Clinical Nurse Specialists Empowering Staff to Improve Patient Outcomes in Temperature Measurement: From PI/EBP to Nursing Research
Brenda A. Artz, MS, RN, CCRN, Karen S. March, PhD, RN, CCRN, ACNS-BC, Rod D. Grim, MA, WellSpan Health-York Hospital, Manchester, Maryland (Artz), WellSpan Health-York Hospital, York, Pennsylvania (March and Grim)
Purpose/Objectives: To establish a nursing culture within an organization that encourages staff nurses to ask and answer questions related to patient care/outcomes.
Significance: The clinical nurse specialist (CNS) is pivotal within an organization to assist staff in identifying problems, conducting performance improvement activities, and reviewing the literature for best practices and to act as a facilitator of nursing research.
Design/Background/Rationale: Within a 558-bed community-based teaching hospital, temperature assessment has routinely occurred via several modalities. Over time, some postoperative patients were found to be hypothermic upon first temperature assessment on an acute-care unit. Realizing that hypothermia can yield consequences that could be detrimental to patients, the CNS empowered the staff to determine the cause(s) of the hypothermia and to identify ways to avoid its occurrence.
Methods/Description: Initially, staff members were encouraged to review their practice. The postanesthesia care unit (PACU) conducted a Performance Improvement (PI) project. Review of documentation revealed that different modalities were used to assess temperature. Postanesthesia care unit staff used temporal artery (TA) thermometers, whereas staff on acute-care units used oral electronic (OE) thermometers. The next step of the process was to review the literature for recommendations. Because the evidence revealed no definitive recommendations, the EBP/Nursing Research Council suggested development of a research project. The study was a repeated-measures design that compared TA and OE to core temperature in normothermic postoperative coronary artery bypass graft patients. Data collection occurred over 5 months.
Findings/Outcomes: Data were collected on 46 patients. There was not a statistically significant difference in OE versus core temperatures; however, OE underestimated core temperature by 0.1[degrees]F. There was a statistically significant difference in TA versus core temperatures. Temporal artery underestimated core temperature by 0.3[degrees]F.
Conclusions: Outcomes in this study indicate that both OE and TA are reasonable options for temperature measurement in normothermic patients. Further study on hypothermic patients should follow.
Implications for Practice: Results of this study begin to answer questions about accuracy of TA and OE temperatures. The CNS empowered staff in a process from PI/EBP through research that would potentially improve patient outcomes.
A Culture of Caring: Implementation of Relationship-Based Care at a Rural Hospital
Shelley R. Ashby, MSN, CNS-BC, APN, Sarah Bush, Lincoln Health Center, Mattoon, Illinois
Purpose/Objectives: The overall project objective is to create a caring environment for registered nurses and patients at a rural acute-care hospital through the implementation of a relationship-based model of care delivery.
Significance: A rural acute-care hospital in central Illinois has been experiencing stagnant patient satisfaction scores and nursing job satisfactions score below industry norms for several years. Various organizational initiatives have proven unsuccessful in improving these scores. An evidence-based model of care is currently not used within the organization.
Design/Background/Rationale: Literature is replete regarding links between nursing caring behaviors and patient satisfaction. Analyses reveal that nurses directly relate job satisfaction to the connectedness with patients. Studies indicate that nursing quality of care has a substantial influence on patient satisfaction scores and subsequent referrals to the institution. Using Kurt Lewin's 3-Step Model of Change to guide the implementation process, a relationship-based model of care delivery was integrated into the medical/surgical, women and children's, critical care, and emergency department nursing units at a rural hospital.
Methods/Description: A guiding formula, I2E2 (inspiration, infrastructure, education, evidence) was used to engage staff in the integration process A Results Council and Unit Practice Councils oversaw the entire implementation process. The Revised Nursing Work Index was used to assess nursing job satisfaction scores Monthly NRC-Picker reports were used to evaluate patient satisfaction scores and institutional indicators for quality of care.
Findings/Outcomes: Postimplementation outcomes for this project are (1) improvement in nursing job satisfaction scores, (2) improvement in all 8 dimensions of the NRC-Picker patient-centered care scales, and (3) improvement in NRC-Picker institutional quality indicators.
Conclusions: Review to be completed by December 2010.
Implications for Practice: Relationship-based care provides a strong foundation to achieve cultural transformation in the way care and services are provided to patients and families. Engagement in the principles of relationship-based care results in a nursing culture that embraces the patient as the central focus, where nurses are valued and respected, and morale is high.
A Pilot Study to Evaluate the Feasibility and Effectiveness of a Multicomponent Intervention for Prevention of Delirium in Critically Ill Adults
Jan Foster, PhD, APRN, CNS, Miranda Kelly, MS, APRN, ACNP, CNS, Texas Woman's University, Houston (Foster), Memorial Hermann the Woodlands Hospital, Texas (Kelly)
Purpose/Objectives: The purpose of this pilot study is to establish the proportion of delirium in critically ill adult patients in a medical intensive care unit (ICU) and to evaluate the feasibility and effectiveness of a multicomponent intervention aimed at prevention. The objectives are to (1) establish the proportion of delirium; (2) identify the risk factors; (3) determine which components of the intervention are feasible and which are problematic; and (5) determine which components of the intervention are most effective in the prevention of delirium.
Significance: Delirium affects from 20% to 80% of critically ill patients, contributes to numerous complications, and is associated with higher ICU mortality. Delirium adds an average of 10 days to length of hospital stay, and higher overall hospital costs to the tune of $7 to $20 billion dollars annually. Long-term problems include prolonged cognitive dysfunction, increased need for nursing home placement, decreased overall patient functionality, and posttraumatic stress disorder.
Design/Background/Rationale: Prospective, descriptive, cohort, interrupted time-series design.
Methods/Description: Proportion of delirium in the population of ICU patients in the ICU is in progress, using a validated instrument. Implementation of the prevention intervention will follow. Postintervention delirium rates will be measured at 1- and 2-month intervals and graphically plotted. The intervention consists of 5 items: (1) daily sedation cessation, (2) promotion of sleep/wake cycles, (3) patient mobility, (4) promotion of meaningful sensory stimulation, and (5) provision of patient-preferred background music.
Findings/Outcomes: Descriptive statistics will be used to report demographic data and barriers to and success with the intervention; frequency statistics will be used to report proportion of delirium preintervention and postintervention. Proportion of delirium in preintervention and postintervention cohorts will be compared using the binomial test; logistic regression analysis will be used to determine the relative risk of developing delirium with implementation of the prevention intervention.
Conclusions: Delirium rates, sample characteristics, and barriers and promoters to implementation of the intervention will be reported. Results of the pilot study will be used to refine the intervention, and determine sample size via power analysis for a larger, multisite study.
Implications for Practice: Determining effective strategies for prevention of delirium may improve care for hospitalized patients, reduce costs, and prevent long-term cognitive dysfunction.
A Shared Governance Approach to Innovatative Budget Smart Practice
Christine Townsend, RN, Darleen Williams, CNS, Orlando Health, Orlando, Florida
Purpose/Objectives: The objective is to improve bedside practice with a budget concious model. This process will lead to improved relationships with leadership and staff and improved documentation.
Significance: In July 2009, the Orlando Regional Medical Center emergency department's (ED's) leadership team approached the unit's Nursing Practice Council (NPC) regarding rising costs for medical and nonmedical supply utilization in the department. As a part of shared governance, the leadership team and NPC reviewed 6 months of financial data, and confirmed the ED was consistently over budget. The objective of this project was to increase team member's awareness and change practice to reduce monthly costs.
Design/Background/Rationale: This is a process improvement project. The NPC's main objective was to increase the entire department's knowledge regarding supply utilization and foster a sense of ownership for departmental supply utilization.
Methods/Description: Six months of financial data for both medical and nonmedical supplies used in the ED were reviewed. Council members were educated regarding documentation and its impact on capturing revenue. Following this education, the ED itself was thoroughly inspected, which revealed hoarding of supplies and excessive overstocking as a common practice. Nursing Practice Council members and participating staff took pictures of some of these areas as examples and displayed them on a bulletin board in the staff lounge. The inspection results generated many ideas and suggestions for practice changes including the development of par levels. All ED staff members were given hospital e-mail, and the department's specific Web site was expanded to allow for notices, memos, and other information along with staff education to be posted. This electronic communication contributed greatly to the rapid reduction of paper utilization.
Findings/Outcomes: Six months prior to implementation, the medical supply costs were 58% over budget. During implementation, these costs were reduced to 25% over budget, and within 6 months following implementation, costs were 2.9% under budget. Nonmedical supplies ("Going Green") had similar results. Prior to implementation, nonmedical supplies were 9.3 % over budget. During implementation, a reduction in cost of 39% was noted, and following implementation, cost savings of 44% under budget were achieved.
Conclusions: Shared governance is an effective method to improve parctice.
Implications for Practice: The continued success of the "Campaign to $ave" and Going Green has given the NPC and the entire department a sense of accomplishment. This sense of success has led the way for many team members to take on additional projects.
Achieving Zero Line Infections in Adult Acute Care: A Replication Study
Todd Olrich, MS, RN, Crouse Hospital, Syracuse, New York
Purpose/Objectives: Determine the effects of a multimodality central line bundle on catheter-related bloodstream infections (CRBSIs) in an inpatient adult unit.
Significance: Reducing CRBSI is a goal for all clinicians and hospitals. A total of 250 000 CRBSIs have been estimated to occur annually in the United States, with an attributable mortality rate of 12%-25% and a cost of $25 000 per episode.
Design/Background/Rationale: This study used a quasi-experimental design. Data at a central New York hospital show that the CRBSI rate on the oncology/gynecology unit is 3.69 per 1000 catheter-days. This is greater than the national average of 1.5 infections per 1000 catheter-days. Our current data suggest that we have significant opportunities for improvement.
Methods/Description: On the experimental unit, a bundle, replicated from the quasi-experimental Harnage (2008) study, was implemented. The bundle consisted of 2 main parts: ownership of peripherally inserted central catheter (PICC) line care by the PICC team and changing to a neutral pressure needleless connector. The clinical nurse specialist led a multidisciplinary team in developing and implementing the study. He also educated nursing on current infection control data, infection control (IC) recommendations, appropriate placement of Biopatch, frequency of needleless connector changes, proper cleaning of connectors, flushing protocols, and need for early referral of PICC candidates. In addition, the clinical nurse specialist rounded daily reinforcing protocol, collaborated with IC to determine origin of infection, reported monthly on infection rates for experimental unit, and met weekly with PICC team to troubleshoot issues. Data were collected daily by IC nurses who investigate each positive culture to determine if they are associated with a central line and if they are nosocomial or community acquired according to Centers for Disease Control and Prevention guidelines. These data were collected 52 months prior to the implementation and 15 months after implementation.
Findings/Outcomes: The research study data are ongoing. Preliminary data show a prestudy mean of 3.69 infections/1000 line-days. Eight months after implementation, results show 0.75/1000 line-days.
Conclusions: A multimodality central line bundle that includes nursing interventions and new technology can reduce catheter-related central line bloodstream infections.
Implications for Practice: Additional research needs to be conducted examining each nursing intervention and device as a single variable to determine the effectiveness of each.
Affective Literacy for the Clinical Nurse Specialist
Dennis Ondrejka, PhD, RN, CNS, Exempla Lutheran Medical Center, Wheat Ridge, Colorado
Purpose/Objectives: This presentation will allow participants to "integrate the value of affective teaching and then apply some tools of affective teaching into their practices" to effect higher levels of learning.
Significance: The topic of changing one's teaching methods has historical and current relevance for clinical nurse specialists who often state there is a need for balance between affective and cognitive teaching methods. This has also been supported by the National League of Nursing's teaching competencies. However, most educators have difficulty knowing how such teaching methods are possible. Nurses today want to know if the disseminated new knowledge impacts them in a personal way-through affective development. Schools of nursing and health care institutions are heavily laden with the behavioral and cognitive domain of learning exemplified by behavioral course objectives and competency based learning with an endless use of PowerPoints.
Design/Background/Rationale: This presentation is taken from years of literature review, research, and current standards for teaching excellence. Schools of nursing and health care institutions are heavily laden with the behavioral and cognitive objectives and competency demands.
Methods/Description: Participants will be provided examples of care pedagogy, critical reflection, and more to allow for a valuing and skill building toward affective teaching. Participants will learn of the origin of affective strategies and teaching methods that include Bloom's first affective taxonomy in 1964. This presentation contributes new and reinforces old ideas that have not surfaced in most training or classrooms today.
Findings/Outcomes: The presenter will use a weaving of cognitive and affective teaching methods to demonstrate the concepts and allow the participants to experience their value for them personally. This weaving process was one of the findings identified by this author's personal research and will be used here.
Conclusions: The presenter's personal research on this subject helped to identify an affective teaching taxonomy as well as the following 5 themes.
* Theme 1: Limited awareness of affective literacy and pedagogy
* Theme 2: Faculty risks in implementing affective pedagogy
* Theme 3: Using theory to ground our understanding of affective learn environments
* Theme 4: Refining affective learning environment
* Theme 5: Interweaving affective and cognitive pedagogies
Implications for Practice: Affective teaching is not just a "nice" thing to be aware of-it is critical to effective teaching methods, learner's needs, and effective learning. The participants will now have an opportunity to use this in their practices for greater learning outcomes at all levels and in all settings.
An Innovative Approach to Revising a Clinical Nurse Specialist Curriculum to Meet Core Competencies in 3 Specialty Tracks (Adult Health, Gerontology, and Psychiatric-Mental Health)
Cynthia Arslanian-Engoren, PhD, RN, ACNS-BC, FAHA, Laura Struble, PhD, GNP-BC, Barbara-Jean Sullivan, PhD, PMHCNS-BC, NP, University of Michigan School of Nursing, Ann Arbor, Michigan
Purpose/Objectives: To revise 3 existing clinical nurse specialist (CNS) educational tracks (adult health, gerontology, and psychiatric-mental health) with current CNS core competencies and educational expectations in a cost-effective, pedagogically effective manner.
Significance: Adherence to national curricula guidelines is critical to quality CNS student education.
Design/Background/Rationale: Curricular recommendations from the National Association of Clinical Nurse Specialist Association (NACNS) include core competencies by the 3 spheres of influence of CNS practice: (1) patient/client; (2) nurses and nursing practice, and (3) organization/system. Advanced practice registered nurses (APRNs) Consensus Model educational requirements include a minimum of 500 faculty-supervised clinical hours; separate graduate courses in pharmacology, pathophyiosology, and advanced physical assessment; and content in differential diagnosis, disease management, decision making, and role preparation.
Methods/Description: This educational initiative, led by 3 doctorally prepared CNS faculty members from each specialty track, was designed to (1) align with NACNS core competencies and APRN Consensus model recommendations, (2) create innovative learning environments, (3) meet the needs of diverse student populations, (4) align with emerging DNP programs, (5) create a high-efficiency and quality environment to manage human and fiscal resources, and (6) to reduce duplication of efforts.
Findings/Outcomes: Over a 9-month period, NACNS curricula guidelines; APRN Consensus model recommendations; CNS adult health, gerontology, and psychiatric-mental health competencies; and current specialty track curriculum content were reviewed. Courses were revised that did not meet current CNS educational preparation expectations. A total of 11 didactic and clinical sequences courses were developed for the ACNS, GCNS, and PMHCNS tracks to (1) ensure minimum numbers of clinical hours; (2) expand content on health promotion and risk reduction; primary, secondary, and tertiary prevention; APN role development, and the health care delivery system; (3) consolidate clinical courses into the fall and winter semesters, and (4) resequence foundational content before beginning clinical courses.
Conclusions: Revisioning a CNS curriculum in 3 specialty tracks is challenging but doable using innovative and creative approaches.
Implications for Practice: For CNS basic and continuing education, the innovative process used to revise our CNS curriculum will assist other nurse educators faced with similar program delivery challenges to meet future directions for educating CNS students in advanced nursing practice.
An Innovative Educational Approach in Transitioning to Family-Centered Maternity Care From Traditional Maternity Nursing
Kathleen Kleefisch, MSN, CNS, FNP-BC, Valparaiso University, Lowell, Indiana
Purpose/Objectives: Current US perinatal statistics indicate that maternity care continues to need improvement. Guided by the PARIHS framework, this evidence-based project hypothesizes that no practice change will occur unless nurses understand and appreciate the relevance of evidence-based maternity care. The clinical nurse specialist has the knowledge and skills to provide the necessary education for implementation of family-centered maternity care (FCMC). A within-group design will be used to address the clinical question: "In the transition to FCMC from traditional maternity care, what is the effect of an educational intervention on the staff nurse's nursing knowledge of evidence-based FCMC as compared with the knowledge of traditional nursing maternity practices?"
Significance: In 1978, the Interprofessional Task Force on Healthcare of Women and Children endorsed the concepts of FCMC as an acceptable approach to maternal/newborn care. Education, training, and support in evidence-based practices are essential to implement FCMC. Nurses require education regarding FCMC. New skills and knowledge are necessary to function successfully and to integrate the new philosophy.
Design/Background/Rationale: The major steps of the project are to (a) identify new skills and knowledge needed by the staff nurses to function successfully and to integrate the new philosophy of FCMC, (b) select through a process of professional consensus the top evidence-based clinical recommendations, (c) design educational modules to increase staff nurse's knowledge of FCMC, (d) measure knowledge gained, to determine the impact of the educational intervention.
