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Clinical nurse specialist practice is essential in providing the clinical expertise, leadership, and organizational influence necessary for attaining the excellence in care reflected by the American Nurses Credentialing Center's Magnet designation. Clinical nurse specialists, prepared as advanced practice nurses, bring clinical expertise, knowledge of advanced physiology, and pathology and a system-wide vision for process improvements. This unique curriculum specifically prepares clinical nurse specialists (CNSs) to immediately practice as leaders of interdisciplinary groups to improve outcomes. Clinical nurse specialist graduates possess an understanding of complex adaptive systems theory, advanced physical assessment, and pathophysiology and knowledge of optimal learning modalities, all applicable to improving the health care environment. Their practice specifically links complex clinical data with multidisciplinary partnering and understanding of organizational systems. The basis for optimal clinical practice change and sustained process improvement, foundational to Magnet designation, is grounded in the combined educational preparation and systems impact of CNS practice. This article describes the role of the CNS in achieving and sustaining Magnet designation in an urban, academic quaternary care center. Using the National Association of Clinical Nurse Specialists model of spheres of influence, focus is on the CNS's contribution to improving clinical outcomes, nurse satisfaction, and patient satisfaction. Exemplars demonstrating use of a champion model to implement practice improvement and rapid adoption of optimal practice guidelines are provided. These exemplars reflect improved and sustained patient care outcomes, and implementation strategies used to achieve these improvements are discussed.
Clinical nurse specialist (CNS) practice has long been recognized as essential in establishing, maintaining, measuring, and ensuring the continuity of quality patient care.1 Attainment of Magnet recognition is considered a distinction reflecting high-quality nursing care and the overall processes used to deliver nursing care. Both the quality of care provided and the processes of care delivery are integral to attaining and maintaining Magnet designation. For agencies that are applying for redesignation, the narrative portion of the application must demonstrate complete enculturation of the improved care processes. Furthermore, the daily practice of the clinical nurses must demonstrate their awareness and active participation in designing and evaluating any attempts at improving care delivery. Use of the Magnet model directs clinical nurses, advanced practice nurses (APNs), particularly CNSs, and administrators to focus their efforts on improving the overall care delivery system. In addition, through monitoring multiple institutional metrics, including nursing-sensitive outcomes, the Magnet model provides a platform for continuous evaluation. The CNS's specific APN role is to provide group leadership and the local, unit-based, clinical expertise and leadership needed to influence and improve practice, both directly and indirectly through the clinical nurses' practice. To prompt further opportunities for performance improvement, the practice model must be continuously updated and relies heavily on APN input to validate the quality of care provided. The CNSs role models a lifelong commitment to learning, evidenced by their awareness and application of professional practice trends in pursuit of optimal patient care. Historically, performance measures were oriented on tasks, but recent literature includes references indicating the influence nursing processes have on improved quality.2,3
The purpose of this article is to describe the CNS's role in achieving initial and subsequent Magnet recognition, establish the essential link between Magnet designation and the domains of CNS practice, and describe the use of a champion model to positively influence patient outcomes at the Hospital of the University of Pennsylvania (HUP). Evidence of improved patient outcomes resulting from process improvements is provided, and patient care quality metrics necessary for Magnet designation are discussed.
The Magnet Certification Program is the highest level of recognition from the American Nurses Credentialing Center and recognizes health care institutions that provide the services of registered nurses. Originating in 1984, the Magnet designation program initially attempted to identify the factors that encouraged the retention of highly competent registered nurses in the workforce. Later iterations expanded to focus on the processes that result in providing quality patient care. During a revision in 2007, the 14 Forces of Magnetism (FOMs) were clustered into 5 components of Magnetism (Figure 1), clarifying how the FOMs systematically reinforce and synergize the attainment of excellence in nursing practice.3 The original 14 FOMs were coalesced into empirical domains, reflected in the 5 components.4 These 5 components are (1) transformational leadership, (2) structural empowerment, (3) exemplary professional practice, (4) generation of new knowledge through innovation, and (5) improvement and empirical quality outcomes.
