Implementation of a Standardized National HIV Curriculum in a Primary Care Nurse Practitioner Program : Nurse Educator

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Implementation of a Standardized National HIV Curriculum in a Primary Care Nurse Practitioner Program

Hays, Deana DNP, FNP-BC; Kridli, Suha PhD, RN; Kruse, Julie A. PhD, RN

Author Information
doi: 10.1097/NNE.0000000000001252
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Abstract

In 2019, the United States announced efforts to end the human immunodeficiency virus (HIV) epidemic by 2030.1 This initiative came nearly 40 years after HIV was first discovered in the United States. Despite efforts to end this epidemic, nearly 1.2 million people in the United States are living with HIV including approximately 1 in 7 persons who is unaware they have HIV infection.2 HIV infection ranks among one of the leading causes of death for persons aged 25 to 44 years.3

Despite the success in treatment of HIV infection, there continues to be a rise in HIV-infected cases, particularly due to the growing opioid epidemic.4 According to data reported by the Centers for Disease Control and Prevention, in 2019 alone, there were nearly 40 000 new cases of HIV infection in the United States, with the highest number of new cases among people aged 20 to 34 years. People of color also continue to be disproportionately impacted. In 2019, the highest rates of HIV infection were among Blacks/African Americans (42%), followed by Hispanic/Latino persons (28.5%).5

In addition, there is a significant shortage in the number of health care professionals who are trained to provide care for persons living with HIV (PLWH)6 coupled with an expanding population of PLWH, which complicates efforts toward ending the epidemic. According to the American Academy of HIV Medicine, the shortage of health care professionals who are trained to provide care for PLWH is expected to worsen over the next 10 years.7 There is an apparent need to not only expand clinical services for PLWH but also prepare a competent health care workforce.

Preparing primary care nurse practitioners (NPs) to manage care of PLWH through educational programming is one solution to meeting this training shortage. NPs are the largest and fastest growing group of nonphysician prescribers in the United States, particularly in rural and low-income areas.8 For primary care NPs to meet the HIV workforce shortage, educational preparation must be a priority. A multipronged approach is needed that includes high-quality, easily accessible, up-to-date HIV education for trainees and practicing providers.6

Although efforts have been made to improve and integrate HIV curriculum in schools of nursing,9,10 little has been done to standardize the integration of HIV curriculum and competencies related to HIV care in primary care NP programs. The need for standardized HIV education in NP programs is further highlighted by persistent gaps in knowledge related to HIV prevention including testing behaviors and pre-exposure prophylaxis (PrEP) among NPs.8,11

In an effort to address these providers' gaps in knowledge, the AIDS Education and Training Center Program, in collaboration with the University of Washington and Health Resources and Service Administration (HRSA), developed a National HIV Curriculum (NHC) to address the HRSA national strategic goal of increasing access to care and optimizing health outcomes for PLWH.12 The primary aim of the NHC is to increase the number of health care professionals who can competently provide care for PLWH by providing up-to-date, evidence-based standardized curriculum related to HIV screening, diagnosis, ongoing treatment, and prevention.13 In addition, this curriculum is structured around 6 core competencies developed by a multidisciplinary panel of expert HIV clinicians and educators.14 This NHC could serve as a tool for NP faculty to ensure that NPs transitioning into practice have the necessary knowledge and competencies to provide high-quality care for PLWH. The purpose of this study was to understand the effect of integrating the 6 core competencies from the NHC on NP students' perceived knowledge about HIV care.

Methods

Design, Sample, and Setting

This was a quasi-experimental study with a pre/posttest design that measured NP students' self-perceived knowledge of the 6 core competencies from the NHC. The curriculum was delivered in 3 parts designated as training sessions 1, 2, and 3. Participants included all students who were enrolled in the following core courses for the NP program over a 5-semester span of time: pathophysiology (n = 178), pharmacology (n = 113), and a chronic disease course (n = 84). Each course was offered twice a year during the study period. The pathophysiology and pharmacology courses were taken by the NP students during the first year of the program. The chronic disease course was the second course in the clinical sequence and was taken in year 2, the semester prior to graduation. Training 1 of the NHC was completed in the pathophysiology course, training 2 in the pharmacology course, and finally training 3 in the chronic disease course.

