The Development of Educational Tool to Support Disease Management Nurses for Preventing the Recurrence of Brain Infarction

Sunday, 27 July 2014

Yasuko Fukuoka, MSN, RN, PHN
Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
Yae Takeshita, MSN, RN, PHN
Graduate school of Biomedical and health Sciences, Hiroshima University, Hiroshima, Japan
Masahiro Kamouchi, PhD, MD
Department of Health Care Administration and Management, Kyushu University, Fukuoka, Japan
Michiko Moriyama, RN, PhD
Division of Nursing Science Graduate School of Health Sciences, Hiroshima University, Hirosima, Japan



Stroke, including brain infarction, is the top cause of producing care-needy condition and one of the highest disease categories of national medical expenditure in Japan(Health and Welfare Statistics Association., 2010) as well as other developed countries(Johnston, 2008). Stroke is reported as a high recurrence rate(Hata et al., 2005), and is aggravated by a recurrence even if it was a mild disability at the first time(Hankey, Jamrozik, & Broadhurst, 2002).

For preventing the recurrence, Stroke evidence-based clinical guideline 2009, Japan, recommends to control risk factors with medication and lifestyle modification(Shinohara et al., 2011). From medical care delivery system's perspective, one of the methods to solve the recurrence of stroke is disease management (DM) system(Howe, 2005; Warren & David, 2001).

DM is defined as "a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. DM supports the physician or practitioner/patient relationship and plan of care; Emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies; and Evaluates clinical, humanistic, and economic outcomes on an on-going basis with the goal of improving overall health"(Care Continuum Alliance., n.d.). Developed nations such as United States, Germany and Australia have adopted DM as a national strategy. Following those countries, national council on social security system reform, the Japanese government, in 2013, finally recommended developing DM strategies to prevent chronic disease aggravation into the integrated community care system, and to effectively use nurses in this disease management system. DM is the key to resolve preventing disease aggravation/recurrence and the reduction of the medical expenditure as a result(Moriyama et al., 2009; Moriyama, Takeshita, Haruta, Hattori, & Ezenwaka, 2013; Otsu & Moriyama, 2011). Therefore, we are now in the process of developing DM system in Japan.

Purpose of this study

In order to effectively operate the DM system in Japan, we have developed the disease management center outside of medical facilities, and started to provide DM to clients who have been discharged from acute care hospitals and also clients of medical insured who are targeted through analysis of medical receipt/claim data and health check-up data.

In this study, we have developed the educational tool to support nurses who newly came into to DM field for them to understand and be able to practice evidence-based DM programs. This reports development of the Stroke educational tool for nurses.

Significance of this study

Nurses providing DM programs (Disease Management Nurse: DMN) assess clients’ health conditions through physiological laboratory data, physical examinations, and interviewing lifestyle of clients, and focus target risk factors. DMNs also need to acquire skills of behavior modification, motivational interviewing, and communication skills to feed back to clients' physicians. These are high abilities which need to educate to DMNs even who have clinical experiences at hospitals. When DMNs use this educational tool, they can provide high quality, stable skills to clients, and this tool makes reliable quality condition to DMNs, as consequently, clients can receive reliable DM services.


Process of the development of education tool for DMN

The target

The target population, using this educational tool is DMN. Clients who receive DM services through this trained DMN are clients who had brain infarction whose modified Rankin scale is 0-3, who can conduct self-management after having an education from DMN.

Scheme and contents of the tool

This tool is based on a critical pathway format, including intervention timeline, intervention contents to both clients and their physicians. Intervention contents were extracted from evidence-based clinical guidelines of stroke, hypertension, diabetes, dyslipidemia, chronic kidney disease (CKD), alcohol, and smoking cessation, and arrhythmia. We placed those items with criteria. Decision map/algorithms were embedded. Nurse’s intervention such as self-management education (understanding of disease/condition, diet, exercise, self-monitoring and etc.), motivation interviewing tools, and nursing actions such as foot examination were included.

The goal setting, planning, and stratification

As the education subjects vary depending on risk factors of each client, we set a stratification groups divided by hypertension, diabetes, dyslipidemia, CKD, and atrial fibrillation. The criteria values for the stratification were extracted from clinical guidelines. Then, the frequency and the subjects of the intervention were set in every stratification group.

We create an algorithm to do automatic select of necessary extra medical data and education subjects. In addition, the education methods were arranged due to the clients’ level of understanding and enforcement for the self-management of the disease.

How the algorithm works

According to the inserted basic client information (e.g., risk factor, medical history, and physiological data), the necessary extra data, education subjects and other information needed are automatically displayed on the screen. During input the data, if there are some abnormal data, the warning appears on the screen. Furthermore, reminding function is added. The actions need to be taken to the abnormal data (e.g., additional patient education and report to the physician) appears on the screen automatically.

Intervention method

The intervention period is three months. DMN make a face-to-face interview for the first time, and total phone calls are 5 times for every 2 weeks.

Validity verification

The validity of the tool is clinical indicators and educational contents were checked and compared to the neurologists and clinical nurse specialist nurses. Also for checking validity, we compared the extracted indicators with the examination subjects and those frequencies by using medical records of brain infarction outpatient.

Ethical consideration

This study was approved by the Ethics Committee of Hiroshima University.


The purpose of this educational tool is to ensure a certain level of patient education quality for preventing of brain infarction recurrence. For the achievement of this goal, there are two distinctive characteristics of the tool.

1. The reminding function automatically selects strategies which cope with the abnormal data. This function ensures the proper action to choose what kind of intervention to take and also reduce omissions the necessary intervention.

2. As the stratification groups are made due to the risk factors, this tool customizes support to match the risk factors of the clients. This function made it possible to standardize the thinking process for disease management. It is important to customize the support depending on the risk factor which the client has, because the brain infarction has many risk factors.


Those functions help to keep the quality of DM even when inexperienced nurse need to perform the intervention. The practicability of this tool, however, is not confirmed yet. Now we are in the process to check and proof the ability of the tool.

 This work was supported by JSPS Scientific Grant A Number 22249069 ” Construction of a new model of providing chronic disease care  by the role function expansion of a nurse and the medical insurer”(Representative Michiko MORIYAMA).