Methods/Description: Eight pretests and posttests have been designed to assess the participant's knowledge of educational module objectives. Descriptive statistics such as number, mean, and SD will be used to analyze demographic data. Paired-samples t test will be used to analyze the pretest and posttest scores. A 95% confidence interval will be set (P = 0.05).
Findings/Outcomes: The evidence-based project is currently in the implementation phase.
Conclusions: The provision of expert facilitated evidence-based education, guided by the PARIHS framework, which considers organization influences, can be an impetus for change in health care practice.
Implications for Practice: An innovative educational program tailored to the learning needs of experienced staff nurses can contribute to improvements in nursing competencies and patient care.
Back to Basics: Improving Skin Assessment and Pressure Ulcer Prevention in a Unique Population
MAJ Ann Kobiela Ketz, MN, BSN, ACNS-BC, MAJ Shannon Womble, MSN, BSN, CCNS, ACNP-BC, CAPT Ann Marie Carlin, MS, RN-C, CWOCN, LCDR Meredith Moore, MSN, RN, CWOCN, CCRN, Landstuhl Regional Medical Center, Landstuhl, Germany (Ketz and Womble), Department of Veterans Affairs (Carlin), St Rose Dominican Hospital, Siena Campus, Henderson, NV (Moore)
Purpose/Objectives: The purpose of this project is to develop a clinical nurse specialist-led skin care and pressure ulcer (PU) prevention program. The objectives of the program are to (1) increase staff awareness of the PU risk in a unique population; (2) standardize PU prevention across the continuum of care; and (3) standardize PU management across the continuum of care.
Significance: Landstuhl Regional Medical Center, the largest US Military Medical Treatment Facility in Europe, provides state-of-the-art care to ill and traumatically injured patients from Operation Enduring Freedom and Operation Iraqi Freedom. Operation Enduring Freedom and Operation Iraqi Freedom patients may have unique risk factors for PU development because of their injury patterns and lengthy air transport.
Design/Background/Rationale: An increased number of PUs were noticed on patients arriving from Operation Enduring Freedom and Operation Iraqi Freedom. Further investigation revealed inconsistent documentation of skin/wound assessment and PU staging, as well as inconsistent prevention and treatment strategies for patients at risk.
Methods/Description: The medical-surgical and critical-care clinical nurse specialists lead the skin care team and have been augmented by a variety of staff nurses, including 2 Navy reserve certified wound care nurses who were assigned to Landstuhl Regional Medical Center for 1 year. The team utilizes the FOCUS-PDSA (organize, clarify, understand, select, plan, do, check, act) model for performance improvement. The plan includes publishing an evidence-based skin care policy with PU management guidelines, standardizing skin and wound care products used in the organization, formalizing nursing education with the use of a PU model, conducting weekly skin care rounds with nursing staff, and enhancing the skin assessment and Braden Scale portions of the electronic medical record. The team developed a standardized tool for reporting PU for tracking purposes. Quarterly prevalence measures are ongoing.
Findings/Outcomes: Data collection is ongoing.
Conclusions: Initial interventions have led to providers, nurses, and even administrative staff demonstrating an increased knowledge and awareness of the risk of PU in this unique patient population.
Implications for Practice: The team continues to improve the process; future plans include implementing multidisciplinary skin/wound rounds, analyzing PU prevalence measures, obtaining permanent certified wound care nurse(s), and expanding the improvements to other inpatient and outpatient areas of the organization.
Beyond the Basics: A Strategy for Nurse Retention
Marilyn St Amand, MSN, RN, APRN-BC, OCN, Catherine Draus, MSN, RN, ACNS-BC, CCRN, Jennifer Michalski, MS, RN, Jean Talley, MS, RN, Jennifer Ernst, BSN, RN, Mary Munley, BSN, RN, Mary Parent, BSN, RN, Henry Ford Hospital, Detroit, Michigan
Purpose/Objectives: The objectives of the program are to increase the graduate nurse's satisfaction with their role, decrease anxiety, and decrease new nurse turnover.
Significance: The successful transition of a graduate nurse into a functioning registered nurse is a complex process. Studies show that a 30% to 61% turnover rate during the first year of practice is not uncommon.
Design/Background/Rationale: There are many factors involved, both from the new nurse's experiences prior to graduating to multiple factors within the organization. "Beyond the Basics" is a daylong education program attended by graduate nurses who have completed their unit orientation and have been practicing for 3 to 6 months.
Methods/Description: Beyond the Basics planning committee consists of clinical nurse specialists from medical, surgical, and cardiology specialties, a nurse manager, an assistant nurse manager, and a nursing education specialist. Prior to the first session, the committee sent an exploratory needs assessment to nurses who had completed orientation within the previous 6 months, asking them what topics they would like to see in a postorientation program. The responding nurses were most interested in how to handle a code, how to recognize a potentially serious patient condition to prevent a code, how to be an effective charge nurse, delegating to nonlicensed assistive personnel, and death and dying. Content was devised to fit those specific needs, with speakers recruited from within the organization, such as nurses from the Rapid Response Team and experts on communication. In addition, a nursing administrator speaks, thanking the graduate nurse for their dedication to their patients.
Findings/Outcomes: The program was initiated in November 2008 and has been offered at least once a year since. The overall retention rate for graduate nurses who have attended the program is 93%, with a range of 90% to 94%. The attendees' overall evaluation of the program shows a consistent 100% agreement in enhancing skills to handle clinical and management situations.
Conclusions: Beyond the Basics has been an effective program in enhancing retention of the graduate nurse.
Implications for Practice: It has allowed the graduate nurse the opportunity to enhance skills needed at the bedside, while providing them the opportunity to be supported in their new role.
Blazing a New Role for the Clinical Nurse Specialist With Implementation of Electronic Health Record
Laurel Courteny, MS, RN, CNS, AOCN, The Arthur G. James Cancer Hospital and Richard J Solove Research Institute, Powell, Ohio
Purpose/Objectives: To delineate clinical nurse specialist (CNS) involvement at unit level when converting from paper to electronic health record.
Significance: Electronic health records offer an opportunity to improve care for patients. However, to improve care and efficiency, the electronic record cannot be a high tech replication of a paper chart. A CNS can lead workflow changes that utilize the functions of an electronic record.
Design/Background/Rationale: As health care organizations transition to an electronic health record, a CNS can bridge the technical aspects of a system with the clinical needs of the electronic health record user. The CNS can assist in educating staff on workflow change and documentation in the electronic record.
Methods/Description: Nursing at a major medical center is involved in transitioning from a paper chart to an electronic record. A small group of ambulatory CNSs worked together to develop standard workflow for clinic areas. The group was tasked with developing individualized education handouts for each nursing role prior to "go live." The organization created a new role for a CNS to assist with further optimization of the ambulatory applications. The role encompasses practice, education, and research. The new role bridges information technology and nursing informatics.
Findings/Outcomes: The new CNS role continues to evolve in the organization. The CNS assists users in navigating the application. The CNS works with information technologists on enhancements as well as changes to existing applications for regulatory compliance. The CNS serves as consultant to inpatient units who is beginning his/her journey to electronic record. The CNS has developed standardized checklist for units for port draw rooms and infusion areas and educated staff on medical necessity documentation in electronic records.
Conclusions: New technology and electronic health records will continue to influence nursing practice. A CNS strategically placed in the organization can lead in the adoption of new technology, workflow, and electronic documentation.
Implications for Practice: This presentation will outline how a CNS can influence the transition from a paper chart to electronic record.
Bottoms Up! An Innovative Approach to Code Blue
Kathleen Fisher, MS, RN, CCRN, CCNS, Laura Sink, MSN, RN, Jesse Brown VA Medical Center, Chicago, Illinois
Purpose/Objectives: Resuscitative efforts require a team approach in a stressful situation. The goal of the project was to increase interdisciplinary team training in resuscitation.
Significance: Resuscitation of a pulseless patient creates unfamiliar staff to panic in a stressful situation. Code blue emergency requires a well-rehearsed team of doctors, nurses, and allied professionals to work together under extreme pressure. Basic life support and advanced cardiac life support (ACLS) skills degrade over time. Lack of positive team dynamics can negatively affect patient outcomes.
Design/Background/Rationale: Per the American Heart Association guidelines (2005), when immediate cardiopulmonary resuscitation and defibrillation occur within 3 to 5 minutes, the reported survival rates from VF sudden cardiac arrest are as high as 74%. The learning needs assessment, code debriefing, and chart review revealed the need for interdisciplinary team education to improve code practices, thus improving patient outcomes.
Methods/Description: The clinical nurse specialists collaborated to develop an educational bundle including high-fidelity simulation scenarios for mock codes. Further teamwork, with nurse managers, respiratory department, physicians, and pharmacy, coordinates staff participation. Learners were given evidence-based scenarios and realistic situations. The "Bottoms Up" mock code blue scenarios incorporated patient assessment, prebriefing of ACLS algorithms, code team responsibilities, and documentation. This approach of the crash cart was to familiarize and standardize the management in a code blue. For example, staff initiated resuscitation efforts working from the bottom drawer of the crash cart. Mentoring and coaching were provided immediately in debriefing. In 2010, 16 mock codes were initiated with more than 90 interdisciplinary participants.
Findings/Outcomes: Qualitative data revealed 83% of staff acknowledged an improvement of familiarity of ACLS protocol, increased comfort level of code procedures, and improved teamwork. A quantitative analysis found that enrollment in ACLS class increased by 35%. A chart review demonstrated an improvement of documentation.
Conclusions: The Bottoms Up program, combined with high-fidelity simulation, refreshed ACLS skills and team communication and reinforced code blue skills in a controlled, nonthreatening environment. This education encouraged critical thinking and skill transference to actual situations.
Implications for Practice: This course required few new resources and is easily transferable to all other units or other medical centers. Future plans are to expand training and to evaluate patient outcomes.
Building a Business Case for Investment in the Clinical Nurse Specialist
Fiona Winterbottom, MSN, APRN, ACNS-BC, CCRN, Ochsner Medical Center, Mandeville, Lousiana
Purpose/Objectives: The purpose of this presentation is to discuss building a business case for investment in the clinical nurse specialist (CNS).
Significance: The CNS plays a pivotal role in appraising evidence, identifying gaps in delivery systems, and providing goal-directed innovative solutions to care by exercising fiscal responsibility, implementing best practices, and rapid cycle evaluation.
Design/Background/Rationale: The CNS liaises across interdisciplinary and interdepartmental lines in 3 spheres of influence: system, nurse, and patient. Acting as a clinical expert, consultant, researcher, change agent, and educator, the CNS promotes organizational initiatives and improves outcomes.
Methods/Description: At this institution, CNSs network to facilitate quality outcomes and organizational transformation across the continuum of care in areas of telemedicine, ambulatory clinic, medical-surgical nursing, critical care, research, and palliative care.
Findings/Outcomes: Clinical nurse specialist-led project outcomes include (1) Sepsis management resulted in a 30% decrease in raw mortality and estimated cost avoidance of $2 million annually; (2) falls prevention program led to a 17% reduction in injurious falls and $400 000 cost reduction; (3) critical-care orientation/education curriculum ameliorated turnover by 25% and reduced expenditures by $325 000; (4) therapeutic hypothermia post-cardiac arrest improved survival to discharge from 20% to 65%; (5) neurology telemedicine program resulted in 17% improved time to thrombolytic therapy in eligible stroke patients and increased facility transfers; (6) palliative care program increased consults by 69% with 27% improvement in bereavement satisfaction; and (7) CNSs facilitated 7 journal clubs, 11 research studies, and 72 scholarly works in 2009.
Conclusions: The CNS embodies innovative leadership and expertise by embracing cultural change, empowering nurses, enhancing professional practice, implementing research-based strategies, and measuring quality outcomes.
Implications for Practice: Translating CNS-driven outcomes into cost-avoidance data and engaging staff nurses in scholarly activities provide support for both maintaining the role and increasing CNSs in areas of need.
Chill Out! Improve Neurological Outcome in Postarrest Patients
Jeannie Burnie, MS, EN, CEN, Jennifer McCord, MSN, RN, PCCN, CCRN, CCNS, Bethesda North Hospital, Cincinnati, Ohio
Purpose/Objectives: The objective of the study was to develop an evidence-based protocol for the implementation of therapeutic hypothermia in patients following cardiac arrest.
Significance: Decreasing mortality in cardiac arrest patients has a positive effect on patients, staff, physicians, and community. Through implementation of the evidence and collaboration by clinical innovation experts, this can be achieved.
Design/Background/Rationale: In October 2002, the International Liaison Committee on Resuscitation recommended that adult patients with return of spontaneous circulation after cardiac arrest should be cooled to between 32[degrees]C and 34[degrees]C to improve functional recovery. Despite these recommendations and the research supporting its use, the practice has not been widely implemented.
Methods/Description: The literature was evaluated to determine best-practice methods to implement a successful therapeutic hypothermia program in a community-based hospital. A physician champion was utilized from an emergency department (ED) perspective to increase buy-in from the physicians. A continuing education program was developed and presented to the ED physicians and staff nurses in the intensive care unit and ED. Order sets were implemented; physician, nurse, ancillary staff, and EMS education were provided. Needed administrators were brought to the table for financial and other support.
Findings/Outcomes: A final order set was approved and implemented by the pulmonary section medical director. Guidelines for care were developed to assist the ED staff nurses in the implementation of therapeutic hypothermia in appropriate patients. To date, 16 patients have been recipients of therapeutic hypothermia, with 3 patients experiencing no adverse events after cardiac arrest. Evidence suggests that the number needed to treat for benefit to be seen is 7. Currently, our statistics are above this benchmark.
Conclusions: Implementation of large-scale programs can be challenging, but beneficial for staff, patient, and physicians alike. Therapeutic hypothermia is a useful tool to preserve neurological function in cardiac arrest patients.
Implications for Practice: Utilization of clincial innovations experts is key to successful EBP implementation and change.
Cleaning Up Hand Hygiene
Barbara Quinn, MSN, RN, Sutter Medical Center, Sacramento, Folsom, California
Purpose/Objectives: The purpose of this poster is to share our strategy to improve hand hygiene among health care workers at Sutter Medical Center, Sacramento.
Significance: The Centers for Disease Control and Prevention estimates that 1 of every 10 to 20 patients hospitalized in the United States develops a hospital-acquired infection (HAI). There are 1.7 million HAIs each year in the United States, with 99 000 associated deaths. Hand hygiene among health care workers plays a central role in preventing the spread of infection in the acute-care setting.
Design/Background/Rationale: The hand hygiene rate at Sutter Medical Center, Sacramento, was at 64% in 2008-far below our goal of greater than 90%. A team of clinical nurse specialist-led staff nurses accepted the challenge. Results of a staff survey revealed barriers: (1) too busy; forget, (2) limited/inconvenient access to sinks, (3) unavailability of hand hygiene product, (4) skin irritation from frequent hand washing.
Methods/Description: The clinical nurse specialist and staff nurse team selected the Influencer Model as a framework (Vital Smarts). Interventions to address barriers and all 6 domains to address behavior included (1) personal motivation: shared significance of HAIs and let staff choose which hand hygiene guidelines they wanted to follow (World Health Organization), (2) personal ability: staff education was provided about when and how to perform hand hygiene, (3.) social motivation: asked respected leaders to be role models, (4) social ability: taught peer mentoring, (5) structural motivation: monthly audits and environmental culture results were shared with staff, (6) structural ability: additional dispensers were installed, and a high-quality hand lotion was selected.
Findings/Outcomes: Hand-hygiene compliance increased by 24% in 18 months. Run charts of total hand-hygiene compliance, World Health Organization's 5 Moments, compared progress of registered nurses and physicians.
Conclusions: The Influencer Model is effective as a framework to change behavior. Engaging the frontline staff in defining the problem and how to solve it is essential to success. Standardizing and simplifying whenever possible make it easier for staff to do the right thing. Using measurement data to drive improvement leads to appropriate interventions for continued success.
Implications for Practice: The Influencer Model can be applied to other clinical projects that require a change in behavior.
Clinical Emergencies: Broadening the Scope of Emergency Response
JoAnne Phillips, MSN, RN, CCRN, CCNS, The Hospital of the University of Pennsylvania, Philadelphia
Purpose/Objectives: Response by an appropriate team of clinicians to a clinical emergency can significantly impact morbidity and mortality. Over the past decade, a paradigm shift recognized the need for emergency response beyond the classic cardiac arrest patient. There has been a broadened understanding of a need for specialized teams in nontraditional areas, such as the operating room and outpatient facilities.
Significance: The organization demonstrated a commitment to have staff, equipment, and processes in place to respond to a deteriorating outpatient or visitor.
Design/Background/Rationale: The clinical nurse specialist (CNS) for patient safety played a key role in the development of a very successful Rapid Response System (RRS) in an academic medical center. Her experience in the development of that team led to the innovation of 3 other teams within our organization. This presentation will include a brief discussion on the consultative role of the CNS in the development of the Obstetrics Emergency Team and the Perioperative Intervention Team. The focus will be on the broaden scope of the inpatient RRS to respond to clinical emergencies in a new 500 000-ft2 outpatient facility.