The students enrolled in these courses included 2 primary NP education tracks: the family nurse practitioner (FNP) and adult-gerontology primary care (AGPCNP). This study was implemented between September 2019 and December 2021.

Educational Intervention

The NHC is a comprehensive, evidence-based curriculum designed for multiple health professionals including nurses and physicians13 and is composed of 6 modules focused on HIV prevention and clinical care. These core competency modules include the topic areas of (1) HIV Screening, Diagnosis, and Linkage to Care, (2) HIV Primary Care, (3) Antiretroviral Therapy, (4) Co-occurring Conditions, (5) HIV Prevention, and (6) Key Populations. Each of these 6 core competency topic areas is included in all 3 of the training sessions. Although the topic areas remain the same for each of the training sessions, the curriculum is scaffolded where new content is added and concepts are built upon as students' progress through the curriculum in the training sessions.

Each of the 3 training sessions for the NHC was delivered via an e-learning platform and accessed through a public website sponsored by the University of Washington and funded by HRSA. The NHC website provides tools and resources to support and enhance education delivery and improve the competencies of health care practitioners in HIV care and prevention. The NHC is free for faculty and students, and a link to access the modules was placed in our school's learning management system. Accessibility to modules, tools, and resources is achieved by creating an account with the NHC website (which consists of using a valid email address and creating a password). Each of the modules contains lessons with learning objectives. The purpose of the NHC is to improve competencies specifically for primary care health care professionals in the 6 specific areas of HIV care as outlined previously.

The integration of the NHC at this school of nursing (SON) consisted of 3 phases. The first phase included developing a curriculum map to assess gaps related to each of the 6 competencies. The gap analysis was conducted by the primary investigator, who is a certified primary care NP and an educator. The NP curriculum is organized into 3 areas of concentration: foundational, clinical core, and specialty courses. The clinical core courses include pathophysiology, pharmacology, and health assessment. Each of clinical core and specialty courses is taught by primary care NPs. The gap analysis identified a lack of HIV prevention and clinical care content in all of the 3 clinical core courses. Additional gaps were also noted in the specialty courses in areas related to health promotion and chronic disease management. Once the gaps were identified, the 6 competencies were reviewed for alignment in each one of these courses. The alignment was based on each course description, objectives, and student learning outcomes, outlined in the course syllabus.

The second phase included meeting with the NP program director and primary care NP faculty members at the SON to discuss the curriculum map, program gaps, and the integration plan. Faculty expressed concern about adding the NHC modules to the health assessment and health promotion courses due to the large amount of content that already existed in the 2 courses. Therefore, it was decided the NHC would be integrated into the pathophysiology, pharmacology, and chronic disease courses.

The final phase included the approval of the curriculum integration plan. Approvals were obtained from the NP faculty, Graduate Committee on Instruction, and Faculty Assembly.

Data Collection and Analysis

All students enrolled in the courses completed the modules as part of their course requirements. To understand the effect of implementing the NHC, students rated their perceived knowledge for all 6 competencies by completing pre- and posttest surveys. These tests contained the established NHC questions that are used to evaluate the curriculum. After each of the 3 training sessions, students completed anonymous pre- and posttest surveys on a voluntary basis. A secured web link was sent to all students to complete the pre- and posttest surveys via the course web page. The core competency areas that were assessed included the application of evidence-based: (1) recommendations to provide HIV screening, diagnosis, and linkage to care; (2) primary care to PLWH; (3) antiretroviral therapy for PLWH; (4) recommendations for the evaluation and management of co-occurring conditions in PLWH; (5) recommendations for the prevention of HIV transmission; and (6) recommendations for PLWH. The pre- and posttest surveys contained a 4-point Likert scale with the following ratings: 1 = poor to 4 = excellent.

After each training session, students also were asked to rate their responses to “what extent do you intend to apply the knowledge you gained from the NHC to your future work” and “before studying material from the NHC, to what extent did you anticipate working with PLWH and people at high risk of HIV in your career?” A 5-point Likert scale was used to rate the last 2 questions, with 1 = not at all to 5 = a great deal.

Data were analyzed using IBM SPSS software version 28.15 Paired-samples t tests with Cohen's d were conducted to determine differences between pretest scores and posttest scores for all participants as well as the effect size.