This shift to quality outcomes resulted in a simultaneous shift to identifying the best and most relevant practice, signaling an understanding of the nurse's central role in culture transformation and their role in embodying and sustaining significant clinical change.5 The CNS roles of leader, clinical expert, and collaborator provide the clinical direction for efforts that result in improved patient outcomes. Redesignation as a Magnet facility emphasizes this shift, recognizing the Magnet framework as a means of organizing nursing services. Emphasis on the clinical nurse's role in transforming practice is essential, and the partnership between the clinical nurse and CNS practice is foundational to the transformation.4
The 3 spheres of CNS practice are the patient/client/family sphere, the clinical nurse sphere, and the organizational sphere (Figure 2). Originating from the Statement on Clinical Nurse Specialist Practice and Education,6 the domains of practice link the essential role of expert practitioner with systems transformation designed to improve patient outcomes. Considered fluid, dynamic arenas, the CNS domains of practice interplay within specialty practice and are based on specialty standards and knowledge. This dynamism demonstrates the flexibility within the CNS role to prioritize and respond to the unique needs of patients, staff, or organizations. The patient/family sphere subsumes the nursing and organizational systems, indicating the primary intent of influencing patient care and supporting excellence in outcomes, goals shared by the Magnet Recognition Program.4,7 Lacking a uniform role definition has been an advantage to CNSs in their pursuit of optimal role interpretation to achieve improved clinical outcomes. The CNSs operationalized the 3 spheres of influence to varying degrees, individualizing their role to best address the institutional needs. A reflection of the success of this individualization is noted by how nursing administrators value the influence of CNS practice in attaining Magnet status. Administrators recognize CNSs' compelling role as consultants and resources for expert practice and the unique capability of CNSs to influence sustainability by navigating the complexity in organizations.8 This navigation is integral to the enculturation required for redesignation as a Magnet organization.
Through their educational preparation, CNSs are poised to provide multiple levels of both direct and indirect advanced interventions, linking innovative and effective nursing strategies with optimized clinical outcomes. Graduate preparation provides the training in clinical practice. Their advanced training includes knowledge of physiological responses and disease management skills, foreshadowing and symptom recognition awareness, and techniques for reducing unplanned transitions and complication rates. Similarly, the CNS's unique didactic preparation includes specialized training on coaching, goal setting, and adult learning principles applied in a variety of formats. Cognitive restructuring required for complex multisymptom management9 and the development of self-care confidence10 is essential to ensuring transitions in care. This focus on advancing self-care management and self-care confidence is crucial to safely achieve the next level of care.
Magnet designation demands that certain criteria be met and mastered by the applying institution. The application process requires that exemplars be submitted that demonstrate nursing excellence across care settings.4 The CNS has a clear role in all of the 14 original FOMs, with several specific forces having particular relevance related to the synergy of evidence-based practice (EBP) and patient care outcomes. Successful engagement of the clinical nurse in developing and implementing EBP empowers the nurse's role, supporting these forces, resulting in improved patient outcomes and increased nurse satisfaction.