Methods/Description: The CNS led a multidisciplinary team to develop, implement, and evaluate the clinical emergency response in the outpatient facility. Development included establishment of standardized equipment and processes; as well as education of staff at all levels. Drills were held, and processes were evaluated and revised.
Findings/Outcomes: Ongoing evaluation of clinical emergency response in the outpatient setting includes team debriefings, systems analysis, and review of clinical scenarios. Process changes resulted in a decrease in response time from 8 to 3 minutes. Data demonstrated a dramatic increase in the number of calls in the first 2 years of operation, from 57 calls in fiscal year 2009 to 244 calls in fiscal year 2010.
Conclusions: The outpatient environment has changed dramatically, and health care must change with it.
Implications for Practice: The successful implementation of the outpatient RRS has demonstrated the need for such a service even within the outpatient setting.
Clinical Nurse Specialist Multidisciplinary Rounds as a Strategy to Translate Evidence-Based Practice to the Bedside
Melissa Johnson, MSN, RN, CNS, CNRN, Rhonda Amber, MSN, RN-BC, CNS, Donna Cahill, MSN, RN, CNS, CEN, CHTP, Scot Nolan, DNP, RN, CNS, PHN, CCRN, CNRN, Nancy Azuma, MSN, RN, AOCNS, Judy Davidson, DNP, RN, CNS, FCCM, Scripps Mercy Hospital, San Diego, California
Purpose/Objectives: The purpose of this article is to describe a facility's utilization of clinical nurse specialist (CNS) multidisciplinary rounds as a strategy to translate evidence-based practice (EBP) to the bedside.
Significance: The literature suggests that EBP improves patient outcomes, although EBP is frequently not used by bedside clinicians to guide practice.
Design/Background/Rationale: The ACE Star Model of Knowledge Transformation identifies discovery, summary, translation, integration, and evaluation as necessary steps for translating evidence into practice. Bedside rounds, using the steps of the ACE Star Model, are a useful strategy to integrate EBP into nursing practice.
Methods/Description: Rounds were developed in trauma, critical care (intensive care unit [ICU]), medical/surgical, oncology, and telemetry areas using a variety of tools to collect data and demonstrate population specific outcomes. Using ICU rounds as an example: multidisciplinary rounds include nursing, respiratory therapy, physical therapy, occupational therapy, speech therapy, pharmacy, case management, social work, chaplaincy, and infection control representatives as well as the critical-care medical director. Evidence-based practice focus areas of ICU rounds include progressive mobility, ventilator associated pneumonia, venous thromboembolism prevention, removal of unnecessary central lines and urinary catheters, and glycemic management. Rounds are conducted 1 hour per week on high-risk patients. Data are collected during the rounds process and evaluated for trends at routine intervals.
Findings/Outcomes: Over 8 months, in two 24-bed intensive care units, CNS-led critical-care rounds were completed on 193 patients. Five hundred thirty-one evidence-based recommendations were discovered and integrated into care during the course of these rounds.
Conclusions: Population-based outcome probes serve as useful reminders to integrate evidence into practice during CNS-led multidisciplinary rounds. The rounds also provide a vehicle for the CNS to facilitate interdisciplinary collaboration and communication.
Implications for Practice: The CNS is in a position to expedite the translation of EBP to the bedside by influencing the care delivered to the patient. Multidisciplinary rounds can effectively be tailored to the population to promote best practice.
Clinical Nurse Specialists Get Your MUVE ON! Using a Multiuser Virtual Environment to Facilitate Nursing Journal Clubs-A Mixed-Methods Study
Karen Rice, DNS, APRN, ACNS-BC, ANP, Luanne Billingsley, DNP, APRN, ACNS-BC, MAB, Marsha Bennett, DNS, APRN, ACRN, Fiona Winterbottom, MSN, APRN, ACNS-BC, CCRN, Shelley Thibeau, MSN, RNC, Ochsner Medical Center, New Orleans, Lousiana (Rice), Southeastern Louisiana University, Hammond (Billingsley), Louisiana State University Health Sciences Center, School of Nursing, New Orleans (Bennett), Ochsner Medical Center, New Orleans, Lousiana (Winterbottom and Thibeau)
Purpose/Objectives: The purpose of this mixed-methods descriptive study was to report the experience of using Second Life, a virtual environment, to facilitate nursing journal clubs (NJCs).
Significance: Clinical nurse specialists work to move clinical practice forward by leveraging technological advances, incorporating cutting-edge research, and building on evidence-based practice to improve the health of individuals, families, and communities. As clinical innovation experts, clinical nurse specialists are well positioned to influence practice, education, and research. Nursing journal clubs provide an opportunity to master competencies necessary to integrate research into practice and allow participants an opportunity for scholarly discussion. Common barriers to traditional NJCs include getting sufficient participation due to time constraints and availability of mentors. Innovative technological advances, such as using the Internet to access virtual learning environments, provide low-cost venues to engage nurses and mitigate barriers associated with face-to-face NJCs.
Design/Background/Rationale: Thirty-four registered nurses from 6 facilities were consented to participate in mentored NJC activities in 1 of 4 specialty groups (adult, critical care, neonatal, psychiatric) from June to September 2010. Each group participated in 4 sessions: orientation, 2 sessions of critiquing research literature using a structured tool kit, and debriefing/planning for NJC sustainability. Clinical experts with competencies in critiquing literature facilitated all sessions.
Methods/Description: Nonparametric statistics will be used to analyze project outcomes using presurvey, postsurvey, and 30-day follow-up survey developed for this project. Presurvey and postsurvey (35 items) measured self-reported levels of confidence (0- to 10-point scale) addressing MUVE and critiquing skills. Content analysis from audio-video screen castings (>20 hours) of NJC activities will be analyzed for themes using NVivo8.
Findings/Outcomes: Findings from 29 of 34 participants include Fisher exact identified significantly (P < .05) improved competencies in determining design, interpreting statistics, linking conclusions/findings, and identifying limitations after the NJCs. No differences were identified in determining population, sample, implications, or interpreting qualitative findings.
Conclusions: Preliminary findings support that nurses perceived improved competencies in critiquing research reports during the MUVE-facilitated NJCs and expressed a desire to continue virtual NJCs beyond the study.
Implications for Practice: The expansion of NJC activities into a highly flexible, interactive format such as Second Life may decrease barriers to participation and provide a venue for regional activities and beyond.
Clinical Precepting of Clinical Nurse Specialist Graduate Students: Special Approaches for the Experienced and Expert Nurse
Brenda Shelton, MS, RN, CCRN, AOCN, Bridget Carver, MSN, RN, CCRN, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland (Shelton), Johns Hopkins School of Nursing, Baltimore, Maryland (Carver)
Purpose/Objectives: This session describes the challenges of providing clinical mentorship for experienced registered nurses in clinical nurse specialist (CNS) graduate programs. The session explores educational expectations and assumptions from the perspective of both the preceptor and the clinically experienced CNS graduate student and provides suggestions for strategies to enhance the educational experience.
Significance: Clinical rotations for CNS graduate programs are an important component of the educational curriculum and are designed to create an immersion experience that assists the student in developing clinical expertise and role-related knowledge and skills. These clinical rotations are not always reflective of the specific clinical expertise or ultimate interests of the student, but are meant to broaden clinical knowledge and develop expert CNS role performance. Challenges of staff acceptance, adequate time for relationship building, skill in performing physical assessments, and identifying translatable expertise must be considered when planning any clinical rotation.
Design/Background/Rationale: When a highly experienced and expert clinical nurse attends graduate school, creating an experience that uniquely challenges these nurses can be daunting. Many of these graduate students hold leadership roles in their current employment and have mastered some of the role components of the CNS.
Methods/Description: Specific strategies to utilize the existing skills of the graduate student and the strengths of the preceptor to enhance this mentorship experience are outlined. Methods to optimally address the challenge of assisting clinically experienced CNS students to appreciate the differences between their previous role as a "clinical expert" and their new role as a "clinical nurse specialist" are explored. Demonstration examples of briefing and debriefing exercises, journaling, and situational analysis are included in this presentation.
Findings/Outcomes: Discussion of difficulties and innovative strategies to achieve this role transition through the clinical rotation are drawn from the presenter and student testimonials.
Conclusions: Specific successful techniques and affective impressions demonstrate that these special graduate students require unique educational experiences.
Implications for Practice: Clinical nurse specialist academic faculty and clinical preceptors should consider the backgroundand experience of the graduate student in selecting a clinical rotation and the focused experiences and expectations within that clinical course. This session offers innovative and proven successful strategies for both preceptor and student.
Clinical Nurse Specialist Education: Preparing Practice Portfolios
Irene Gilliland, PhD, RN, CNS, ACHPN, Jeanette McNeill, DrPH, RN, CNE, AOCNS, Mary Elaine Jones, PhD, RN, University of the Incarnate Word, San Antonio, Texas
Purpose/Objectives: The project's primary purpose was to help students showcase their professional education, training and experiences to compete for better jobs in the health care marketplace. Second, the portfolio preparation assisted students to reflect on their learning across the program. Third, the opportunity for peer review and comments was provided as online students reviewed each other's portfolios.
Significance: As more online programs are being offered for clinical nurse specialist (CNS) education, socialization experiences may be lacking to develop interpersonal and marketing skills in preparation for seeking employment. New CNS graduates are competing with nurse practitioners and physician assistants in primary care settings where physicians may not be familiar with the value-added aspects of CNS preparation.
Design/Background/Rationale: Portfolios have been popular for many years in the education and art communities as a way for a job applicant to demonstrate the skills necessary for a particular position (Alexander, 2002). In nursing, applicants fill out a generic application that fails to discriminate between applicants except for objective information as to previous job experience and education. With the advent of technology, students can develop Web-based portfolios that are easily navigated by potential employers and give the employer a better picture of the skills and training of the CNS.
Methods/Description: Students in the final semester of an online CNS program (2 cohorts, n = 14) were required to develop a professional Web-based portfolio that would "paint the picture" of who they are and demonstrate how they meet the qualifications for a specific position. The categories included a philosophy of nursing; a current curriculum vitae; evidence of participation in professional organizations; transcripts; syllabi of CNS required courses; evidence of verbal, written, and computer communication skills; evidence of leadership; evidence of practice hours in the specialty; and evidence of critical thinking ability through projects, research, and writing.
Findings/Outcomes: Students reported being favorably impressed when they saw all of their accomplishments displayed. Peer and faculty support was received. Students reported successfully using these portfolios when searching for their first job.
Conclusions: Portfolio is an effective way to market CNS skills.
Implications for Practice: Portfolio development is an important skill for the CNS.
Clinical Nurse Specialist Innovation and Collaboration: Guiding Frontline Nurses to Implement New Evidence When the Research Changes
Rebecca Stamm, MSN, RN, CCNS, CCRN, Anne Muller, MSN, RN, ACNS-BC, Eileen Gallagher, MSN, RN, ACNS-BC, PCCN, Hospital of the University of Pennsylvania, Lansdowne (Stamm), Hospital of the University of Pennsylvania, Philadelphia (Muller and Gallagher)
Purpose/Objectives: The session will demonstrate how the clinical nurse specialist (CNS) led the development and implementation of a new glycemic protocol and target range in a cardiac surgical population based on the emergence of new evidence.
Significance: Overall intensive glycemic control (80-110 mg/dL) has not improved mortality as original studies have shown. In fact, tight glycemic control in the critically ill has resulted in poor outcomes. The focus has shifted to maintain glucose levels at a more modest level of 140 to 180 mg/dL in critically ill intensive care unit patients.
Design/Background/Rationale: The NICE-SUGAR (Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation) study showed concern with hypoglycemic events and increased mortality related to strict glycemic control. At our institution, the research was evaluated on a multidisciplinary level to determine a new target range.
Methods/Description: An online survey of current practice and inquiries about hypoglycemic events was conducted with the cardiac surgical nurses. Prior to the protocol change, nurses identified increased occurrences of hypoglycemic events that required the nurse to deviate from the protocol. The CNS orchestrated the development of a new protocol and target range in conjunction with the multidisciplinary team. Unit-based education of the new range and protocol was provided prior to initiation. Subsequent auditing by the CNS and clinical nurses with evaluation of hypoglycemic events and compliance was performed.
Findings/Outcomes: Anecdotally, there have been less hypoglycemic events reported since the implementation of the new protocol. Follow-up survey is currently being conducted, and results will be presented.
Conclusions: The CNS was recognized as a change agent by evaluating and implementing new evidence at the unit level.
Implications for Practice: Clinical nurse specialists are critical in identifying new evidence and assisting the frontline nurse to translate into practice.
Clinical Nurse Specialist Orientation: Ready, Set, Go!
Linda D. Urden, DNSc, RN, CNS, NE-BC, FAAN, Kathleen M. Stacy, PhD, RN, CNS, CCRN, PCCN, University of San Diego, San Diego, California (Urden), Palomar Medical Center, Escondido, California (Stacy)
Purpose/Objectives: The purpose is to describe a clinical nurse specialist (CNS) orientation tool based on the 3 spheres of CNS practice. The incorporation of CNS mentor and CNS preceptor roles will also be delineated.
Significance: Transitioning into a CNS role can be exciting, challenging, and daunting for both the novice and experienced CNS. Both novice and experienced CNSs need a consistent orientation so that all in the role have the same knowledge base from an agreed-upon set of expectations.
Design/Background/Rationale: The novice CNS will likely be coming from a direct care clinical position with no other expanded role experiences. There are no other systems or independent practice experiences from which to base their new role. The experienced CNS new to the organization or department will bring knowledge and more confidence in the role, but will need guidance, facilitation, and entry into the organization.
Methods/Description: Our CNS team conducted a literature review and contacted external CNSs and professional nursing organizations to determine if there were orientation tools that would encompass all CNS specialty and practice settings. None were found meeting those criteria; thus, we formulated a tool based on the 3 spheres of CNS practice and competencies. The new CNS Competency Validation Check List was piloted for 3 months by CNSs in different practice settings and specialties.
Findings/Outcomes: Findings from the trial were compiled, with slight revision of the tool, and the orientation process was implemented for all new CNSs. This tool is used in addition to the hospital and unit-based orientations (if appropriate).
Conclusions: A CNS preceptor is assigned to new CNSs and is responsible for the orientation and evaluation during the initial 3 months. A CNS mentor may or may not be the same as the preceptor and meets periodically over the next year to ensure socialization into the role and setting, along with professional guidance.
Implications for Practice: The tool is an evidence-based tool that provides a framework based on the 3 spheres of CNS practice to document CNS orientation. It can be reviewed for adoption or revision into other settings, adding institution-specific competencies or expectations. It can also be a beginning step to track the impact of CNS practice on outcomes.
Clinical Nurse Specialist Influencing Practice Outcomes: Reducing Bloodstream Infections
Rose Lee, MS, APRN, CCRN, CCNS, Jill Slade, BSN, CCRN, Queen's Medical Center, Honolulu, Hawaii
Purpose/Objectives: The purpose of this project was to eliminate central line-associated bloodstream infection (CLABSI) in coordination with a statewide iniative program called Hawaii on the CUSP: STOP BSI (CUSP = comprehensive unit-based safety program).
Significance: The literature reports that 12% to 25% of each CLABSI attributes to mortality. Central line-associated bloodstream infection also adds additional cost of $35 000 to $56 000 per case, which is no longer reimbursed by Medicare. We have committed to eliminate CLABSI utilizing a multifaceted approach to effectively adapt evidence-based practice (EBP) changes. This was a concerted effort of a multidisciplinary team (ie, chief nursing officer, chief medical officer, physicians, nurse managers, vascular access device nurses, staff nurses, central services, purchasing department, infection control, electronic medical record support services, and clinical nurse specialists [CNSs]).
Design/Background/Rationale: There were multiple efforts at each unit level to reduce CLABSI, but no formalized organization program or project existed. There were multiple variances dependent on the beliefs and attitudes by physicians, nurses, and unit culture. This project was to bring EBPs to the whole organization and provide consistent high standards.
Methods/Description: This project was heavily influenced and managed by the CNS to guide the organization with EBP changes while streamlining processes and providing concerted educational efforts. An organization task force was formed, made of representatives of the unit-based teams. We reviewed charts, literature, policies, and procedures. The CNS identified multiple variances and lead discussions for standardizations in alignment with literature support. Hence, we have standardized equipment and process flows. We addressed accessibility and/or purchasing of necessary equipment. Central line checklist was developed for insertion procedures. We prioritized target units with an organized educational plan: (1) preassessment survey, (2) self learning modules, (3) roving in-services/hands-on validation, (4) reminder/commitment campaign, and (5) postassessment survey measurements. And most importantly, we have developed forums where learning points were discussed among units.
Findings/Outcomes: Implementation of this project is anticipated to decrease CLABSI while providing standardization among all the units at our hospital.
Conclusions: Multidisciplinary team with a multifaceted approach for eliminating CLABSI is important for successful outcomes.
Implications for Practice: The clinical nurse specialist's role (as consultant, expert clinician, and influencer among multiple spheres) adds great value to achieving outcomes.
