HIV can't tell a physician from a nurse practitioner. Neither can studies that look at patient outcomes for each group. In recognizing a need, plus a chance to improve HIV/AIDS care, the Johns Hopkins University School of Nursing (JHUSON) has turned these truths into a tremendous opportunity for students.
An innovative new curriculum at JHUSON, developed by Associate Professor Jason Farley, PhD, MPH, CRNP, FAAN, and recently approved by the Maryland Higher Education Commission, will launch in September as a specialized education option available within the Adult Geriatric Nurse Practitioner and MSN/MPH/AGNP programs.
"For many years these specialty training programs in HIV have been available for physicians," Farley says. "This is the first time JHU is offering them to non-physician providers. It's quite an important development. When you look at data comparing patient outcomes with physician care and with nurse practitioner care in HIV, whether in the United States or in sub-Saharan Africa, those outcomes are the same."
One factor in those positive results, Farley says, is that nurse practitioners routinely spend more time with patients than physicians do: "In many studies, we see that patient-provider interactions are especially strong with nurse practitioners, and may result in improved adherence by patients to their treatment regimens."
The development of the new HIV curriculum is being financed by a five-year, $1.5 million grant from the Health Resources and Services Administration, the main federal agency tasked with improving health care access for the uninsured and otherwise underserved populations.
Farley opted to place the Hopkins training module inside the nurse practitioner degree program in response to current trends in HIV care. Slowly but steadily, more and more of that care has been migrating into primary care settings and out of specialized clinics. That trend is likely to accelerate. "The design of our program starts with the recognition that HIV care cannot be provided in a silo, that it needs to be integrated holistically into primary care," Farley says. "We want our students to get this training right at the same time they're getting their advanced training in primary care."
One innovative twist in the curriculum extends the length of time students spend on field placements in clinics. Most nursing programs operate on a semester model for such placements, but students in the HIV program will work in one location for an entire year. "In the semester model, you may see a patient just twice before it's time to move on, maybe three times at the most," Farley says. "That makes it difficult to really know if you're managing their hypertension well, for example, or their diabetes."
That will also put students and their physician or nurse practitioner preceptors in a better position to evaluate their work at the end of the placement.
"We are striving here to offer a continually reflective model of training," Farley says. "That will be a big help to students when they get out in the field and start managing much larger patient panels. They'll be prepared to do the work of implementing interventions in ways where they can really measure progress going forward and see what's succeeding and what they need to work on."
All in all, there are 20 sites where students will be working, ranging from specialty care facilities to prevention-oriented programs and primary care clinics. Most are in Baltimore, but three are in Washington, DC, and one is focused on HIV care in rural areas. "I expect that the continuity of care that comes with the year-long HIV primary care schedule will have real productivity benefits for our field sites," Farley explains.
Another key component of the program is a type of sensitivity training that pushes students to identify preconceptions they hold about the patient populations they'll be serving, notions that could affect care. Then they will go out on "harm-reduction walks," distributing condoms and health information to sex workers, as well as offering HIV testing. "We really want them to reflect about what their preconceptions were and what the reality was," Farley says
Farley prefers the phrase "culturally relevant" to the more popular "culturally competent" when it comes to educating students to deliver care to members of unique social and cultural groups. "If you see one transgendered patient during your training, that's not going to make you 'competent' in caring for the transgendered," he says. "But if we train you to be open and flexible and amenable, if we train you in the skill set you need to learn and understand and react to a new culture, that's going to make you a better provider."
Farley expects the new curriculum to launch with an enrollment of 10 to 12 students. One measure of its success in the coming years will be what kind of jobs students land upon earning their degrees. Farley plans to track those outcomes, and he expresses hope that most students will remain in the Baltimore and Washington regions, both of which rank in the top 10 in the country for both the number of individuals with HIV and the number of new infections per year.
"Our HIV provider population is aging," he says. "Just for one example, there are 12 non-physician providers at the Moore Clinic (an HIV-care facility operated by the Johns Hopkins AIDS Service at the School of Medicine where Farley works as a nurse practitioner), and I am one of the two youngest of those providers. I've been there for 11 years now. We really need to get these new young people in so that they can learn from the providers who've been doing this for a long time."