One method to engage the staff nurse is by placing them in fundamental roles related to an improvement effort, often referred to as a champion model. One of the most prominent demonstrations of a successful champion model can be found in the Six Sigma program.11 Used to transform processes, Six Sigma was developed to strategically improve organizational performance.11 Six Sigma aligns project management efforts with known performance deficiencies. Focused on cost, capacity, and customer service, multitudes of businesses have used Six Sigma methodology to identify issues and develop strategies to improve performance. In a Magnet model of shared governance, identifying issues is frequently informed by benchmark metrics, but methods of resolving and improving care processes are decentralized into unit-based leadership councils and unit-based champions. Champions are charged with dissemination of recommendations, auditing for compliance and reporting efforts and resolution to their peer group. Champion groups meet regularly, and records, tools, and summations are posted on the Web-based nursing home page. Once initial processes are resolved, essentially forming the Donabedian process-outcome-structure foundation of further improvement,12 new initiatives are identified by the champions and their peers. This evolving process is informed by the CNSs' knowledge of best practice guidelines and literature trends. This decentralization of power corresponds to Kramer's13 concept of "Control of Nursing Practice," limiting reliance on traditional hierarchical models that typically deliver "top down" control, and more firmly places the locus of control in the hands of the clinical nurse staff. This level of fundamental engagement empowers the clinical nurse to be a "champion" for an element of care that is considered key to their practice and critical to their patient. Kramer describes 5 attributes characteristic of control of practice. These attributes are (1) access to power, (2) participation, (3) recognition, (4) accomplishment, and (5) EBP initiatives.13 Successful improvement efforts using a champion model have included all of these 5 attributes. Improved practice outcomes have been described in multiple direct care and environment-of-care areas. Examples of improved outcomes include reduced medication errors,14 patient falls, and pressure ulcer formation or extension.15 Mentoring the frontline team was considered essential to success and sustainability, with particular emphasis on developing expertise in the quality improvement process. Furthermore, champion teams were empowered to assume leadership roles in identifying barriers to optimal care and developing customized policies and procedures to support change within their practice arena. Several prominent programs, notably the "Transforming Care at the Bedside" initiative sponsored by the Robert Wood Johnson and the Institute for Healthcare Improvement agencies, have formalized this transformation, relying on the successful transition of power from a central to a decentralized source for quality initiatives.13
This level of engagement improves the work environment, results in improved quality of care, and reinforces all elements of nursing as profession.10 Initial steps in empowering the frontline staff include creating practice structures focused on change, identifying measurable goals reflective of nursing practice, and providing sustainable collaborative leadership. These groups require leadership and mentorship from individuals who are expert clinicians, who hold key positions to effect system-wide change, and who are practiced at tailoring indirect influence with staff at varied levels: the CNS.
In 2005, prior to initiating the Magnet journey, at the Hospital of the University of Pennsylvania (HUP) the CNS group, with the support of senior leadership, established 7 EBP groups. The groups were charged to (1) evaluate the state of EBP within nursing practice, (2) implement standards of care for improving patient-centered (empiric) outcomes, and (3) engage clinical nurses in performance improvement at the point of care. Each group was charged to change practice by effectively addressing the topic of concern and expected to contribute to excellence in care delivery. Fundamental to achieving this goal was to gather a core group of clinicians, representative of each care area and armed with the latest knowledge and skills, to serve as unit resources and change champions. Topics of concern were chosen based on improvement efforts that affected either a patient outcome (prevention of complication) or improving a process affecting a patient outcome. Public reporting, regulatory requirements, pay for performance, patient expectations, and known system challenges were also compelling considerations in determining EBP groups' focus.
Evidence-base practice groups were formed with CNSs serving as chairs or cochairs with senior clinical nurses. Clinical nurses with experience levels ranging from novice to expert were recruited as participants. These groups met regularly with release time for either monthly or quarterly meetings a significant resource allocation. Staff actively engaged in meaningful problem solving, aligning the EBP groups with organizational goals, viewed as essential to successful transformation required for redesignation and the essence of the champion leadership model.14-17
During the initial meetings, members of each EBP group discussed their understanding of the reported outcome and their familiarity with the quality reports and metrics described. Proficiency in data analysis was considered an essential goal to a successful process. Next, using their its experience of barriers to improvement, the group collaborated with the CNS chairs in choosing the implementation strategies deemed most likely to be effective. Chairs informed the unit-based nursing leadership teams of the proposed plans for implementation and expectations regarding the champion's role in practice redesign.1 Individual nurse's performance in disseminating findings to their peers and their contribution to the EBP group solution finding were documented in exemplars for clinical advancement and included in annual manager and peer review and evaluations. Champions were expected to keep their clinical nurse peers informed and to actively disseminate both the unit's current outcome status and the proposed solutions. Champions often described their proactive efforts to facilitate change and embed process improvement in their care environments. Between meetings, individuals used e-mail, meeting discussions, and personal messaging to share successful implementation strategies and engaged in lively debate during meetings. Other intradisciplinary partners were included in solution development, and membership in EBP groups became a coveted role among the nursing staff. Successful EBP champion role implementation was evidenced by consistent meeting attendance, often requiring schedule planning well in advance of the meetings and a dedication to searching for solutions and reporting findings back to other staff members.