Results

A total of 375 student NHC training sessions were implemented across 5 semesters. The survey response rate was 60.5% (227/375).

In each of the 3 courses that integrated the NHC, there were statistically significant increases in student knowledge from pre- to posttest for each of the 6 competencies (Table). Prior to the educational intervention for all 3 training sessions, students rated their knowledge for the competencies as “poor” but no greater than “fair.” Postintegration of the NHC, students rated their knowledge in each of the 6 competencies as “good.” The highest increase in reported knowledge was in core competency 3 (antiretroviral therapy) for training sessions 1 and 3 (t values = 27.58 and 23.95, respectively. For training 2, the highest reported knowledge increase was in core competency 6 (key populations) (t value = 40.13) (Table).

Table. - Paired-Samples t Test Comparison of Pre- and Posttest Scores for Students Who Completed HIV Training Sessions
Parameter Pretest Posttest t P Cohen's d
M SD M SD
Training 1a
1. HIV Screening, Diagnosis, and Linkage to Care 2.01 0.27 3.39 0.05 12.07 <.001 0.26
2. HIV Primary Care 2.05 0.20 3.30 0.10 15.58 <.001 0.18
3. Antiretroviral Therapy 1.99 0.20 3.31 0.14 27.58 <.001 0.11
4. Co-occurring Conditions 2.09 0.23 3.47 0.06 16.58 <.001 0.19
5. HIV Prevention 2.54 0.15 3.72 0.07 12.85 <.001 0.21
6. Key Populations 2.24 0.13 3.66 0.16 16.60 <.001 0.19
Total score 12.92 0.88 20.85 0.12 22.23 <.001 0.79
Intent to Work with PLWH in Future 2.45 0.23 3.08 0.25 6.88 .002 0.20
Training 2b
1. HIV Screening, Diagnosis, and Linkage to Care 1.87 0.15 3.22 0.21 12.72 <.001 0.24
2. HIV Primary Care 1.83 0.16 3.16 0.15 12.45 <.001 0.24
3. Antiretroviral Therapy 1.68 0.17 3.10 0.24 11.06 <.001 0.29
4. Co-occurring Conditions 1.86 0.19 3.19 0.13 12.27 <.001 0.24
5. HIV Prevention 2.10 0.21 3.23 0.16 23.34 <.001 0.10
6. Key Populations 2.02 0.12 3.13 0.16 40.13 <.001 0.06
Total score 11.44 0.45 19.02 0.86 15.81 <.001 1.07
Intent to Work with PLWH in Future 2.34 0.20 2.79 0.19 4.16 .014 0.23
Training 3c
1. HIV Screening, Diagnosis, and Linkage to Care 2.01 0.18 3.30 0.05 12.67 .001 0.20
2. HIV Primary Care 1.97 0.15 3.34 0.04 19.47 <.001 0.14
3. Antiretroviral Therapy 1.83 0.06 3.25 0.06 23.95 <.001 0.12
4. Co-occurring Conditions 1.96 0.08 3.29 0.08 ...d ...d ...d
5. HIV Prevention 2.23 0.32 3.36 0.06 7.30 .005 0.31
6. Key Populations 2.07 0.21 3.38 0.03 14.56 <.001 0.18
Total score 12.07 0.89 19.91 0.05 16.74 <.001 0.93
Intent to Work with PLWH in Future 2.29 0.34 2.66 0.17 3.94 .029 0.19
Abbreviation: PLWH, persons living with HIV.
an = 98.
bn = 73.
cn = 56.
dt cannot be computed because the standard error of the difference was zero.

A paired-samples t test was also conducted to evaluate the impact of the NHC on students' total core competency scores. There were statistically significant increases in posttest scores from NHC pretest scores for each of the training sessions (training 1 pretest: M = 12.92, SD = 0.88, posttest: M = 20.85, SD = 0.12; training 2 range: M = 11.44, SD = 0.45, posttest: M = 19.02, SD = 0.86; training 3 pretest: M = 12.07, SD = 0.89, posttest: M = 19.91, SD = 0.05). Cohen's d effect size16 for total competency scores was large (0.79, 1.07, and 0.93) for training sessions 1, 2, and 3, respectively.