Development of a Nurse-Driven Obstructive Sleep Apnea Risk Assessment and Management Protocol
Linda Jenkins, MSN, RN-BC, ACNS-BC, Centra Lynchburg General Hospital, Lynchburg, Virginia
Purpose/Objectives: The purpose of this multidisciplinary team effort was the development of a clinical protocol based on nurses' assessment to guide management of patients with diagnosed or screened at risk for obstructive sleep apnea (OSA).
Significance: An estimated 18 million Americans have OSA, and 16 million of these people remain undiagnosed. Obstructive sleep apnea is becoming more common and can lead to serious health problems if undetected. The first step to managing patients in the hospital with OSA is to identify those at risk.
Design/Background/Rationale: A multidisciplinary team consisting of nurses, physicians, pharmacists, and respiratory therapists worked together to develop a hospital-wide policy and management protocols for patients with OSA.
Methods/Description: Phase 1 consisted of nurses, respiratory therapists, and physicians collaborating to develop an inpatient management protocol for patients with diagnosed OSA. Phase 2 incorporated physicians from multiple disciplines and pharmacists in addition to nurses and respiratory therapists to develop a protocol for patients identified as at risk for OSA. The at-risk protocol is activated for patients who receive procedural sedation or anesthesia. Electronic order sets were developed for each protocol.
Findings/Outcomes: Over a 6-month period, a policy was developed for management of inpatients and outpatients with diagnosed, or at risk for, OSA. The policy and subsequent protocols were implemented in 3 hospitals within the health care system.
Conclusions: Because of a lack of current research for OSA, the protocols were based on published evidence, expert opinions, and best practices. Education of all nurses and physicians working at the 3 hospitals was and continues to be a huge challenge. Education for patients and families has presented a number of interesting opportunities as well. Ongoing audits are in place to validate the appropriate implementation of the protocols as well as tracking of patient outcomes.
Implications for Practice: This is an important safety initiative to improve the clinical outcomes for patients with diagnosed OSA or screened at risk for OSA. The implementation of these nurse-driven protocols allows patients to be appropriately monitored and managed on general nursing floors without overutilization of critical-care resources.
Diversity Certification Program: An Innovative Model of an Organization's Quest for Diversity and Cultural Competence-One Person at a Time
Marianne Allen, MN, RNC, Pinnacle Health System, Harrisburg, Pennsylvania
Purpose/Objectives: Describe the expertise of clinical nurse specialists (CNSs) in the development of an innovative diversity certification program at Pinnacle Health System.
Significance: Culturally competent care must recognize cultural perspectives and diversity of those served. Providers must be willing to modify treatment approaches to provide care that is culturally acceptable to patients. Organizations must also provide a healthy work environment for employees. Pinnacle Health System embraces diversity as an essential component of its mission for both the population served and its workforce. Clinical nurse specialists provide leadership in the collaborative diversity initiatives and serve on the Diversity Steering Committee/Clinical Practice and Education Subcommittee. In 2006, CNSs conducted a study of educational interventions for nurses using a theoretical framework describing the journey toward cultural competence. The results showed that patient satisfaction scores related to diversity, and cultural sensitivity improved on the interventional units. The education was then offered to other departments.
Design/Background/Rationale: Challenges of offering "live" in-services to 5000 employees led us to develop the Diversity Certification Program, an innovative approach to offer all employees the opportunity to pursue the journey toward competence in diversity based on individual needs/interests. The Diversity Certification Program consists of 2 levels: diversity champions demonstrate beginning achievement of skill and knowledge, and diversity leaders demonstrate advanced knowledge and skill to function as mentors to promote the organization's mission. Based on principles of adult learning, the 2-level certificate program provides recognition of achievement in diversity education.
Methods/Description: This presentation describes the CNS role as expert in establishing the Diversity Certification Program within the 3 spheres of influence.
Findings/Outcomes: Results include employee participation, enthusiasm, and accomplishments. Format of self-assessment, identification of learning needs, and pursuit of individual interests meet the needs of adult learners. Anecdotal comments provide rich evidence of the personal impact of journeys toward cultural competence.
Conclusions: The Diversity Certification Program is a model of an innovative, low-cost approach to move organizations toward the quest for cultural competence and inclusion for the diverse clients and employees.
Implications for Practice: Clinical nurse specialists can positively impact our organization's journey toward diversity and cultural competence by developing educational models that utilize each of the CNS spheres of influence-organization, staff, and clients.
Emergency Department Severe Sepsis Alert and Practice Protocol
Darleen A. Williams, MSN, CNS, CEN, CCNS, CNS-BC, EMT-P, Katrin Breault, RN, CEN, Orlando Regional Medical Center, Orlando, Florida
Purpose/Objectives: In the United States, severely septic patients and patients in septic shock continue to experience significant mortality. The use of standard practice protocol and guidelines has demonstrated improved outcomes for septic patients. The objective of the ED Severe Sepsis Alert and Practice Protocol is to initiate early goal-directed therapy and expedite the patient's admissions process.
Significance: According to the Centers for Disease Control, sepsis is the 10th leading cause of death in the United States. Early recognition and time-sensitive appropriate interventions are essential to patient survival. The Society of Critical Care Medicine's "Surviving Sepsis Campaign" acknowledges the important role that standard practice protocols and guidelines play in improving outcomes for septic patients (http://www.survivingsepsis.com).
Design/Background/Rationale: This was a process development and implementation project led by the ED's clinical nurse specialist.
Methods/Description: An interdisciplinary team was formed and the 2008 Surviving Sepsis Campaign's international guidelines were used to help develop the process. In addition, current existing alert processes were also reviewed and components from them adapted for this project. Data were collected through a retrospective electronic medical record review. To maintain interrater reliability, all data were collected by the clinical nurse specialist and the ED staff nurse assisting on this project.
Conclusions: The literature supports that increased awareness of severe sepsis and early goal-directed therapy improve patient outcomes. After implementation of the severe sepsis alert and practice protocol, the marked decrease in the door to first antibiotic administration times and the reduction in patient's hospital length of stay support the continuation of this program.
|Table. Comparison of Initial Antibiotic Administration Before and After a Severe Sepsis Alert and Protocol Implementation (N = 44)|
Implications for Practice: The positive results have inspired the ED to begin developing a formal research study to evaluate the planning of a formal research study and greater staff involvement as our process is further refined.
Enhanced Preoperative Patient Education Improves Indwelling Urinary Catheter Removal Rates Postoperatively
Karen Mahnke, MSN, APN, CNS-BC, CWON, Northwestern Lake Forest Hospital, Illinois
Purpose/Objectives: The purpose of this study was to examine the effects of enhanced preoperative patient education on indwelling catheter removal rates postoperatively.
Significance: With the recent changes to the Centers for Medicare & Medicaid Services guidelines, hospitals no longer receive reimbursement for hospital-acquired, catheter-associated urinary tract infection. Prevention of these infections is key. Despite changes in standardized postoperative total joint replacement patient orders, RN and MD education, and regulatory ramifications, a medical record review for the fourth quarter 2008 (4Q08) identified that 36% of urinary catheters at Northwestern Lake Forest Hospital were left in past postoperative day 1.
Design/Background/Rationale: Preoperative education for the total joint patient was enhanced to a multidisciplinary team providing the education in a classroom, group-education format, instead of the individualized physical therapy-focused education provided previously. Using the Relationship-Based Care Model to frame the education, specific content was added related to indwelling catheters and the importance of timely removal postoperatively.
Methods/Description: Total joint replacement patient medical records were reviewed before enhanced education (4Q08) compared with after enhanced education fourth quarter 2009 (4Q09). Descriptive and [chi]2 analyses were used to compare 4Q08 and 4Q09. Data from 1Q09 and 1Q10 were analyzed to determine the sustainability of removal of the indwelling catheter on postoperative day 1.
Findings/Outcomes: A total of 360 total joint replacement patient medical records were reviewed. There was a favorable change (60%) in indwelling catheter removal rates after enhanced education (P = .0060) comparing 4Q08 to 4Q09. This is statistically significant. There was a favorable change in the indwelling catheter removal rates from 1Q09 to 1Q10 (P = .0534) after enhanced education. This is trending toward statistical significance.
Conclusions: These preliminary data suggest that including the patient at the center of care planning with enhanced preoperative education may have improved indwelling catheter removal rates.
Implications for Practice: Reducing HAIs requires a well thought-out, multidisciplinary effort to be successful. Including the patient at the center of the care planning process and, when possible, extending the care plan to the preoperative phase may influence compliance with these efforts.
Establishing a Nursing Research Internship Program
Thresa Brown, MSN, RN, ACNS-BC, Nancy Summerell, Amanda French, Smita Glosson, Moses Cone Health System, Greensboro, North Carolina
Purpose/Objectives: Clinical nurse specialists are actively involved in evidence-based practice change and nursing research. In early 2009, the Nursing Research Committee formed a team to explore the development of a Nursing Research Internship Program designed to mentor staff nurses through the research process.
Significance: Based on literature review and feedback from Moses Cone Health System nurses, they perceive numerous barriers to becoming actively involved in individual research projects at the bedside. Among the barriers are lack of knowledge, practical experience, time, and organizational support.
Design/Background/Rationale: Literature review revealed that internship programs can positively influence staff nurses' attitudes toward nursing research and evidence-based practice, address barriers, and compile resources and tools needed to conduct nursing research. The Nursing Research Internship team drafted a proposal describing the program, goals, anticipated benefits, program design, application and evaluation process. A faculty member from the University of North Carolina at Greensboro School of Nursing joined.
Methods/Description: In October 2009, the proposal was submitted to the appropriate committees. After recommendations and approval, late fall 2009, the Nursing Research Internship Program was announced. In early winter 2010, the Nursing Research Internship team selected candidates based on a blinded application process review using a standardized evaluation tool. In May 2010, the interns began the program.
Findings/Outcomes: Six nurses received and accepted internship offers. Three research studies are in progress, 2 interns per team. Their learning is supplemented by reading assignments, interactive discussions, and real-time problem solving. Each Nursing Research Internship committee member is paired with an intern to serve as mentor. The planned timeline for completion of the program is May 2011.
Conclusions: The interns have verbalized enjoying the internship and knowledge gained. Multiple staff nurse inquiries related to the internship program offers anecdotal evidence of increasing interest in participating in the program and conducting nursing research.
Implications for Practice: The Nursing Research Internship team developed a research study on the participating interns with the purpose of measuring their attitudes and knowledge of nursing research prior to participating the program and upon completion. Implementation of a successful nursing research internship has potential of impacting quality of patient care and nurse satisfaction.
Measuring Outcomes of Evidence-Based Practice for Mechanical Venous Thromboembolitic Prophylaxis
Brenda G. Larkin, MS, RN, ACNS, CNOR, Matthew Beier, MS, RN, CNS-BC, CNOR, Cindy Lewis, MSN, RN, Kimberly M. Mitchell, BSN, RN, CNOR, Aurora West Allis Medical Center, West Allis, Wisconsin (Larkin), Aurora St Luke's Medical Center, Milwaukee, Wisconsin (Beier, Lewis, Mitchell)
Purpose/Objectives: The objective of the study was to determine evidence-based practice for implementation of mechanical venous thromboembolic (VTE) prevention in the perioperative period based on a systematic literature review.
Significance: Occurrence of VTE in the postoperative surgical patient is considered by the Centers for Medicare & Medicaid Services to be a "never event." Use of both mechanical and pharmacological methods to prevent VTE in surgical patients has been used; however, the timing of initiation of mechanical prophylaxis has not been universal across surgical settings. This review was done to determine optimum timing and rationale for initiation of mechanical VTE prophlaxis and to standardize perioperative care of at-risk surgical patients in a hospital system.
Design/Background/Rationale/Methods: Systematic literature review of the Ovid database for all available years was conducted to answer the following question: What evidence exists for
* optimal application time of intermittent pneumatic device (IPC) and compression stockings for perioperative prophylaxis;
* addressing the benefit of using a combination of IPC and compression stockings;
* regarding efficacy of use of mechanical prophylaxis both perioperatively and postoperatively;
* alternative configurations of mechanical prophylaxis for use on specialty operative tables?
* Optimal application time was determined to be as soon as possible prior to the surgical procedure. In some instances, the application of device(s) may be as much as 1 hour prior to transport to surgery.
* There is no consensus in the literature that the combination of compression stockings with IPC offers any additional benefit in preventing VTE.
* Fibrinolytic activity is increased by use of external compression and that the effect lasts up to 3 days postoperatively.
* No alternative configurations with significant supporting evidence were identified for use with specialty operative tables.
Conclusions: Evidence suggests that implementation of mechanical prophylaxis as early as possible in the perioperative period decreases occurrences of VTE for the surgical patient.
Implications for Practice: For ambulatory patients, prophylaxis should begin as soon as they are settled and prior to transport to the operative suite. Prophylaxis should be maintained for all patients throughout the perioperative period. Currently, 2 of 15 hospitals have implemented this process.
From Rowing the Boat to Navigating the Ship: The Journey From Novice to Expert
Sarah Pangarakis, MS, RN, CCNS, CCRN, Sue Sendelbach, PhD, RN, CCNS, Methodist Hospital, St Louis Park, Minnesota (Pangarakis), Abbott Northwestern Hospital, Minneapolis, Minnesota (Sendelbach)
Purpose/Objectives: Key concepts of a mentor-protege relationship include the sharing of knowledge and information from one who is more experienced or expert with one who seeks to learn from the expert. The purpose of this session is to describe the relationship between a novice clinical nurse specialist (CNS) (protege) and an experienced CNS (mentor) and the strategies utilized by both to ensure a successful transition into practice.
Significance: The first year as a novice CNS is exciting but can be challenging and stressful. Most novice CNSs will transition from a staff nurse position where he/she is at an expert level of clinical practice to now being in the position of being a novice again.
Design/Background/Rationale: One strategy to successfully navigate the transition from a novice CNS to an interal part of the health care team is to develop a mentor-protege relationship between an expert CNS and the novice CNS.
Methods/Description: A review of the literature on mentorship-protege relationship with a dedicated focus of the perspective of the first year of practice as a CNS. Examples of strategies utilized by a mentor to facilitate the transition of the novice CNS into practice and case studies by the protege will be presented to provide both an evidence-based and the experience of the novice and seasoned CNSs. Differentiation of preceptorship and mentorship will be also be presented.
Findings/Outcomes: After 1 year in practice, the novice CNS became an integral and valued participant of the clinical team. She was able to help facilitate a major change in the governance meetings and other clinical aspects of practice.
Conclusions: Successful transition of a novice CNS into practice can be successfully navigated in a mentor-protege relationship with benefits for the mentor and the protege and for the profession of nursing.
Implications for Practice: It is important for the novice CNS to find mentor so he/she can have a smooth transition into practice. There are also benefits for the mentor and for the profession of nursing.
Getting the Job: Professional Portfolio Development for the Clinical Nurse Specialist
Eileen P. Geraci, MA, ANP-C, Eileen Campbell, Western Connecticut State University, Danbury, Connecticut (Geraci)
Purpose/Objectives: A review of the literature indicates that professional portfolios have been largely adopted by teachers, business professionals, and some nurses, to showcase their "best work" and/or to provide evidence of experience gained throughout a specific program of study. However, there are no studies that discuss how to best address documentation of progression toward expertise in clinical nurse specialist students.
Significance Documentation and evaluation of student learning and achievement as they progress through their program of study have long been a subject of concern for nursing educators. Use of the professional portfolio has been suggested as a method of assessing student progress in undergraduate nursing programs but not in advanced practice nursing students.
Design/Background/Rationale: This presentation will discuss the process used by faculty in a department of nursing to develop a framework for assessing portfolios as an outcome measure of professional growth for advanced practice nursing students. A clinical nurse specialist graduate will also discuss his/her experience in portfolio development and how he/she used the portfolio for interviewing.
Methods/Description: Case study.
Findings/Outcomes: Both authors have found that the design and organization of the portfolio led to improved learning and job opportunities.
Conclusions: The professional portfolio can serve as a method of evaluating progress toward individual and programmatic goals for advanced practice students.
Implications for Practice: Documentation and evaluation of student learning and achievement as they progress through their program of study have long been a subject of concern for nursing educators. Use of the professional portfolio has been suggested as a method of assessing student progress in graduate advanced practice nursing education.
GRADE-ing the Evidence: Education to Advance Innovations in Practice
Howard T. Blanchard, MEd, MS, RN, ACNS-BC, CEN, Massachusetts General Hospital, Boston
Purpose/Objectives: The purpose of this presentation is to describe how clinical nurse specialists (CNSs) in a large academic medical center in the northeast are implementing the GRADE scheme to weigh evidence for practice. The GRADE scheme is described.
Significance: Clinical nurse specialists seeking clear guidance for evidence-based practice (EBP) face the immense tasks of finding the body of evidence and then leveling the evidence using 1 of the109 taxonomies, major barriers to implementing innovations in practice. Clinical nurse specialists are the drivers of innovation in clinical practice and need to gain competence in EBP to accelerate the translation of research findings into practice.
Design/Background/Rationale: Evidence-based practice has come into routine use in the glossary of nursing discussion. Identifying sources of varying qualities of evidence is as convenient as a search on a smartphone. Although it may be tempting to adopt into practice the recommendations of a well-written article from a peer-reviewed journal, EBP impels us to judge the entire body of evidence, not single studies. The EBP process can be daunting, but the use of the GRADE system can facilitate the work. The GRADE system, gaining popularity since it was first required by the British Medical Journal and others in 2006, clearly differentiates between the quality of the evidence and the strength of recommendations. Organizations listed as endorsing or using this taxonomy on the GRADE working group Web site includes World Health Organization, Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee, and Agency for Healthcare Research and Quality.