Initial champion activities, supported by the CNSs, included evaluating current evidence and literature, data collection, and analysis; suggesting innovations in practice; and communicating results. Later meetings included the use of appreciative inquiry, positive deviance, and coaching skills. Intrapersonal aspects of the change process were growth goals for the clinical nurses as well as CNSs. Individuals were more accustomed to action plans that were the purview of their individual departments. Planning and implementing strategies with intradisciplinary team partners, establishing and solidifying partnerships, and negotiating solutions cognizant of local work flow were challenging. Additionally, staff was challenged to engage their peers, and coaching, scripting, and role playing strategies were all demonstrated. To solidify group identity and foster collegial support, results were widely shared on both a unit and a system level. For issues determined to be "wicked problems" that required multiple efforts at local solution finding,17,18 champions collaborated intensely, rounded on outlier units, and demonstrated best practice bundling and auditing outlier cases. This strategy identified barriers unique to the individual areas, which were then collaboratively addressed using solutions devised by the EBP groups and the unit shared governance councils. Rounds persisted until improvements were sustained, with sustainability confirmed through ongoing surveillance by unit-based CNSs, who used monthly quality reports and daily infection surveillance to monitor for outcome excursions. Champions were expected to report in each staff meeting, and reports were forwarded to unit councils for monitoring. Individual nurses were expected to be responsible for the direct care they provided and the consequences of that care. By actively engaging the staff nurse in the process of translating evidence into practice, frontline staff have emerged to become frontline leaders. Taking EBP to the point of care and using principles of transformational leadership enabled improved and sustained outcomes, a process demanded by redesignation as a Magnet facility.
The central role of the CNSs as change agents was embedded in their activities orchestrating multiple aspects of the change model. The CNSs held global roles that ranged from supporting clinical nurses in performing guided reviews of the literature to devising strategy implementation, designing evaluation processes, monitoring and disseminating metrics, and establishing organizational partnerships. Metrics reflective of these improvements include a sustained reduction in the instances of hospital-acquired conditions such as infections and hospital-acquired pressure ulcers and improved satisfaction, both nurse and patient. Specifically, nurses' improved positive perception of their role as innovators of practice and champions of care was consequently linked to improved patient satisfaction through the Press Ganey survey system. Often, elements relevant to these same topics were part of the department of nursing leadership development series, a monthly presentation focused on professional development and clinical inquiry topics pertinent to the nursing leadership group. Unit council chairs also attended the presentations during bimonthly meetings with nursing leadership. Combining the educational presentations with leadership meetings ensured that unit council chairs shared the learning processes and that these process innovations were prioritized for the entire department, broadly disseminated throughout all levels of leadership.
Clinical nurse specialist EBP chairs shared their findings at monthly CNS forum meetings; disseminated meeting minutes, educational materials, and auditing tools; and supported units experiencing problems achieving their metrics. The CNS chairs shared their group's progress and learning and collaborated with unit-based CNSs charged with implementing the changes. This communication strategy, using the departmental leadership meetings, the unit council meetings, and the CNS forum meetings, allowed for the consistent development of the clinical peer leadership role while minimizing redundancy of effort. The unit-based CNSs were accountable to incorporate organizational imperatives on their assigned units and within specific patient populations. Initially, the CNS chairs focused their efforts on ensuring the leadership development of the clinical nurse cochair, emphasizing the importance of developing their own authentic leadership style. Evidence-based practice meetings were held either monthly or quarterly, a decision that reflected the optimal method for engineering change after considering the complexity of the issue. Champions became proficient at identifying complex process issues that would need to be resolved prior to attempting the change process.