Students were also asked “To what extent do you intend to apply the knowledge you gained from the NHC to your work.” Reponses were rated on a 5-point Likert scale, with 1 = not at all to 5 = a great deal. Mean scores ranged from 2.80 to 3.65, with most mean scores above 3, indicating students intended to apply knowledge from the NHC to their future practice settings a moderate amount of the time. In addition, students rated their intent to work with PLWH in the future before and after integration of the NHC. For each of the training sessions, there were statistically significant increases in posttest scores when compared with pretest scores (Table); however, the impact of this training revealed a small effect size according to Cohen's d.16

Finally, students were asked about the usability of the e-learning platform including ease of use and clarity of instructions provided by the faculty on how to access the e-learning platform. Ninety-four percent of students found the e-learning platform was easy to navigate. Faculty instruction on how students accessed the platform was also favorable, with 93% of students indicating faculty provided clear instructions on how to access the e-learning platform.

Discussion

To our knowledge, this is the first study to evaluate perceived knowledge from a competency-based HIV curriculum. The data from this study reveal that the NHC is an effective tool for improving HIV knowledge in areas relevant for NPs entering primary care. This is consistent with findings from other studies that integrated HIV content into NP curriculum.10 Students who completed the pre- and posttest surveys of HIV content reported improvements in HIV-related knowledge in all 6 competencies of the NHC. Mean scores in each of the competencies increased from “poor or fair” to “good” after completion of each of the training sessions. In contrast to other studies that integrated HIV curriculum,9,10 the largest increase in reported knowledge was in antiretroviral therapy. In addition, students indicated improvement in competencies pertaining to HIV screening, diagnosis, and prevention. Improving primary care NP competencies for HIV screening and prevention is critical as NPs are more likely to prescribe preventive strategies than other health care professionals. However, awareness of strategies such PrEP have been found to be lower among NPs than among physicians.8

Although completion of the NHC only had a small effect on students' intent to working with PLWH, this may be due to the perception that PLWH are referred to specialty clinics for management of their HIV diagnosis and co-occurring conditions. Students may have not viewed HIV care on a continuum where PLWH also need primary care services such as immunizations and management of other acute and chronic conditions.

As with other studies,10 we found faculty are willing to include HIV course content when curriculum consultation and course materials are provided. The integration of a standardized HIV curriculum in NP education is essential in meeting the US strategic goal to increase access to care and optimize health outcomes for PLWH.17 Prevention strategies in HIV care is paramount for ending the epidemic in the United States. Faculty integration of the NHC in NP programs would provide a more consistent approach to HIV education. This study found that the integration of the NHC addressed curricular gaps within our program related to HIV competencies. Because the NHC is directed at multiple health care professionals (including physicians, pharmacists, and NPs), it could also mean a more comprehensive multidisciplinary approach to HIV training.

Recently, the American Association of Colleges of Nursing announced a new model and framework for nursing education using a competency-based approach.18 This new focus on competency-based education will create an opportunity to integrate the NHC into other courses in the primary care NP programs.

Limitations

Although the initial curriculum plans included integration of the NHC in 5 of the primary care NP courses, we were only able to integrate the content into 3 courses. This was a challenge for both students and faculty as it led to an increase in the overall content in each course. Another limitation is that the NHC pre- and posttest surveys only assess perceived knowledge as opposed to actual knowledge gained. Finally, although all students enrolled in the NP program received the NHC content, only 60.5% of the students completed both the pre- and posttest surveys.

Conclusion

NPs in primary care have a pivotal role in ending the HIV epidemic. This project supports using a standardized HIV curriculum as part of primary care NP curricula. The NHC offers NP students the ability to gain core knowledge in multiple areas of HIV care including prevention, screening, and treatment. Prior to the implementation of the NHC, our primary care NP program did not include competencies important in the delivery of primary care for PLWH. Without the integration of HIV content and attention to meeting essential competencies in HIV care, more NPs will graduate without the necessary training and knowledge to deliver safe care to PLWH. In addition, NPs will be unprepared to provide basic HIV screening and prevention upon entering practice. The NHC could serve as an essential tool for faculty in meeting curricular gaps in HIV education.

References

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Keywords:

competency-based education; HIV competencies; HIV curriculum; primary care nurse practitioner

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