Methods/Description: Twenty CNSs formed an EBP working group for the purpose of building capacity in EBP in part by learning to critique evidence using the GRADE scheme.
Findings/Outcomes: Clinical nurse specialists are gaining experience using GRADE, consequently supporting the adoption of innovations into practice. When consensus is reached, there is also a collective confidence-driving practice change.
Conclusions: Clinical nurse specialists have found the GRADE scheme to be useful in providing a common language, a systematic approach, and a way to scrutinize the evidence for clinical practice.
Implications for Practice: New CNSs may benefit from awareness of GRADE being used in the evidence-leveling step of advancing innovations into practice.
Helping Patients Learn New Skills: Does Involving CVA Patients and Their Families in the Design of a Patient Education Program Improve Outcomes?
Jessica Brier, MS, RN, CVCNS - BC, Michelle Carpentier, BSN, RN, Jean Moreau, RN, The Miriam Hospital, Providence, RI
Purpose/Objectives: A nurse manager and staff approached the CV clinical nurse specialist (CNS) to assist them in evaluating their cerebral vascular accident (CVA)/transient ischemic attack (TIA) education program because of concern related to the effectiveness in helping patients utilize the information given in making necessary lifestyle changes. Together, the group decided a research project might help answer the question of how much information patient should be given and what the best way to present that information is from the patients' perspective. The overall goal of the research was to evaluate a redesigned patient education program for a population of TIA/CVA patients, using information about the health literacy of the population, quality of teaching, and readiness for discharge as reported by patients. Outcome measures for evaluating the success of the educational program were knowledge acquisition and coping ability after discharge home.
Significance: Stroke is the third leading cause of death and major disability among older adults in the United States. Nearly 800 000 strokes occur in the United States every year, and about 600 000 of these are first attacks, whereas nearly 200 000 are recurrent strokes (American Heart Association, 2010) Among stroke survivors, there is a limited awareness of risk factors and symptoms as well as significant delays in seeking treatment when new symptoms occur. A major risk factor for stroke is a prior CVA/TIA. Stroke is often a catastrophic event for survivors and their families. Significant numbers of stroke survivors experience limitations after they return home; therefore, continuing and targeted education is crucial to minimize stroke's impact.
Design/Background/Rationale: Preintervention and postintervention comparison measures.
* A convenience sample of 30 patients admitted with CVA/TIA was asked to participate.
* Subjects were asked to complete the validated tools for health literacy, cognitive screening, readiness for discharge, and quality of discharge education.
* Two to 3 weeks after discharge, a member of the research team conducted a telephone interview to determine knowledge level and complete the discharge coping measure.
* After implementation of the revised teaching, an additional convenience sample of 30 patients/caregivers were asked to participate, and the same procedure was followed.
Findings/Outcomes: The comparison of the outcome measures for both groups will be reported. The preintervention group will begin in October 2010. We expect to complete data collection on the postintervention group by December 2010.
Conclusions: To be added once data collection has been completed.
Implications for Practice: The partnership of a nurse manager, clinical nurse specialist, and staff-driven unit council made research accessible to frontline staff, and it is to be hoped they will demonstrate improved ability to meet our patients' education needs and improve outcomes.
Developing a Clinical Leadership Program to Promote Professional Advancement to the Clinical Nurse Specialist Role
Susan Ebaugh, BSN, RN, CEN, Angel Dewey, BSN, RN, CCRN, Susan Conley, BSN, RN, RN-BC, Ludmila Santiago-Rotchford, BSN, RN, PCCN, Bayhealth Medical Center, Dover, Delaware
Purpose/Objectives: The objective of the study was to provide a clinical nurse specialist (CNS) for each patient care area to improve patient safety and clinical outcomes in a 2-facility community hospital system in central Delaware.
Significance: The CNS has long been recognized as an expert, positioned to create a positive impact on practice, education, and research. Recruitment for CNSs with specialty certification and experience proved generally unsuccessful. The organization, Bayhealth Medical Center, committed to the development and integration of a clinical practice leader (CPL) program, which would result in professional growth and advancement in clinical practice. This program enabled certified BSN-prepared nurses interested in the advanced practice role to pursue graduate studies while serving in a leadership position mirroring the CNS.
Design/Background/Rationale: The need for clinical experts at the unit level was identified by nursing leadership. Prior to the CPL program, all clinical responsibilities fell upon the nurse manager for each nursing unit. Opportunities for performance improvement in patient outcomes, core measures, and patient safety measures challenged nursing leadership for a solution. The organization recognized the CNS advanced practice role as aligning with the emerging Centers for Medicare & Medicaid Services guidelines in a pay-for-performance era and the quest for Magnet status.
Methods/Description: The CPL role is a precursor to the CNS functioning within the 3 spheres of influence while learning the advanced practice competencies of the CNS. The position became available to clinically experienced, certified BSN nurses committed to enrolling in a MSN CNS program in preparation for board certification as an advanced practice nurse. A small team of CNSs served as mentors to the CPL group guiding the way to improving patient outcomes, cost containment, and evidence-based practice.
Findings/Outcomes: As a result of the CPL program, the organization has significantly reduced health care-acquired infections, improved core measurements, and enhanced patient safety initiatives as well as integrating the use of evidence-based practice.
Conclusions: The CPL program has proven to be a significant benefit to the organization by providing clinical expertise, education, and process development at the unit level while enhancing leadership and promoting professionalism.
Implications for Practice: Improve patient outcomes, decreasing "never events" while maintaining fiscal considerations.
How New Graduate RNs Describe Success in an Orientation Program
Maureen Krenzer, MS, RN, ACNS-BC, Laurie Funk, RN, NE-BC, Lynda Dimitroff, PhD, RN, CHES, Rochester General Hospital, Rochester, New York
Purpose/Objectives: The purpose of the study was to determine how new graduate registered nurses (RNs) describe success in an orientation program.
Significance: Orientation of new graduates is the foundation for a successful career in nursing. Successful orientation and assimilation into the nursing profession in today's world are thought to be more difficult as today's nurse handles such challenges as higher patient acuity, the nursing shortage, and the exit of highly skilled, baby-boomer nurse preceptors who are retiring or leaving acute care. The transition for the new graduate is full of milestones and "firsts" that often make or break the decision to stay in his/her clinical setting. Turnover is very high for nurses in their first 6 months to 1 year of practice. A literature review failed to identify papers relating to the purpose of this study.
Design/Background/Rationale: The method for this study was qualitative inquiry with a narrative descriptive design.
Methods/Description: Focus groups were used to collect data. Constant-comparative analysis was used to analyze the data and identify emergent themes.
Findings/Outcomes: The 4 themes identified as important to the success of new graduate RNs in an orientation program included strong support from other nurses, a structured orientation program, great communication skills, and care and respect toward new graduate nurses.
Conclusions: Overall, supportive communication and treatment of the new graduate are as important as the structured orientation program. Innovative approaches to clinical orientation are important, and the ability to communicate well is paramount. An unexpected finding was the unique clinical nurse specialist role in orientation of new graduate nurses.
Implications for Practice: The clinical nurse specialist has the responsibility to use innovative teaching techniques to ease and support the assimilation of the new graduate RN into practice. Our results demonstrate the need to look closely at the structure, supports provided, and the way we interact with each new graduate nurse to promote success. The study results will allow for modification of the orientation process and potentially aid in the recruitment and retention of nurses. The qualitative approach provided a narrative perspective to expand current nursing literature related to orientation of new graduate RNs.
I'm Hungry, Mommy: Evidence-Based Initiatives to Improve Breast-feeding Outcomes of Newborns
Marianne Allen, MN, RNC-OB, Stacy Chubb, BSN, RNC-MN, Pinnacle Health System, Harrisburg, Pennsylvania
Purpose/Objectives: Of the many challenges facing newborns, feeding is essential for survival. By using an evidence-based practice (EBP) model, we improved breast-feeding outcomes through staff education, enhancing inpatient and outpatient services, community collaboration, and parent education.
Significance: Breast-feeding requires newborns to coordinate sucking, swallowing, and breathing. Successful breast-feeding is associated with decreased risks of childhood obesity, sudden infant death syndrome, allergies, and asthma. Ineffective breast-feeding is associated with hyperbilirubinemia, dehydration, and weight loss. Seventy-five percent of the 4300 infants born annually at our hospital are breast-fed. One in every 8 infants is premature and at risk for ineffective breast-feeding and hyperbilirubinemia.
Design/Background/Rationale: Iowa Model of Evidence-Based Practice to Promote Quality Care Clinical Nurse Specialist role.
Methods/Description: An interdisciplinary team led by the clinical nurse specialist (CNS) recommended EBP changes that were implemented by nurses, pediatricians, and community partners.
Findings/Outcomes: An interdisciplinary team of CNSs, nurse managers, nurses, lactation consultants, social workers, pediatricians, information services, home health, and medical equipment providers reviewed current literature and explored development of education, clinical practice changes, and partnerships within the organization and the community to improve breast-feeding outcomes. Nurse and ancillary staff education was completed. Practice changes included
* term newborn and late-preterm infant order sets
* "skin-to-skin" standard of care
* maternal/newborn risk assessments
* redefine role of lactation consultants with at-risk infants a priority and nurses providing support/teaching for low-risk infants
* electronic lactation consultant referrals/documentation/communication
* parent education materials revised
* system-wide and unit-based breast-feeding committee reorganization
* improved availability of consignment breast pumps/related equipment with DME on-site
* outpatient breast-feeding clinic for early breast-feeding support/follow-up care
* strengthened community links for home health breast-feeding standards, follow-up, and collaboration between hospital and WIC lactation consultants
Conclusions: The CNS within the client, staff, and community spheres of influence and application of an EBP model resulted in improvement of breast-feeding outcomes that included
* consistent evidence-based patient education/ breast-feeding support,
* task force addressing hyperbilirubinemia and hospital readmissions, and
* community collaboration with improved continuity of care/breast-feeding support.
Implications for Practice: Clinical nurse specialist practice within the the 3 spheres of influence facilitated translation of research into practice to improve breast-feeding outcomes for vulnerable infants through use of an EBP model and interdisciplinary collaboration between hospital and community partners.
Improving Patient Satisfaction With Pain Management Utilizing Six Sigma Methodology
Thresa Brown, MSN, RN, ACNS-BC, Kendall Johnson, MBA, RN, MSIE, Michael Hayes, PharmD, Mona Easter, MBA, RN, Moses Cone Health System, Reidsville, North Carolina (Brown, Hayes, and Easter), Moses Cone Health System, Greensboro, North Carolina (Johnson)
Purpose/Objectives: Our goal as a health system is greater than 90th percentile in key publicly reported indicators. Patient satisfaction with pain management indicated a downward trend compared with fiscal year 2009. Our project purpose is to increase patient satisfaction related to pain management to at or above the 90th percentile (QDM) and to 67.0 (RBC) in the third quarter (April/May/June) fiscal year 2010. Of note, RBC data measurement changed after start of project; goal changed to 86.4.
Significance: Literature supports that decreased patient satisfaction related to pain management affects complaints, compliance, and safety. Financial impact is difficult to assign; one can infer that the cost of poor quality could be the customer choosing a different facility, increased length of stay, and/or complications.
Design/Background/Rationale: Using Six Sigma methodology and review of evidence, a multidisciplinary team was formed to review current status. The intervention accepted for pilot was pharmacist bedside consultation with patients.
Methods/Description: Pharmacist education moved forward to improve knowledge base. Patients were identified during daily progression meetings. Triggers for pharmacy consults included PCA utilization greater than 48 hours, frequent PRN medication administration, pain uncontrolled by current regimen, and RN/MD request.
Findings/Outcomes: Pharmacy pain management consults began on May 14, 2010. To date, 14 consults have occurred. Mean pain score prior to consultation, 3.81; after consultation, it was 2.95. For quarter 2, prior to project the score for "Staff did everything they could do to help with pain" was 85.0; upon completion of quarter 2 after project initiation, it was 90.24; and for quarter 3, it was 90.24. For the question, "Pain controlled," quarter 2 prior to project, it was 54.0; after project initiated, it was 79.46; and in quarter 3, it was 80.83. For RBC data, quarter 1, 8046; quarter 2, 85.14; and quarter 3, 86.4 against goal of 86.4.
Conclusions: Pain management consults appear to have a positive impact on average pain scores. Limitations to this service include pharmacy hours, staffing levels, patient acuity, hospital census, patient recognition, and tasks.
Implications for Practice: Research supports that pain intensity is only one factor to be considered; other factors are patient expectation, patient education, and quality of interaction with health care providers. Institutional review board approval is under way to survey patients/families assessing these factors.
Initial 24-Hour Fluid Resuscitation of Adult Thermal Burn Patient
Ann Brennan-Cooper, MS, RN, CCRN, The New York Presbyterian Hospital-Weill Cornell Medical Center, New York
Purpose/Objectives: The objectives of the study were to introduce the learner to the fluid resuscitation algorithm used at The New York Presbyterian Hospital-Weill Cornell Medical Center for adult burn-injured patients within the initial 24 hours after injury, its implications for practice, and the importance of a nurse-driven protocol in avoiding harmful outcomes associated both with underresuscitation and overresuscitation in this population.
Significance: Burn-injured patients with significant total burn surface area percentage (%TBSA) sustain intravascular volume depletion within the first 24 hours of injury. Fluid requirements necessary to replace fluid loss are calculated based on weight, %TBSA. Restoration of fluid volume is necessary to maintain organ function. Historically, the Parkland formula has been the basis for calculating the first 24-hour fluid requirement. Because burn-injured patients are at risk for fluid overload, a nurse-driven protocol allows for titration of intravenous fluid hourly based on urine output. Studies have highlighted the detrimental effects of overresuscitation and indicate a need for a nurse-driven protocol to manage fluid more accurately. The fluid resuscitation algorithm is indicated to prevent fluid creep-the phenomenon in which burn patients receive far more resuscitation fluid than originally predicted by the Parkland formula. Fluid creep is associated with compartmental compression, increased need for mechanical ventilation, and abdominal compartment syndrome. Research indicates that when a patient is resuscitated with 250 mL/kg in less than 24 hours, the risk for abdominal compartment syndrome is greater.
Design/Background/Rationale: A Parkland formula calculation worksheet and a flowsheet algorithm for the bedside were designed for use by the physicians and nurses of the unit. Education was provided to the medical and nursing staff.
Methods/Description: Data were analyzed for each patient admitted after implementation of the algorithm to determine the final amount of fluid in milliliters per kilogram per %TBSA and compared with a cohort of patients in a previous study conducted prior to use of the algorithm.
Findings/Outcomes: In our retrospective study of burn patients, the average resuscitation volume was 7.7 mL/kg/%TBSA. After introduction of the nurse-driven protocol, volumes averaged 5.4 mL/kg/%TBSA. Outliers were excluded, and the study is ongoing.
Conclusions: Using a resuscitation algorithm reduced the amount of fluid volume received by burn patients.
Implications for Practice: Nurse-driven resuscitation protocols utilizing this algorithm play a significant role in reducing fluid volumes and negative sequelae of overresuscitation in burn patients.
Innovations in Implementation Science: A Journey to Oz
Linda M. Hoke, PhD, RN, CCNS, ACNS-BC, CCRN, AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, Hospital of the University of Pennsylvania, Philadelphia
Purpose/Objectives: The clinical nurse specialist (CNS) must bring the clinical research to the bedside in an efficient and equitable manner. This session will demonstrate how the CNS utilizes innovation to implement best practice and translate evidence-based findings into common practice.
Significance: Clinical nurse specialists are critical in improving the adoption of optimal practice changes that are beneficial to both patient and staff. Everyone uses the buzz words evidence-based practice (EBP) and translation; however, there are numerous examples from daily practice that demonstrate a delay in taking the evidence and implementing it on the frontline. Clinical nurse specialists promote implementation science by using creative innovation strategies. Understanding change supports nursing engagement and effective implementation of frontline research.
Design/Background/Rationale: Evidence-based practice starts with research utilization and translation. This comes in the form of passive to active dissemination. Translational roadblocks exist when the evidence is delayed, between the formulation of clinical guidelines and the delivery of routine clinical practice. It is this gap that must be understood and narrowed by the application of implementation science. Aligning Kotter's 8-step change model with popular movie films generates enthusiasm and excitement to rally the frontline staff around the change initiative.
Methods/Description: The CNS used the Wizard of Oz as a framework to promote inquiry and instill a sense of fun and engagement. Kotter's 8-steps of change guided the frontline staff through the change process by creating a sense of urgency and a strong vision empowering the team. This presentation will take you on a journey down the yellow brick road of change using multiple clinical examples. It will provide you with a structure to implement change and promote frontline engagement in EBP.
Findings/Outcomes: Utilizing a creative approach to implement change and promote EBP infused a sense of excitement and promoted clinical inquiry. It brought the research front and center in a format easily understandable and real to the frontline staff.
