Good Habits
Grant initiative allows nurse consultants to team up with family practice clinics to encourage healthy lifestyle choices

By Donna Hemmila
March 5, 2004

Jeanne Baumann is spending a lot of time on the road these days tackling one of medicine’s greatest challenges—how to motivate people to change bad habits.

Acting as a nurse consultant, Baumann, MSN, RN, is part of a research initiative that is test-driving ways to help family practice clinics improve the health of their clients.

Operating under the Great Lakes Research in Practice Network in Lansing, Mich., the research is one of 17 Prescription for Health projects funded by The Robert Wood Johnson Foundation and the Agency for Healthcare Research and Quality. This five-year grant initiative focuses on four risky behaviors: smoking, drinking, poor diet and inadequate exercise. All of these behaviors are recognized as significant factors in heart disease, diabetes and other chronic conditions.

The grant competition was open to family practice-based research networks and attracted 70 applicants. The proposed research projects had to target at least two of the risky behaviors and propose an innovative way to deal with them. Each of the grantees received $125,000 to fund 16-month projects. One of the criteria was to come up with innovations that could easily translate to other family practices.

The mission of all the projects is the same: to help family practices work with patients to develop healthier lifestyles. Several of the projects, like Baumann’s, rely heavily on nurses to get that job done.

“Consulting for a medical practice is new to me, and I think it’s relatively new to nursing,” Baumann said. “Nursing has traditionally been based in the hospital. More and more, it is outpatient-based and more involved with disease management.”

Working in the rural upper Michigan peninsula, Baumann sometimes must drive three hours to get to the outlying clinics participating in the research. She observes the type of screening and follow-up assessment the clinicians are doing with patients and advises them on how to design a plan that addresses the needs of its specific population.

Logical choice

The Michigan project is based on the idea that a nurse consultant would be someone already employed by a hospital health system in a quality assurance role and someone familiar with family practices. Baumann is an educator in the primary care residency program at Marquette General Health System, and helps train some of the doctors she encounters in the clinics.

Two nurses are testing the consultant model: Baumann, who is working with primary care practices owned by the health system, and Anita Arnold, RN, who works in an urban area with a network of family practices affiliated with the Genesys Health System. Each nurse is working with 10 practices.

Baumann sees her role as a facilitator to help each clinic identify places in its practice where healthy lifestyle changes could be encouraged. She observes a clinic’s procedures to determine if it has a screening process that can identify at-risk patients. Does it also identify the at-risk patient’s readiness to change? How does it assist with the change and follow-up? She also helps the practices determine who on staff should be performing the assessments and follow-ups. The project addresses all four of the risky behavior areas.

“Nurses always have a real concern for preventive care,” Baumann said. “That’s right up their alley for nurses. And they’re good at leading change.”

They’re also trained in a team approach to care, she said, and that’s essential when trying to build prevention into a health practice.

Maribel Cifuentes, RN, serves as the deputy director of the Prescription for Health initiative. Many of the projects involve nurses because nurses help manage and run the family practices where the research is being carried out. That provides a natural role for nursing, but several projects are focusing on enhancing the role of nurses and using them as agents of change. That’s a good thing, according to Cifuentes.

“I’m personally biased because I am a nurse,” she said. “The people who go into nursing have certain qualities. They’re very good communicators. They have diverse backgrounds and the passion to do quality work. It strikes me that nurses are very well-suited for this.”

Arnold makes good use of those communication skills. Getting the practices on board requires flexibility and an open mind, she’s found. One of her biggest obstacles has been to convince clinic staffs that she isn’t going to take up too much of their time.

“They have lots of people coming in and auditing them and giving them flow sheets,” Arnold said. “They’re very busy. They just don’t have time to do one more thing.”

Arnold has to negotiate with the various clinics for time to make presentations. Three clinics dropped out of the project, and the research network had to recruit three replacement sites.

“I believe flexibility is key and keeping an open mind, and not being judgmental and trying to fit them into a model,” Arnold said.

Time crunch

In already time-constrained, busy family practices, finding the staff with time to address behavior changes with patients can be challenging.

Another Prescription for Health project is testing the role nurses should play in providing health education. The Hartford, Conn.-based New England Clinicians Forum is conducting its grant research in eight health centers spread out over Maine, Connecticut and Massachusetts. The sites are all federally qualified health centers serving disadvantaged populations.

The project links risky drinking and tobacco use and is looking at whether it makes a difference who provides the screening and intervention.

The project is testing three models. In three clinics, a physician or nurse practitioner handles the screening. In three other clinics, a medical assistant or nurse fills this role, and in two clinics, a health educator from outside the center works with the patients.

As the nature of health care becomes more complex, physicians and nurse practitioners have less time for this kind of intervention, said Jennifer Granger, MPH, director of clinical affairs for the Connecticut Primary Care Association. One of the things the project would like to find out is whether other clinic staff could be just as effective in handling these interventions.

For Laura Anderko, Ph.D., RN, there is no question as to who is best qualified to help people get on track to a healthier life. She is the principal investigator for the only Prescription for Health grant project awarded to an all-nurse research network.

The Midwest Nursing Centers Consortium, a network of academic-based primary care centers, was founded in 2001. The nursing programs at 28 Midwestern universities sponsor the centers, which operate in nontraditional community settings.

The centers typically care for underserved populations who are uninsured and rely on the centers for all their medical needs.

The centers in the consortium are managed and primarily staffed with nurses. Physicians consult and some volunteer. “If a physician happens to be working at a center, a nurse is [the doctor’s] boss,” Anderko said. “When students come in, they can’t believe how autonomous we are.”

That’s been an asset in conducting the research, according to Anderko, interim associate dean for practice at the University of Wisconsin-Milwaukee College of Nursing. The consortium’s grant project is testing 16-week programs focused on improving diet and exercise. Each clinic site has a different array of exercises. Some offer mall-walking, for example. Others have yoga classes. Participants are encouraged to keep journals and to enlist a health buddy to keep them motivated. About 16 RNs are working on the project along with nursing students.

The cornerstone of the consortium’s project is intensive nurse outreach, using the support systems and social networks the centers are already tapping into. The practices are situated in neighborhood centers that also may house day care or preschool programs, in subsidized housing projects or in other nontraditional settings. That puts the nurses in close contact with their clients.

Nurses understand the psychosocial aspects of making lifestyle changes, Anderko said, and they’re uniquely qualified to motivate healthy behaviors. Nursing is one of the most respected professions in her area, she said, and as a result people believe what nurses say.

In a recent Gallup poll, nurses ranked higher than any other group when respondents were asked how they rated professions for honesty and ethical standards.

“There’s a right way and a wrong way to go about informing people,” Anderko said. “Sometimes there’s a lack of appreciation of the partnership you have with the patient.”

Nurses have the right training to motivate behavioral changes, she said. They are trained in nutrition and cultural diversity and appreciate the role those factors play in health.

One of the consortium’s long-term goals is to expand its research network nationwide. With research money flowing into projects that take practitioners out of the ivory towers and into the trenches, Anderko said, it’s time for nurses to fill those researcher roles.

Contact Donna Hemmila at dhemmila@prodigy.net.