusively by which to judge appropriate clinical decision making in scenarios (Leung, Daskalopoulou , Dasgupta et al.,2017). The control group will respond as they would do in their usual clinical practice having not been exposed to the educational intervention. The primary feasibility outcome was the proportion of participants who completed the study and the proportion of participants who correctly identified a high-risk case-scenario with the “red traffic light.”

Methodolgy Continued 18 primary care providers at three geographic primary care sites are invited to participate. Assignment randomly of the participants. Approximately half of participants will be assigned randomly to control and half will be randomly assigned to educational intervention group. CI will be measured in scenarios presented. Completion rate will be calculated. The overall correct assertive optimization of scenarios correctly chosen will be coloured as red light or must not proceed without optimization. A yellow group will be indicated for those participants requiring reassessment timely within 1-3 months. Fatigue outcome, in a within-group analysis process will be assessed to determine the amount and prevalence of CI in the second block of six case-scenarios.

Possible Findings Pre and Possibly Post Educational Intervention Barriers Barriers Time constraints in brief visit schedule Reluctance to adjust medications prescribed by a colleague Availability of a regular consistent provider Competing multiplicity of complex concerns in short appointment allotted Prevalent use of episodic care for chronic disease management Pharmacare medication costs and coverage Attributing hypertension to white coat syndrome

Probable Opportunities Post Intervention Importance of regular consistent provides, ongoing education of providers and patients about prevalence of CI and need for assertive measures to reach goal in timely manner after diagnosis.

References Ajzen, I. (2002). Perceived behavioral control, self‐efficacy, locus of control, and the theory of planned behavior. Journal of applied social psychology, 32(4), 665-683. Mohan, A. V., & Phillips, L. S. (2011). Clinical inertia and uncertainty in medicine. Jama, 306(4), 383-384. Leung, A. A., Daskalopoulou, S. S., Dasgupta, K., McBrien, K., Butalia, S., Zarnke, K. B., ... & Gelfer, M. (2017). Hypertension Canada's 2017 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Canadian Journal of Cardiology, 33(5), 557-576. Nahapetyan, L., Orpinas, P., Glass, A., & Song, X. (2014). Planning Ahead: Using the Theory of Planned Behavior to Predict Older Adults’ Intentions to Use Hospice if Faced With Terminal Illness. Journal of Applied Gerontology, 0733464817690678. Reach, G. (2014). Clinical inertia, uncertainty and individualized guidelines. Diabetes & metabolism, 40(4), 241-245. 1.5 billion people worldwide are projected to have hypertension by 2025. Hypertension has now become a global burden, watch this video to learn more about how to recognise hypertension risk factors, from modifiable to non-modifiable, and, how to manage your hypertensive patients and increase medication adherence.

References  Saposnik, G., Sempere, A. P., Prefasi, D., Selchen, D., Ruff, C. C., Maurino, J., & Tobler, P. N. (2017). Decision-making in Multiple Sclerosis: The Role of Aversion to Ambiguity for Therapeutic Inertia among Neurologists (DIScUTIR MS). Frontiers in Neurology, 8, 65. http://doi.org/10.3389/fneur.2017.00065 Tierney, J. (2011). Do you suffer from decision fatigue. New York Times Magazine, 33. Ulrich, K. (2013). The burden of hypertension. Eurointervention Journal, 9.