For example, the EBP pain champion group met monthly for 2 hours, meeting after completing chart audits of nursing documentation of patient's pain level, interventions for pain, and reassessment of pain. Pain champions performed the chart audits, entered their findings into a central database, and then met to review new initiatives or policy developments. Barriers to innovation were examined through the lens of positive deviance; presentations often included descriptions of issues that emerged after engaging with different departments and diverse care areas. This focus fostered team building and awareness of other's work considerations while also disseminating findings. Often, areas that frequently interacted in providing patient care were fundamentally unaware of the work flow considerations in other areas. For instance, the postoperative recovery area did not use the same pain rating scale as the inpatient surgical critical care units, resulting in inadequate communication of the patient's pain experience. Groups worked to standardize practice to use the same rating scale, efforts that subsequently revealed an additional need for a nonverbal assessment tool.
Alternatively, the hospital-acquired infection groups (bloodstream, urinary tract, and ventilator-associated infections) and the pressure ulcer group needed a different strategy to affect improved clinical outcomes. These groups experienced more complex clinical intervention processes and relied on a mix of monthly update meetings and formal 4-hour quarterly meetings to ensure continued progress toward practice improvements. Meeting topics included product use and selection, guideline formation, and policy revision. Educational presentations focused on either a detailed examination of factors that could have potentially contributed to the infection or an aspect of wound or skin assessment. Meetings were deliberately constructed to improve champion's skill base, solidifying their role as a clinical resource for their peers. The meeting schedule coincided with the hospital-wide point prevalence data collection. Data collection required that the champions examine each patient present on the unit, review the nursing documentation related to skin risk assessment and interventions, and evaluate the adequacy of the documentation. Findings were entered into a central database, and results were made available within 2 weeks. Linking the provision and documentation of individual patient care with real time data collection confirmed the direct connection between care provided and resulting clinical outcomes. As improved practices were successfully embedded in unit culture, opportunities arose to address newly emerging priorities, shifting the EBP group focus to new quandaries, reinforcing the organizational commitment to improvement, and ongoing partnerships for optimal care.
The leadership role assumed by the CNS group in building strong relationships and high levels of employee engagement within the EBP groups was critical to improving clinical outcomes. The success of these groups resulted in dramatic and sustained improvements across several metrics, commonly considered hospital-based conditions. There has been an 86% reduction in the incidence of catheter-associated bloodstream infections (CA-BSIs); additionally, there has been a 47% reduction in catheter-associated urinary tract infections (CA-UTIs) (Figure 3). Many units have sustained a zero or near-zero incidence of CA-BSIs and CA-UTIs for several years. The improvement is credited to the successful implementation strategies, auditing, and surveillance efforts by the champions and the unit-based CNSs. The CA-BSI and CA-UTI groups found that areas of high infection rates required an in-depth examination of all aspects of care, from insertion techniques to daily dressing types to order sets indicating need for ongoing catheterization. The CNS chairs were diligent, with their efforts ranging from surveying operating room staff insertion techniques, trialing new dressings, and noting the potential for invasive line caps to harbor bacteria, to suggest just a few of the areas they pursued (Table). Chairs were excited to describe champions' growing willingness to consider and suggest innovative care modalities.
As another example of the effectiveness of the EBP groups' work, in the past 3 years, annual hospital-acquired pressure ulcer prevalence decreased 39%. Overall, the annual percentage of total hospital-acquired pressure ulcer prevalence at stages 3 and 4 significantly decreased during this time as well (Figure 4). These whole-sale reductions reflect successful organizational-wide dissemination of changes in practice. Improvement occurred in stages with measures adopted at rates that reflected the contextual factors identified by the champions. It became clear that context greatly informed and influenced care delivery. Despite the many setbacks and discouraging moments they encountered, the EBP chairs and champions remained committed to continually and effectively engaging the clinical staff. Often, this required approaching clinical nurses, nursing assistants, and ancillary services individually, and their role and their relevance to the patient's care emphasized. This recognition of personal accountability for care processes ushered in the level of engagement required for improvement to occur and innovation in care to emerge. These process improvement techniques have been fully adopted, and the processes used to deliver complex, highly technological, and specific care to acutely ill populations were validated as effective. The CNS role greatly facilitated the success of these initiatives.