Conclusions: Numerous challenges persist in providing evidence-based nursing care. The gap between evidence and practice needs to be narrowed by the creative application of implementation science.
Implications for Practice: Clinical nurse specialists are critical in creatively implementing the evidence into everyday practice to achieve sustained outcomes.
Invisible Bruises: The Experience of Verbal Abuse for Women With Disabilities
Linda Carman Copel, PhD, RN, CNS-BC, NCC, CNE, FAPA, Villanova University, Pennsylvania
Purpose/Objectives: The purpose of this study was to explore the lived experience of verbal abuse endured by women with disabilities (WWDs). A phenomenological approach was utilized to address the research question: What is the lived experience of verbal abuse for WWDs? The research objectives were to (1) describe the experience of verbal abuse by WWDs, (2) determine if verbal abuse was an antecedent to additional abuse, and (3) construct a model explaining the experience of verbal abuse for WWDs.
Significance: Verbal abuse by an intimate partner is considered a health risk affecting the emotional and social well-being of women. Women with disabilities have reported that the occurrence of intimate partner violence (IPV) is related to their partner's inability to cope with their disability, physical limitations, or chronic health conditions. Verbal abuse is suspected to be an antecedent to IPV.
Design/Background/Rationale: There is a dearth of research on the experience of verbal abuse endured by WWDs. This study used a qualitative research design, phenomenology, to address verbal abuse as it was experienced by physically disabled women.
Methods/Description: The population was physically disabled women who experienced verbal abuse from an intimate partner within the past 2 years. A convenience sample of 24 women was recruited from support groups in a community agency. After informed consent was obtained, participants were interviewed and audiorecorded. Transcripts were analyzed using Colaizzi's method. All participants confirmed the transcripts and study results.
Findings/Outcomes: The findings included a description of the abuse experience. Six themes, accusatory comments, defensiveness, verbal or nonverbal responses, collision of words, escalation, and violent outbursts were identified. The women shared their abuse experiences and validated the proposed model.
Conclusions: Each woman described verbal abuse as a precursor to other types of IPV. A model was developed to explain her experiences of verbal abuse. Further research is necessary to support the model and determine its educational and clinical significance.
Implications for Practice: After additional validation, the model may be used to educate health care providers, WWDs, and their partners about verbal abuse as a significant health risk affecting a person's well-being. It has implications for explaining how verbal abuse contributes to relationship deterioration.
Journey to Improve Door to tPA Times for Stroke Patients
Sarah Badalamenti, MSN, RN, Banner Thunderbird Medical Center, Glendale, Arizona
Purpose/Objectives: The purpose of this project is to align our hospital with best practice standards for administration of tPA.
Significance: Primary Stroke Center Certification elements identify the need for efficiency in determination of eligibility for and adminstration of tPA to new-onset symptoms of ischemic stroke.
Design/Background/Rationale: This presentation will walk through the steps a stroke program coordinator utilized as a change agent with the stroke team to decrease the door-to-needle tPA times that were more than 90 minutes at the initiation of the project.
Methods/Description: This descriptive study utilizes the Banner Health Education ASSURE Outcome Model for change.
Findings/Outcomes: This study is in process and will outline our progress through the use of the ASSURE model phases of (1) analysis of need/issue (setting SMART goals); (2) survey investment variables, strategic initiative, assumptions, and external factors; (3) sequence, develop, and implement plan; (4) utilize the change accelerated process; (5) report immediate results of learning, and (6) evaluate long-term outcomes.
Conclusions: The conclusions/interpretations for this study will be based on both the change in door-to-needle tPA times for ischemic stroke patients and evaluation of the ASSURE process for this type of project.
Implications for Practice: Implications for this study include (1) utilization of best practice with the treatment of ischemic stroke patients receiving thrombolytic therapy with tPA and (2) lessons learned with use of the ASSURE process to implement a change.
Knowledge Development for the Doctor of Nursing Practice-Educated Clinical Nurse Specialists
H. Michael Dreher, PhD, RN, College of Nursing & Health Professions, Drexel University, Philadelphia, Pennsylvania
Purpose/Objectives: An ongoing debate is whether the doctor of nursing practice graduate should contribute new evidence for the profession. While the American Association of Colleges of Nursing's "Essentials of Doctoral Education for Advanced Nursing Practice" (2006) indicates graduates should only translate and disseminate nursing evidence, a growing number of practice scholars and doctor of nursing practice (DNP) programs are questioning this kind of restriction on advanced practice nursing student/graduate inquiry. The purpose of this paper is to move this debate forward and more formalize DNP scientific inquiry.
Significance: As many clinical nurse specialists (CNSs) are PhD prepared, and whereas many other master-prepared CNSs already actively participate in the conduct of research in their positions, it seems almost backward to mandate that the newly DNP-educated CNS not participate in new knowledge development.
Design/Background/Rationale: This is the first public presentation of a new model of scientific inquiry for nursing that indicates the DNP graduate may be best positioned to produce practice-based evidence knowledge (rather and evidence-based practice knowledge) or simply practice knowledge for the profession.
Methods/Description: This model, recently published in 2 texts ("Philosophy of Science for Nursing Practice" and "Role Development for Doctoral Advanced Nursing Practice"), proposes that DNP-educated APRNS or (DAPRNs) use the lens of practice inquiry (input) to use practice research methods (process) to produce practice knowledge (output).
Findings/Outcomes: The dimensions of the model emphasizing practice knowledge development will be the focus of this paper.
Conclusions: Arguments presented will assert that DNP-educated CNSs' (and other DAPRNs) stewardship for the nursing discipline is best realized when its graduates contribute practice knowledge, rather than other considered possibilities including practice inquiry, mode 2 knowledge, actionable knowledge, or even no new knowledge at all. Examples of practice knowledge from CNSs who have completed DNP programs will be highlighted, and a revisionist discussion of "what is evidence" as proposed by colleagues from the Joanna Briggs Institute will be presented.
Implications for Practice: Certainly, the ability of DNP-educated CNSs to innovate will be thwarted if their domain of scientific inquiry is restricted unnecessarily.
Measuring the Level of Moral Distress in Critical Care Nurses and Transitional Care Nurses
Nancy Bevan, MSN, RN, ACNS-BC, Jennifer McCord, MSN, RN, PCCN, CCRN, CCNS, Melissa Wilson, BSN, RN, Diana Goettemoeller, MS, RN, CCRN, Bethesda North Hospital, Cincinnati, Ohio (Bevan and McCord), University of Cincinnati College of Nursing, Ohio (Wilson), Wright State University College of Nursing and Health, Dayton, Ohio (Goettemoeller)
Purpose/Objectives: The objectives of the study are to examine the level and frequency of moral distress in staff nurses working in a medical-surgical intensive care unit and a transitional care unit in an acute-care hospital in the Midwest and to gather information to potentially guide future support, resources, and interventions for moral distress in staff nurses.
Significance: Nurses working in units where acute and chronic critically ill patients are admitted may encounter moral and ethical issues related to suffering and death. Moral distress has been described as painful feelings or psychological disequilibrium that occurs when nurses are conscious of the morally appropriate action a situation requires, but cannot carry out the action because of lack of time, lack of supervisory support, exercise of medical power, institutional policy, or legal limits. Moral distress can lead to nurse frustration and burnout, job resignations, and departure from the profession. When nurses experience moral distress, they may lose their capacity to care or fail to provide thorough care to the patient and family. In 2008, the American Association of Critical Care Nurses published a position statement on moral distress, calling it a frequently ignored problem in health care environments. The call to action for nurses is to recognize and name the experience of moral distress and to commit to using professional and institutional resources to address it.
Design/Background/Rationale: This study will be an exploratory descriptive design consisting of study participants completing the moral distress questionnaire. Subjects will rate the frequency and intensity of situations that could engender moral distress.
Methods/Description: Statistical analysis will evaluate the presence, amount, and type of distress experienced. Analysis of variance and multivariate analysis of variance will determine differences in the levels and type of moral distress. Regression analysis will determine if there are personal characteristics that predict the level of moral distress.
Findings/Outcomes: The study is in progress.
Conclusions: Findings will be disseminated at professional forums and submitted for publication. Results will guide the development of institutional interventions, resources, and support for staff nurses experiencing moral distress.
Implications for Practice: Identifying the degree of moral distress can lead to innovative interventions that improve quality of care and the overall health care environment.
Multidisciplinary Collaboration in Best Practices Leads to Outstanding Outcomes for Surgical Patients
Cynthia Stermer, MS, BSN, RN-BC, Stephanie L. McKoin, Abigail C. Strouse, Wellsapn Health, York, Pennsylvania
Purpose/Objectives: The purpose of this project is to optimize the integration of best practices in the care of surgical patients by implementing a multidisciplinary collaborative process to perfect Surgical Care Improvement Project (SCIP) core measure compliance and patient outcomes.
Significance: The SCIP began in 2005 with recommendations for the improvement of surgical care and the prevention of surgical complications. Despite this national quality partnership to promote the adoption of best practices to reduce the incidence of surgical complication, 40% of approximately 42 million surgical procedures result in complications each year. Patients who develop surgical complications are at risk for an increased length of stay and mortality.
Design/Background/Rationale: Our organization's clinical practice strategies focused on preoperative and intraoperative prevention. Strategies such as prophylactic antibiotic administration, appropriate hair removal, and temperature management have been shown to be effective in preventing surgical complications. We realized that, to reach optimal outcomes, prevention strategies needed to be implemented across the entire operative path for all surgical patients in all departments.
Methods/Description: Role owners for each core measure were designated, and roles defined to maximize health care provider and clinical staff accountability in meeting each core measure. A reference aid was used to provide education and resource information to key role owners. A core measure tool was created to provide concurrent monitoring of outcomes. Education to physicians, residents, nurse leaders, and clinical staff created a global awareness to promote a cohesive effort.
Findings/Outcomes: This process captures surgical patients in all clinical areas to provide the best clinical practices that encompass the entire perioperative and postoperative path to improve compliance with SCIP recommendations, which leads to better patient outcomes.
Conclusions: The system-wide designation of roles and responsibilities for implementing best practices creates a culture for the prevention of surgical complications. The collaboration between physicians and nursing staff results in exceptionally safe surgical care.
Implications for Practice: Collaboration between role owners leads to fewer surgical complications and decreased length of stay and mortality. Organizational commitment to best practices to ensure patient safety is evidenced by sustained core measure compliance.
Navigating the First Year: Enhancing Knowledge and Promoting Confidence among New-to-Practice Nurses
Kathleen Wiley, MSN, RN, AOCNS, Penn Medicine, Philadelphia, Pennsylvania
Purpose/Objectives: The objective of the study is to describe the intent and structure of an innovative clinical nurse specialist (CNS)-led support group for new-to-practice nurses.
Significance: New-to-practice nurses in oncology are faced with 2 major challenges. They must transition from the general focus on practice learned in school to specialized oncology nursing. They must further manage emotional strain of caring for acutely ill patients who decompensate quickly and have a high risk of death. Building confidence, creating support, and expanding knowledge are prerequisite to meeting these challenges.
Design/Background/Rationale: Current orientation procedures in our academic medical center include an extensive 12-week orientation. Analysis of hiring patterns, experience of clinical nursing staff, and needs of new-to-practice nurses serves as the impetus to develop extended formal structures to support nurses through their first year of nursing practice, resulting in the development of a CNS-led support group for new-to-practice oncology nurses.
Methods/Description: The support group meets 3 times each month. The first part of each session is education about an oncologic topic. The remainder provides an open forum utilizing guided discussion promoting self-reflection regarding challenging patient scenarios encountered. Nurses participate from employment start until 1 year after hire. After 1 year, the CNS mentors the "graduating" nurse in developing an educational presentation and facilitating a group session.
Findings/Outcomes: Although optional, sessions are well attended and receive positive evaluations. Survey results compare the quantification of perceived level of support received and confidence in nursing care of oncology patients during the first year of nursing practice. To suggest the sessions' efficacy in promoting support, confidence, and specialization, results yielded from nurses who participated in the support sessions are compared with those whose employment preceded the groups' initiation.
Conclusions: Working within the nursing sphere of influence, the CNS provides pivotal support in bridging the gap from novice to advanced beginner nurse and beyond. Although implemented by an oncology CNS, unit-based support groups are easily transferred to other specialties to foster socialization, specialization, and confidence in practice.
Implications for Practice: New-to-practice nurses benefit from innovative methods to increase support and confidence in caring for a specialized population. The CNS fosters professional development and confidence for them to reach maximum potential.
New Communication Technologies: Capacities and Advantages for Providing Useful Home Modification Information for Caregivers
Deborah Messecar, PhD, MPH, RN, GCNS-BC, Oregon Health & Sciences University, Portland
Purpose/Objectives: The purpose of this study was to examine the capacities and advantages of new communication technologies for providing useful home modification information for the caregivers of older adults.
Significance: As the population in the United States ages, a greater number of older adults will find that their preferred living situations-usually their own homes-are no longer are safe. Nurses who specialize in the care of older adults need to have a means of providing information about home modifications that can aide older adults and their caregivers.
Design/Background/Rationale: Home modifications can make caregiving for a cognitively impaired older adult easier. However, a lack of information about what types of modifications are available and how these modifications can be obtained and or installed has been identified by caregivers as a barrier to using this strategy. New communication media (particularly the Internet) could provide potential advantages over older media to inform decision making regarding home modifications.
Methods/Description: Nine focus group interviews with 43 caregivers were conducted to describe caregivers' satisfaction with their current sources of information regarding home modifications and to examine caregivers' reactions to existing (catalogs, commercials) and new media (Internet) formats for receiving information about home modifications.
Findings/Outcomes: Caregivers judged the usefulness of information according to several capacities of the delivery method. Good quality information was specific for the type of problem they were trying to solve, adequate to judge the fit for the older person, produced by a credible source, could be searched or accessed quickly, was limited to a number of well-suited options, and was available just in time when it was needed. Positive comments about catalog formats were that the format was familiar, and they were relatively easy to obtain. Limitations were the lack of tailoring to the specific problem and an overabundance of irrelevant information presented. Commercials improved caregivers' ability to judge the fit to the older person, but concerns were expressed about the credibility of the source if manufacturers produce the information. Younger caregivers and older caregivers registered different impressions about the advantages and disadvantages of Internet-based searching. Younger caregivers liked the convenience and flexibility of Internet searching, but complained about problems with information excess and inability to judge quality of the information. Internet-based information searching was not as popular among older caregivers who reported a lack of skill with searching the Internet and a preference for face-to-face interaction to online formats.
Conclusions: Surprisingly, the source of information caregivers found most useful was not from media components presented in the focus groups but from information provided by experts such as occupational therapists, experienced case managers, and/or other more experienced caregivers. However, many caregivers reported this source of information was not available to them.
Implications for Practice: New communication technologies are not a panacea for providing home modification information for older adults and their caregivers. Blended approaches that combine the human touch and these technologies are needed.
Optimizing Stroke Patient Care Across a Hospital System
Susan Fuhrman, MS, MSN, CCNS, RN-BC, Prohealth Care, Waukesha and Oconomowoc Memorial Hospitals, Waukesha, Wisconsin
Purpose/Objectives: The objective is to ensure that stroke patient care based on clinical practice guidelines was consistently delivered throughout a 2-hospital health care system.
Significance: Stroke is the third leading cause of death and the leading cause of serious, adult, long-term disability. The estimated direct and indirect cost of stroke for 2010 is $73.7 billion.
Design/Background/Rationale: Clinical practice guidelines have been published to promote best practice and patient outcomes. Delay in translation of research/practice guidelines to practice may hinder recovery and lead to higher costs and prolonged patient disability. Although both hospitals were already Joint Commission Certified Primary Stroke; there was an opportunity to improve system-wide care by implementing successful site-specific, evidence-based practices.
Methods/Description: The separate hospital stroke committees were combined into 1 team, and meetings were held across sites via videoconferencing. Common clinical practice guidelines to be used to guide practice across the system were adopted across sites. This multidisciplinary team developed the best practice tools (stroke program policy, documentation processes, forms, physician order sets, and staff education) that enhanced consistent practice and compliance with core measures.
Findings/Outcomes: Length of stay dropped, whereas compliance with stroke core measures as delineated by the Joint Commission has continuously improved, and both hospitals exceed the national average for compliance for all primary stroke centers. Both sites have also been recognized with American Stroke Association "Get With the Guidelines" achievement and quality awards.
Conclusions: Basing changes on national standards and clinical practice guidelines enhances buy-in for implementation. By having key stakeholders at the table at the same time across sites, opportunities for sharing, discussion, planning, and cooperation are significantly improved. Optimizing stroke care across the system improves the patient outcomes.
Implications for Practice: Utilizing this model, practice changes based on current research were able to be implemented in a matter of months rather than several years. This model will be utilized to expand the menu of system stroke services provided.
Predictors of Emergency Department Heart Failure Admissions
Anita Sherer, MSN, RN, PCCN, Willie Abel, MSN, RN, ACNS-BC, Patricia Crane, PhD, RN, FAHA, Moses Cone Health System, Greensboro, North Carolina (Sherer), Unversity of North Carolina at Greensboro, Greensboro, North Carolina (Abel and Crane)
Purpose/Objectives: The purpose of this study was to answer the research questions: What proportion of patients with heart failure (HF) was admitted through the emergency department (ED) on primary admission? What are the differences in those who access the ED with HF and those who do not? What variables predict accessing the ED for HF?