Two databases were used to specifically measure patient and nurse satisfaction. Nurse satisfaction was measured using data from self-reported satisfaction surveys, through the National Database for Nursing-Sensitive Outcomes (NDNQI),19 survey tool. Patient satisfaction was measured using the Press Ganey measurement tool, a self-report survey developed by the Press Ganey Corporation, an independent market survey corporation.20 Results from the NDNQI survey indicate that nursing satisfaction across the institution has risen favorably, particularly in the areas of availability of professional development and their perception of the professional status of nursing. Adding to the testimony that clinical nurses have a strong desire to provide competent care,17 our nurses favorably view their professional development in terms of the presence of career development opportunities, access to CNSs as clinical experts and mentors, access to continuing education programs, access to in-services and conferences, and opportunities for career advancement (Figure 5).
In the NDNQI category of perception of their professional status, our nurses have provided sustained favorable feedback regarding their contributions to a sense of personal achievement, the hospital as a good place to work, overall hospital employee appreciation of their work, and their pride in discussing their work with others. Similarly, nurses' perception of their professional status was influenced by their engagement in clinical care decision making. Their role in improving clinical outcomes increased their empowerment and contributed to sustained favorable feedback regarding their contributions. They reported (1) an improved sense of personal achievement; (2) that they viewed the hospital as a good place to work; (3) they felt, overall, that other hospital employees appreciated their work; and (4) finally, they had pride in discussing their work with others (Figure 5).
The synergy resulting from the increased clinical nurse engagement and increased RN satisfaction scores was also reflected in the area of patient satisfaction. The implementation of the champion model correlated in an increase in the patient satisfaction scores, presumed to be related to the nurses' stronger role in developing direct care practice and recognition of their role in maintaining the patient's well-being. A strong relationship exists between employee satisfaction and patients' perceptions of the quality of their care, measured in terms of their intent to return and to recommend the hospital to others.17,21 The organization has experienced a near 10% increase in raw score patient satisfaction data as reported by the Press Ganey survey tool (Figure 6). The metric indicating patient satisfaction with overall nursing care has continued to increase in parallel with improvements in quality metrics and RN satisfaction, as seen in Figure 7.
The success of our strategic collaboration between CNS experts and emerging clinical champions is further evidence that organizational change cannot occur unless appropriate strategy is in place to support needed cultural change. Findings suggesting that system leaders play a crucial role in establishing the needed infrastructure for organizational learning were also replicated by our experiences and reinforced a spirit of experimentation and innovation.17
The CNS role is essential to implementing innovation and sustaining improved patient outcomes, integral components to the Magnet Recognition Program. The CNS role broadly and specifically supports the process by which care is delineated, changes made, and improvements noted. The CNS leadership and clinical expertise support the critical moment when a nurse, functioning in the broadest sense of the knowledge worker role, contributes his/her expertise to determine a patient's course of care. Based on the clinical decision support tools available, the nurse's decision profoundly affects the course of patient care. The expert clinical practice of the CNS is a significant tool, supporting professional practice and the delivery of world-class, evidence-based care. Magnet designation is an acknowledgement of the care process enabling a clinical nurse's ability to provide high-quality care. The CNSs practice, heavily embedded in the leadership, consultant, and collaborator roles, results in improved empiric outcomes. These outcomes result from systematic, organizational change and reflect a new organizational culture related to practice and patient care. The CNSs are uniquely qualified for the complexity of acting as a change agent and have the knowledge, leadership, and implementation skills to lead in providing improved patient-centered outcomes.
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