Significance: Heart failure is the second highest admitting diagnosis, and most are admitted through the ED. However, little is known about those who access the ED, and thus, we have no information to develop targeted interventions to improve quality of life and decrease admissions.
Design/Background/Rationale: A retrospective cohort study using medical record reviews at a large medical system was conducted with patients hospitalized with documented HF.
Methods/Description: Using a computerized random sample program; we selected 250 medical records of those admitted for HF within a specified period. A standardized data collection instrument was developed to capture selected data from the medical record.
Findings/Outcomes: The majority of admissions were via the ED (80%). No differences in history of myocardial infarction (MI) or coronary artery disease (CAD), atrial fibrillation, renal insufficiency, ejection fraction, insurance, number of discharge medications, body mass index, or serum creatinine were noted in those who were not admitted via the ED and those who were. However, being black ([chi]21 = 5.27, P = .02) younger age (t242 = 2.58; P = .01), and a brain natriuretic peptide (BNP) of more than 400 ([chi]21 = 3.83; P = .05) were associated with ED admissions. In the logistic model ([chi]27 = 23.46; P < .01), those with a history of MI/CAD (P = .011) were 1.7 times as likely and black patients (P = .05) were 1.6 times as likely to be admitted through the ED. Younger patients showed little change in admissions to ED (odd ratio, 0.97; P = .05).
Conclusions: The group that should be targeted for intervention are those with a history of MI/CAD, particularly black patients. Surprisingly, the criterion standard, ejection fraction, was not significant, whereas BNP was significant.
Implications for Practice: Examining the BNP rather than the ejection fraction may be warranted. To affect HF admission rates, clinicians should focus education on early symptom recognition, especially in black patients and those with a history of MI/CAD.
Preparation of the Community Health Clinical Nurse Specialist in an RN-to-MSN Bridge Program: Strategic Success
Lucille C. Gambardella, PhD, APN-BC, CNE, ANEF APN-BC, CNE, ANEF, Wesley College, Dover, Delaware
Purpose/Objectives: The purpose of this presentation is to demonstrate how the RN-to-MSN bridge curriculum provides an efficient and successful model for the RN without a BSN degree to transition to the role of a clinical nurse specialist (CNS).
Significance: As health care reform moves forward to implementation, the need for advanced practice nurses in community/public health will be key to creating successful access to care. There is an insufficient number of BSN graduates ready for graduate work; however, the pool of registered nurses with a diploma or associate degree in nursing who have practice experience are ideal candidates for the RN-to-MSN bridge model. This population of registered nurses can be a ready workforce for community health practice in a short period and be prepared to meet the needs of populations in communities across the country.
Design/Background/Rationale: Understanding the design of RN-to-MSN programs and the sound principles of adult education, these programs utilized as a foundation for the teaching/learning process can transform graduate education's preparation of the clinical nurse specialist. Although this presentation uses a model that prepares community health CNSs, this model template can be adapted to the preparation of a CNS in any specialty area. Furthermore, this model encourages the practicing RN to explore the value of educational mobility for future practice at the advanced level of care.
Methods/Description: The presenter will share the conception, implementation, and evalution of the curricular design in the RN-to-MSN model as experienced in the graduate program in community health at a college in Delaware. A discussion of the strengths and areas for improvement in the design over time with trended data will be shared, and suggestions for future growth explored.
Findings/Outcomes: Overall findings and outcomes for this curricular model design's success are well documented in the presentation of the evaluative data. Outcomes addressing graduate and employer satisfaction rates, licensing and certification success, and practice behaviors will be shared.
Conclusions: Clinical nurse specialist educators responsible for the development and implementation of graduate programs in all specialty areas will benefit from understanding the RN-to-MSN bridge model for educational mobility of current registered nurses who desire to move to the level of advanced practice care.
Implications for Practice: Implications for CNS education include (1) the ability to utilize an efficient, pedagogically sound model for preparing a CNS in a transformational bridge model in an RN-to-MSN curricular model design and (2) improving access to care by utilizing an RN pool in an accelerated learning format for preparation in the CNS role.
Prescription for Clinical Nurse Specialist Education: Take 2 Days and Come Back in a Month
Cathy J. Thompson, PhD, RN, CCNS, University of Colorado Denver, College of Nursing, Aurora
Purpose/Objectives: This session will describe the use of intensive class sessions for clinical nurse specialist (CNS) education.
Significance: Intensive sessions provide the benefits of classroom interaction, including professional networking, with a minimal commitment of on-campus attendance.
Design/Background/Rationale: Nurses, returning to school for advanced education, are challenged to accommodate work and school requirements. Clinical nurse specialist education, scheduled in a intensive format, allows the student to use the "extra" time not dedicated to classroom attendance to work on class assignments or to schedule clinical rotations.
Methods/Description: Intensive class sessions are scheduled for 2 full days once a month throughout the semester. Topics are identified by the new CNS competencies and include both role and population content. Teaching strategies include interactive lecture and case discussions, guest speakers, and student presentations. Online video and/or audio lectures are occasionally used for independent study and/or when content gets "pushed" due to time.
Findings/Outcomes: Lessons learned and challenges to intensive scheduling will be shared.
Conclusions: Intensive class sessions provide an effective format for CNS education.
Implications for Practice: Participants will leave the session with practical information to consider intensive class sessions in their institution.
Quality and Safety Education for Nurses and Clinical Nurse Specialist Practice
Gerry Altmiller, EdD, MSN, RN, La Salle University, Philadelphia, Pennsylvania
Purpose/Objectives: This presentation will introduce clinical nurse specialists to the Quality and Safety Education for Nurses (QSEN) competencies for graduate education, connect them to the clinical nurse specialist's spheres of influence, and provide resources and strategies to support this innovative work to emphasize continuous quality improvement and to create a culture of safety.
Significance: The work of clinical nurse specialists transparently overlaps the 6 competencies for graduate education, which include patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
Design/Background/Rationale: The QSEN collaboration, funded by the Robert Wood Johnson Foundation, was created in response to the Institute of Medicine's call to improve the quality and safety of health care. Their mission has been to transform nursing education by deliberately changing the focus of nursing's professional identity.
Methods/Description: They developed competencies that identified the knowledge, skills, and attitudes that are necessary to increase nursing's ability to address continuous quality improvement and safety for patients. Recently, the knowledge, skills, and attitudes originally developed for undergraduate education were adapted into competencies for advanced practice nursing roles with a clinical focus.
Findings/Outcomes: Clinical nurse specialists understand quality and safety concepts but would benefit from guidance for implementing and emphasizing these concepts in the clinical setting.
Conclusions: Providing educational tools that support the concepts of the QSEN competencies will allow the clinical nurse specialist to transfer this knowledge to nurses and implement standards that improve the quality and safety of the systems in which they work.
Implications for Practice: Clinical nurse specialists are well positioned to influence many in the transformation of developing a clearer understanding of quality improvement and cultures of safety in health care because of the reach within their spheres of influence.
Rise and Shine! The Postanesthesia Clinical Nurse Specialist Emerges
Nicole Hoke, MSN, RN, CCNS, CCRN, Hospital of the University of Pennsylvania, Philadelphia
Purpose/Objectives: The following presentation describes the innovative clinical nurse specialist (CNS) role developed for a postanesthesia care unit (PACU) in a quaternary urban academic care center.
Significance: Both the number and the complexity of outpatient and inpatient surgical procedures are on the rise in the United States. The rise in complexity accompanied by emerging novel medical technologies used in the private sector require competency and technical familiarity from nurses at multiple portals of entry.
Design/Background/Rationale: This highly specialized setting presents many unique challenges to quality and patient safety, issues best remedied through the unique domains of CNS practice. The nurse is challenged to provide safe competent care in an acute, fast-paced environment without the safety net of a conscious patient or family presence to offer collaboration. The PACU CNS role focuses on improving the patient/client sphere and the organizational/system spheres of CNS practice.
Methods/Description: In 2009, at the Hospital of the University of Pennsylvania, the surgical services served as a significant portal of entry, providing postoperative care to 14 000 patients. Both the volume and challenges in this unique setting presented an opportunity to ensure safer patient transitions to the inpatient setting, greater adherence to regulatory mandates, and the implementation of emerging national guidelines relevant to the perianesthesia care arena. The CNS role of clinical expert, mentor, and change agent established the framework for system-wide, comprehensive assessment and integration of improved care practices.
Findings/Outcomes: Successful role development and implementation were measured using national benchmark data focused on surgical and patient safety outcomes. In addition, the CNS role identified system issues related to care delivery and improved efficiency with measurable results.
Conclusions: In the PACU, nursing care is delivered in an extremely abbreviated time frame under highly demanding conditions. The PACU CNS established intradepartmental and interdepartmental collaborations and successfully implemented perianesthesia national guidelines while ensuring improved patient and family outcomes. The leadership, expert clinician, and change agent roles ensured sustained success.
Implications for Practice: Understanding the clinical impact of a PACU CNS improves patient safety and outcomes of this highly specialized population.
Clinical Nurse Specialist Evaluation Tool Supported With Benchmarks and Standards
Cathy Moore, MSN, RN, ACNS-BC, CCRN, Bayhealth Medical Center, Dover, Delaware
Purpose/Objectives: The "Clinical Nurse Specialist Evaluation Tool" project was developed to clarify the role of the CNS and establish expected CNS outcomes.
Significance: Clinical nurse specialists (CNSs) have a variety of specialties causing expected CNS outcomes to remain ambiguous. Individual CNS expectations and the organizational expectations for the CNS must be in alignment to improve nursing practice and patient outcomes. Health care leaders and stakeholders demand accountability for outcomes of patient care. Clinical nurse specialists must be very clear on their role within the health care organization and be accountable for outcomes at the unit and organizational level. Accepting accountability for the outcomes gives the CNS value and credibility within the health care organization.
Design/Background/Rationale: The CNS team at Bayhealth Medical Center reports to different directors, and expected outcomes for the CNS were not consistent and vague to some members of the leadership team and CNS. Currently, Bayhealth Medical Center has 10 CNS specialties.
Methods/Description: The CNS team developed the evaluation tool based on CNS spheres of influence and CNS subroles. The tool was developed to be appropriate to a variety of CNS specialties. The evaluation tool is objective and based on nationally recognized benchmark data. The outcomes on the evaluation tool also include data that are publicly reported by organizations under pay-for-performance programs.
Findings/Outcomes: The evaluation tool utilizes the 3 spheres of influence recognized by all CNSs: patient/family, nurse/nursing practice, and system/organization. Each section of the evaluation tool includes indicators based on traditional CNS subroles such as clinical expert, consultant, educator, researcher, and leader. The evaluation tool also includes outcomes for nontraditional CNS subroles such as practice barriers for nurses, patient satisfaction, Magnet preparation of nurses, and organization and staff professional growth. The evaluation tool allows the CNS to weigh the various sections according to the perceived priorities for the upcoming year. The ability to establish a weighted evaluation tool based on ever-changing organizational needs is vital to CNS success.
Conclusions: All CNSs at Bayhealth Medical Center are accountable for the same outcomes unless not relative to specialty.
Implications for Practice: The evaluation tool accommodates any CNS specialty by changing the indicators of the evaluation tool to reflect various specialty areas.
Studying the Effects of the End-of-Life Nursing Education Consortium at the Institutional Level
Phyllis Whitehead, PhD, APRN, ACHPN, Carilion Clinic, Wirtz, Virginia
Purpose/Objectives: The purpose of this quasi-experimental study was to assess the ongoing impact of the End-of-Life Nursing Education Consortium (ELNEC) training program on registered nurses' death anxiety, concerns about dying, and knowledge of the dying process utilizing the principles of the Comfort Theory and Practice by Kolcaba (2003) at the institutional level. The research hypothesis was that, upon completion of the ELNEC training, registered nurses would have decreased death anxiety, less concerns about dying, and increased knowledge of the dying process.
Significance: Unfortunately, dying in the United States continues to be associated with needless suffering with particular focus on "doing everything" with the maximal utilization of technology (Hammel et al, 2007; Paice et al 2007; Paice et al, 2006). Over the last 20 years, research has illustrated that there are major insufficiencies in palliative care education. Without appropriate end-of-life (EOL) education, it is impossible for nurses to provide adequate EOL care.
Design/Background: The Revised Death Anxiety Scale was used to measure death anxiety, which is a 25-item self-report questionnaire. The Concerns About Dying Instrument was used to measure death attitude or concerns about dying, which includes 3 distinct but related areas for providers: general concern about death, spirituality, and concerns about working with dying patients. Participant's perceived knowledge of dying was measured using a self-report 5-point Likert format, with "0" indicating no level of knowledge to "4" reflecting complete knowledge of death and dying.
Methods/Description: Pretests of all dependent variables were administered to both a treatment and control groups. Posttests were administered 2 weeks after the 2-day ELNEC training, at 6 months, and finally at 12 months to both groups to study its lasting efficiency upon participants at 1 primary care medical center.
Findings/Outcomes: Thirty-eight participants completed all 4 questionnaires, with 27 participants in the control group and 11 participants in the experimental group. Matched pair analysis with 11 participants in each group was conducted with statistical significance found for perceived knowledge about dying at post 2 weeks and 12 months (P = .01) for the intervention group. Death anxiety and concerns about dying were not found to be statistically significant at any testing interval, but mean scores of the treatment group revealed less death anxiety and concerns about dying.
Conclusions: Quality care throughout the continuum of life is promoted in hospital and other health delivery settings, but nurses can provide this quality care only if they are educated in EOL practice standards. Palliative care education is key to unlocking the mystery of why patients are dying in pain and with poor symptom management (Virani et al, 2008). Families will always remember those last moments of their loved one's life, so it is essential that nurses be empowered to minimize needless suffering while honoring their patient's EOL wishes and supporting family members through this journey (Virani et al, 2008).
Implications for Practice: Recommendations included offering the ELNEC training on a routine basis to all registered nurses who care for dying patients. In addition, clinicians and administrators were encouraged to seek out additional funding opportunities to plan more robust studies with larger samples, incentives, and research method triangulation, addressing the qualitative aspects of palliative care.
Teaching New Registered Nurse Graduates How to Shield Themselves From Lateral Violence
Gerry Altmiller, EdD, MSN, RN, Lasalle University, Philadelphia, Pennsylvania
Purpose/Objectives: The purpose of this study was to determine the effectiveness of an innovative strategy to break the cycle of lateral violence.
Significance: Lateral violence in the nursing profession is an aggressive act perpetrated by one colleague against another. It is evidenced by uncivil behaviors and is frequently perpetrated against the weaker members of the profession. Because of their known knowledge deficits and lack of experience, new nurses are particularly vulnerable to lateral violence. The Joint Commission has identified it as a threat to patient safety because it has the potential to interfere with the open and clear communication necessary to provide a safe patient environment. In addition, many nurses leave their staff positions because of this phenomenon. For those that stay, lateral violence that is left unchecked can become cyclical in nature, with the victimized individual eventually acting out these behaviors against new nurses entering the unit.
Design/Background/Rationale: Content analysis using focus groups for data collection was used.
Methods/Description: New-to-practice registered nurses (RNs) (N = 27) in their first nursing position after receiving licensure were provided 1 hour of education focused on the topics of professional behavior and lateral violence during their orientation, followed by 1 hour of education focused on how to shield themselves from lateral violence. Participants were provided 3 x 5-inch laminated cue cards that listed protective, nonaggressive statements to be utilized when confronted with the most frequent forms of lateral violence. After 1 year, they were brought together in focus groups to discuss their experience.
Findings/Outcomes: Findings indicated that this education strategy was useful to the new-to-practice RNs as it allowed them to respond to lateral violence intellectually rather than emotionally. In this way, they could interpret that the affront was not personal, which gave them the ability to stop laterally violent behavior.
Conclusions: Lateral violence is a threat to patient safety and causes distress to new-to-practice nurses. Education is an effective measure to combat the negative effects of lateral violence.
Implications for Practice: The clinical nurse specialist is in a unique position to impact lateral violence in all spheres of influence, decreasing the potential for patient errors due to poor communication, improving the work environment for nurses, and increasing retention of nurses for the organizations in which they work.
Clinical Nurse Specialist Translating Insulin Pump Policy Into Bedside Practice
Susan L. Dayhoff, MS, RN, CNS, Brenda A. Artz, RN, MS, CCRN, WellSpan Health, York Hospital, York, Pennsylvania
Purpose/Objectives: The purpose is to incorporate a safe and effective insulin pump algorithm of care for use by the health care team and the patient while in the hospital setting.
Significance: The clinical nurse specialist (CNS) is pivotal within an organization to collaborate with the health care team and patient to promote processes and outcomes that will incorporate best practices.
Design/Background/Rationale: Within a 558-bed community-based teaching hospital, there was an increase of patients being admitted to the medical surgical areas with insulin pumps. There were inconsistencies in physician orders and nursing documentation. A CNS-led team was instrumental in identifying the problem, coordinating a team, and initiating a process that would improve patient safety and self-management.
* Step 1: A clinical effectiveness interdisciplinary team designed an algorithm of care to assist nurses and physicians to safely care for patients with insulin pumps.
* Step 2: The CNSs retrospectively looked at 24 charts from January 2009 to June 2010 of patients with an insulin pump on the medical-surgical acute-care areas. Data were collected regarding appropriate physician orders and appropriate nursing documentation. The outcomes were suboptimal.
* Step 3: An educational plan was developed and implemented that included computer-based training and oral presentations to nurses and physicians.
After the program development and education, the CNSs now consult with staff, physicians, and endocrinologists on each patient admitted to the medical surgical areas.
Findings/Outcomes: Prospective data collection began July 2010. Data analysis will be completed prior to the conference.
Conclusions: Results of this study will establish the appropriateness of documentation and the safe and effective care of the patient with an insulin pump.
Implications for Practice: By incorporating evidence-based practice through an interdisciplinary clinical effectiveness team, the CNS will improve staff knowledge and staff performance and institute a valuable practice model.
A Clinical Nurse Specialist-Led Restraint Revolution: The Transformation of Nursing Knowledge
Gail Delfin, MSN, RN, CCRN, CCNS, Juliane Jablonsky, MSN, RN, CCRN, CCNS, Hospital of the University of Pennsylvania, Philadelphia
Purpose/Objectives: To improve and inform practice, a clinical nurse specialist (CNS)-led evidence-based practice (EBP) committee constructed a multifaceted approach to educate and support clinical nurses caring for patients requiring physical restraints.
Significance: Working toward the goal of a restaint-free environment, this university teaching hospital established an EBP nurse champion committee chaired by CNSs committed to the preservation of patient dignity and a safe and least restrictive environment of care.
Design/Background/Rationale: Care of the patient requiring restraints presents a conundrum for health systems as well as for clinical nurses. Health institutions are required to adhere to regulatory standards while supporting quality and patient safety initiatives. Nurses endeavor to balance critical-thinking skills while confronting practice issues of fluent documentation and product safety.
Methods/Description: A process is presented describing how the committee identified challenges and designed multidisciplinary approaches to augment best EBP restraint nursing care. This session defines the role of the CNS within the committee including, but not limited to, establishing partnerships, evaluating new products, mentoring nurse champions, and conferring with regulatory consultants.
Findings/Outcomes: This novel and comprehensive plan to maintain best restraint practice is correlated with reduced restraint prevalence over 3 years (1% per year), a high level of compliance to nursing documentation, favorable comparison to national quality data, and successful review by regulatory agencies.
Conclusions: The challenges posed by the care of the patient requiring restraints are multilayered and complex. The CNS conceptualizes the process by which the committee could best resolve both systems and practice dilemmas.
Implications for Practice: An EBP nurse champion restraint committee affords health care institutions the opportunity to address complex restaint practice issues and achieve quality outcomes. This approach is generalizable to other challenging practice issues; the CNS is in the unique position to favorably impact all spheres of influence.
The Newly Minted Clinical Nurse Specialist: Form Follows Function
Myra Cook, MSN, RN, ACNS-BC, CCRN, Kathleen Hill, MSN, RN, CCNS-CSC, Cleveland Clinic, Ohio
Purpose/Objectives: This presentation describes how one helps a bright graduate student transition into a clinical nurse specialist (CNS) who can make material contributions to patient outcomes and nursing practice.
Significance: There is sparse evidence describing strategies used by a CNS mentor to develop a novice student into a contributing advanced practitioner. The future of the CNS role and its contributions to patient outcomes greatly depend on successful and continued mentorship of novice CNSs prepared to contribute to the goals of quality patient care.
Design/Background/Rationale: This presentation details the impact of an intensive mentorship initiative that enhanced the ability of the novice CNS to improve patient outcomes. The mentorship program was strategically developed to foster a collaborative relationship that extended beyond the first year of CNS practice.
Methods/Description: The yearlong journey of a student and the CNS-mentor is presented. The student's ability to translate formal classroom and didactic content into clinically pertinent CNS activity in the critical-care environment is detailed. Included is a description of tools, journaling, and interpersonal skills used by the CNS mentor that were critical to the success of the project. The methods described can be readily translated to other specialty practices and organizations.
Findings/Outcomes: The authors detail the immediate, quantifiable outcomes derived when the match between CNS mentor and intern is maximized. Outcomes of this collaborative relationship included role expansion to obtain prescriptive authority, identification or reimbursement opportunities, expanded policy development, and successful project implementation.
Conclusions: The authors present a program that is practical, outcomes based, and relevant to clinical practice within a structured, nurturing framework.
Implications for Practice: The successes seen with this approach will encourage those in the position of hiring, orienting, supervising, or working collaboratively with the CNS. The program highlights innovative strategies to utilize the expertise of the seasoned CNS.
The Power of the Pyramid: A Proven Sepsis Implementation Program for Saving Lives
Kathleen Vollman, MSN, RN, CCNS, FCCM, FAAN, Advancing Nursing LLC, Northville, Michigan
Purpose/Objectives: The objective was to dentify vital behaviors, resources, and processes that have contributed to successful hospital-wide implementation of a severe sepsis program.
Significance: Severe sepsis and septic shock kill more than 500 patients a day in the United States. The international campaign to reduce the mortality of the septic patient finished in May 2009. The presented data showed a risk-adjusted mortality reduction of 5.4% when the severe sepsis change bundles were used. With more than 15 000 patients worldwide receiving the bundle therapies, why was there only a compliance rate for complete usage of the bundles of approximately 20%? How many lives could be saved if the bundles could be effectively implemented and adhere to within the health care institution?
Design/Background/Rationale: A 4-tier pyramid program model designed for a stepwise institutional implementation was developed and tested.
Methods/Description: The 4-tier pyramid model, including obtaining organization commitment that severe sepsis must be treated aggressively, implementation of triggers and tools to help the nurse identify severe sepsis early and respond quickly, protocols for implementation of the bundles, and lastly process and outcome measurements, was implemented in multiple settings as a clinical nurse specialist consultant. At each level, critical action/resource components were identified as essential for success.
Findings/Outcomes: Key implementation strategies for hardwiring the clinical and process behaviors must be in place for organization change to occur and clinical outcomes of greater than 60% compliance with an average absolute risk reduction in mortality of 10% to 15%. Barriers with reliable actions were addressed.
Conclusions: A robust 4-tier model with actions and deliverables at each level has resulted in the significantly greater compliance to care processes and reductions in mortality.
Implications for Practice: The clinical nurse specialist has the necessary skill sets to move within direct care/nurse development and system change spheres to successfully replicate the 4-tier pyramid program and reach similar results in their organization.
Clinical Nurse Specialist Driving Exemplary Practice and Clinical Innovation in a Magnet Organization
Sharon Gunn, MSN, MA, RN, ACNS-BC, CCRN, Sonya Flanders, MSN, RN, ACNS-BC, CCRN, Bobbi Leeper, MN, RN, CNS, CCRN, Baylor University Medical Center at Dallas, Dallas, Texas (Gunn), Baylor University Medical Center at Dallas, Richardson, Texas (Flanders), Baylor University Medical Center at Dallas, Dallas, Texas (Leeper)
Purpose/Objectives: The objective is to demonstrate how clinical nurse specialist (CNS) practice can help drive a Magnet organization.
Significance: Research has demonstrated that Magnet organizations have better retention, collaboration, quality nursing care, and patient outcomes (Drenkard, 2009; Armstrong et al, 2009). This presentation illustrates the value and contributions of the CNS in a Magnet organization.
Design/Background/Rationale: We will describe how the role of the CNS has evolved in our institution through the development of an Advanced Practice Registered Nurse (APRN) shared governance council. This council has provided an infrastructure upon which innovative and evidence-based nursing practices have evolved and have been implemented within the organization. We will describe the domains of the Magnet model and present CNS-related outcomes that specifically correlate with these domains and the 3 spheres of influence.
Methods/Description: The Magnet model embodies structure, process, and outcomes-and as such is intimately connected with the role of the CNS. We will provide examples of processes and outcomes specific to CNS practice within our institution and how these support our 1000-bed Magnet organization. Examples will include the role of the APRN council, CNS orientation, implementation of evidence-based practice, consultation and mentoring, collaboration, and related outcomes.
Findings/Outcomes: The ability of CNSs to drive evidence-based practice and nursing research within the organization is demonstrated through decreased hospital-acquired infections, implementation of practice bundles, and increased staff participation in nursing research. Working within the 3 spheres of influence, the CNS assesses, implements, and evaluates nursing practice to improve patient outcomes and drive the organization forward.
Conclusions: Clinical nurse specialist practice is integral and invaluable to Magnet organizations.
Implications for Practice: Implications are for CNSs to understand their unique contributions and Magnet criteria and identify innovative strategies for maintaining Magnet designation.
The Value of a Clinical Nurse Specialist to Nursing Leadership: A Phenomenological Study
Carolyn Horne, MSN, RN, BC, Marie Pokory, PhD, RN, East Carolina University-College of Nursing, Greenville, North Carolina
Purpose/Objectives: The purpose of this study is to understand the values that nursing leaders recognize within the clinical nurse specialist (CNS) role.
Significance: Each advanced practice role is valued differently. The CNS role struggles with questions of value. Other advanced practice nurses' value is due to revenue generation. The perceived lack of fiscal contribution makes the CNS role seem less important. Nursing leaders must balance good business practice and value. Daily decisions by leaders project internalized values. These values need exploration to understand how they affect decisions related to advanced nursing practice, particularly CNSs.
Design/Background/Rationale: This study used hermeneutic phenomenology of Gadamer to gain insight into the values held by nursing leaders in regard to clinical nurse specialists.
Methods/Description: After obtaining institutional review board approval, purposive samples of 3 participants with direct line authority of at least 1 CNS were selected. Individual, voice-recorded, open-ended interviews were conducted. Transcripts were transcribed verbatim. An audit trail, reflexive journaling, triangulation of data, and peer debriefing were used to maintain rigor. Analysis of the data followed the 5-step method of Taylor-Powell and Renner (2003).
Findings/Outcomes: Five themes were identified after immersion. The themes are core values, care practitioner, knowledge value, expertness, and relationship builder. Subthemes were also found. Subthemes for core values are reliability, trust, engagement, and willingness. Subthemes for care practitioner are population and resource. Knowledge value related to the transfer of knowledge and program knowledge. Expertness has 2 subthemes: clinical and translational expert. Relationship builder is described as bridging relationships among groups and building expert roles.
Conclusions: The 5 themes conveyed the value of the CNS role. The themes of this study were compared with Dr Peplau's work. The roles described by Dr Peplau are a mirror image of the themes emerging from this study. The one theme in this study that differed from Dr Peplau's was that of core values. The core values of this study describe the foundation of value of this role.
Implications for Practice: The study helps nursing leaders to view their internalized values of advanced practice positions. It also assists leaders to assess the position in terms of total value instead of only monetary gain.
Tipping Point for Decreasing Central Line-Associated Bloodstream Infections
Lenora M. Maze, MSN, RN, CNRN, Kamera Riggins, BSN, RN, Wishard Health Services, Indianapolis, Indiana
Purpose/Objectives: The purpose of this project was to assess central line-associated bloodstream infection (CLABSI) rates in Wishard Health Services intensive care unit (ICU) after the initiation of chlorhexidine gluconate(CHG) bathing.
Significance: Nosocomial bloodstream infections have an attributable mortality rate of 15%. The median age of death from from a nosocomail bloodstream infection is 57 years.
Design/Background/Rationale: Cleansing the skin with CHG prior to catheter insertion has been shown to greatly reduce the incidence of CLABSI in the ICU patient population. Central venous catheters (CVCs) are used extensively in the ICU and non-ICU patient population. Use of CVC is associated with substantial potential for producing iatrogenic disease, specifically bloodstream infections. Research has also demonstrated that the use of "bundles" can lead to a reduction in CLABSIs. Wishard Health Services had already implemented a central line bundle developed along Centers for Disease Control and Prevention guidelines by the Indianapolis Patient Safety Coalition. Central line-associated bloodstream infection rates remained well above external bench marks despite implementation of the central line bundle. After more literature review, Wishard Health Services initiated daily bathing of all ICU patients with CHG.
Methods/Description: Beginning in October 2009, daily bathing with CHG preparation for all ICU patients was initiated. Ongoing tracking of central line utilization days and cultures for bloodstream infections allow for analysis of CLABSI rates using National Healthcare Safety Network (NHSN) definitions.
Findings/Outcomes: Since implementation of CHG bathing, the rates for CLABSI at Wishard Health Services have decreased consistently below the NHSN benchmark. Rates for the first and second quarters of 2010 are down to a rolling rate of 2.5, which falls within NHSN benchmark of 3.6/1000 to 2.1/1000 line-days.
Conclusions: Initiation of CHG bathing along with the use of central line bundles has reduced CLABSI rates in the ICU patient population at Wishard Health Services.
Implications for Practice: Chlorhexidine bathing may be a useful adjuct in decreasing central line bloodstream infections.
Tracking Clinical Nurse Specialist Time for Producivity, Focus, and Research
Mary Fischer, MSN, RN, CCRN, PCCN, Sue Storey, MSN, RN, AOCNS, St Vincent Hospital, Indianapolis, Indiana
Purpose/Objectives: Clinical nurse specialist (CNS) work is complicated, varied, and often ambiguous to others. Clinical nurse specialists identify 5 roles and 3 spheres of influence. To evaluate, redirect, and balance priorities among the spheres and roles, regular attention to tracking is imperative. There is paucity in the literature regarding how to quantify the productivity of the CNS. As a result, an online time tracking tool was customized to demonstrate CNS endeavors.
Significance: The development of a time tracking tool serves multiple purposes. A continuous review of the CNSs' time tracking highlights areas of focus. In addition, it is imperative to demonstrate the value of the CNS. This is especially true during times of economic hardship, where nonbedside nursing is scrutinized. Lastly, it facilitates the performance evaluation process. As the CNSs complete their tool on a regular basis, there is immediate feedback, which allows for timely adjustments in focus of practice.
Design/Background/Rationale: A thorough search of available tracking tools was conducted. An online template was selected for its adaptability to the CNS work and ease of data entry including a "real-time function."
Methods/Description: The time tracking template was customized by 2 CNSs with input from the team members. In keeping with the Statement on Clinical Nurse Specialists Practice and Education, the projects were categorized as the 3 spheres of influence: patient, nurse, and organization, with the addition of a miscellaneous category. Tasks include roles of the CNS; educator, researcher, clinical practice expert, consultant, and leadership/influencer/change agent, with the addition of categories for personal/professional development and administrative.A grid was developed incorporating daily CNS activities. The activities were then placed in 1 sphere (project) and 1 role (task) simultaneously.
Findings/Outcomes: Data are being collected for the purposes of the CNS annual report demonstrating focus. Individually, the CNS and their direct report can use this tool for performance appraisal.
Conclusions: Current analysis of the past of tracking reveals a significant amount of time spent in the domain of clinical practice and in the sphere of nursing.
Implications for Practice: To strategize the work and impact of the CNS, current and future distribution must be understood. This is accomplished with the aid of a customized time tracking tool.
Zero Tolerance for Patient Discomfort: Clinical Nurse Specialist Initiative to Utilize Topical Lidocaine for Nasogastric Tube Insertion
Kimberly A. Fowler, MSN, RN, CNS-BC, PinnacleHealth System, Harrisburg, Pennsylvania
Purpose/Objectives: The clinical nurse specialist (CNS) mentored a novice nurse in the process of researching a clinical question. The question focused on the need for lidocaine during nasogastric tube (NGT) placement. The purpose of the presentation is to discuss how the CNS contributed to optimal comfort for a patient during NGT placement.
Significance: Successful NGT placement requires cooperation and trust of the conscious patient who is experiencing stress and discomfort. Evidence supported the use of topical lidocaine to provide relief of discomfort.
Design/Background/Rationale: The CNS promoted the use of the Iowa Model for Evidence-Based Practice to direct a unit-based project. The clinical question guided the literature review.
Methods/Description: The CNS facilitated a critique of the literature. A high level of evidence supported use of topical lidocaine. A recommendation was made to utilize atomized lidocaine and viscous lidocaine. Organizational support was obtained through our shared governance model, pharmacy, and the medical staff to develop a nurse-driven protocol. Following revisions to current nursing policies, the CNS developed an evidence-based fact sheet to communication the practice change to staff. Implementation occurred within adult, acute-care units in August 2008.
Findings/Outcomes: Six months of data collection revealed that 38% of patients had a previous NGT placed. Of this sample, 67% experienced less discomfort and gagging with the use of topical lidocaine. Nurses surveyed had previously inserted an NGT without the assistance of topical lidocaine, and 80% reported that the procedure was easier with topical lidocaine. One year after implementation, further evaluation of the process suggested a modification to the protocol to allow for less viscous lidocaine administration in the nostril. If needed, a second attempt in the other nostril could be utilized without reaching a maximum daily dose of lidocaine.
Conclusions: This CNS-led practice change impacted a basic patient right to pain management. Staff frequently reported, "This NGT was the easiest I have ever passed." Patients agreed that they experienced very little discomfort.
Implications for Practice: Clinical nurse specialists, operating in the 3 spheres of influence, are leaders in evidence-based practice changes. The CNS collaborates with interdisciplinary teams to impact positive patient outcomes and reduce patient discomfort during routine procedures while utilizing the Iowa Model.