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Diabetes – Summer 2012
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Coffie SD, Froedtert Hospital, Milwaukee, Wisconsin; Fulton J, Knisely M, Indiana University, Indianapolis; Levitt F, St Vincent Hospital, Indianapolis, Indiana
Symposium Overview Abstract: Precepting future clinical nurse specialist (CNS) graduate students can be a challenge for a busy CNS. The experience of teaching in the clinical setting may be described more by trial and error than a defined process. Having targeted strategies, specific tools and appropriate resources to help guide the CNS student could enhance the clinical experience and set the stage for role actualization. Clear and open communication between the faculty, clinical site CNS preceptor and student is critical. This triad partnership should be grounded in programmatic academic standards, clinical role definition, and student learning needs. This symposium will describe 3 roles important to the student experience and share how creating an infrastructure for learning grounded in the NACNS core CNS competencies can serve as a platform for role preparation. Objectives will be met by presentations from CNS faculty, 2011 and 2012 NACNS Preceptors of the Year, and a CNS student. Session content will include triad role definitions, preceptor selection, clinical competencies, and course evaluation. Attendees will gain innovative approaches to enhance a successful clinical experience such as tools to support the clinical experience, student matching, on-boarding, transition from academics to clinical practice, and achieving learning outcomes.
Coffie SD, Froedert Hospital, Milwaukee, Wisconsin; Levitt F, St Vincent Hospital, Indianapolis, Indiana
Purpose/Objectives: This presentation will explore the preceptor's perspective for an effective student-preceptor relationship during the clinical experience. Strategies for successful clinical nurse specialist (CNS) precepting utilizing NACNS core CNS competencies will be shared by NACNS Preceptors of the Year. The CNS preceptor role of the Triadic Partnership Model of faculty, CNS preceptor, and student will be discussed.
Significance: The role of the CNS is critical to clinical outcomes and staff development. Students need real life clinical experiences to provide opportunities for learning the core CNS competencies to promote personal and professional growth. The preceptor-student partnership should be fluid with mutual exchange of knowledge and experiences. Clinical nurse specialist preceptors pave the way for student learning by setting clear expectations and responsibilities to promote a positive relationship. A thoughtful approach for developing CNS students will aid the clinical experience and set the stage for transition into clinical practice.
Background/Rationale: A triad partnership is foundational for successful site learning experience, growth, and development of students entering into complex healthcare environments. Little has been published on the attributes of an effective CNS student preceptor. The core CNS competencies offer a framework to precept the CNS student and aid student experiences while focusing on patient outcomes. The NACNS awards the CNS Preceptor of the Year showcasing the significance of coaching, mentoring, supporting, encouraging, and inspiring students. This symposium will explore and share the characteristics of a CNS preceptor and provide tools to support the clinical experience.
Description: A primary function of the CNS preceptor is to teach the student to gain mastery of and incorporate the core CNS competencies utilizing relevant resources to promote role development. Preceptor responsibilities include open and honest communication, planning experiences, providing feedback on projects, focusing on evidence-based practice, critiquing interactions with patients and staff, leadership development, reflection, identifying opportunities for growth, and evaluation.
Outcome: Preceptors should be role models of CNS practice and enhance the student's experience by embracing the Triadic Partnership Model and the core CNS competencies to achieve clinical proficiency. Preceptors should be setting the stage for clinical portfolio development, reviewing course objectives, soliciting student goals, setting clinical schedules, offering guidance to the student project selection, and completing thoughtful evaluations. By the conclusion of the clinical rotation, the CNS student should be able to implement key behaviors within the core competencies.
Interpretation/Conclusion: Clinical nurse specialist preceptors play a pivotal role in the progression of the CNS student's education and clinical goal attainment. In the role of clinical site supervisor, the decision to be a CNS preceptor requires thoughtful discernment and full engagement.
Implications for Practice: A positive preceptor-student experience will foster confidence and courage in the CNS student. This partnership can offer growth for both the preceptor and the student through tailored clinical experiences as preparation for the student's successful entry into practice.
Fulton JS, Indiana University, Indianapolis
Purpose/Objectives: This presentation will explore the faculty role in the Triadic Partnership Model for the design, delivery, and evaluation of clinical experiences for clinical nurse specialist (CNS) students. Strategies for working with CNS preceptors to achieve learning objectives in the clinical setting are discussed.
Significance: Supervised clinical experiences are required elements of a CNS curriculum. While the experience takes place in a clinical setting under the direct supervision of a preceptor, faculty members are responsible for ensuring all elements of the clinical learning experience meet standards for CNS education.
Background/Rationale: The Triadic Partnership Model assumes a balanced partnership between faculty, preceptor, and student for clinical experiences where faculty enters into the partnership as equals. Faculty share responsibility for ensuring the adequacy of the partnership in meeting learning objectives. The model facilitates student achievement of the core CNS practice competencies within a minimum of 500 supervised clinical practice hours with a qualified CNS preceptor.
Description: Faculty responsibilities for the clinical precepted learning experience include determining learning objectives for each clinical experience, determining evaluation parameters, developing criteria for clinical preceptors, ensuring qualified clinical preceptors and settings are available, matching student interests with preceptor interests and abilities, communicating with preceptors, and evaluating preceptor and student performance.
Outcomes: The NACNS core CNS clinical competencies guide the student learning experience. Students complete a clinical portfolio based on core practice competencies identified for each clinical course. Performance is reviewed by the preceptor, student, and faculty. To support preceptor development, preceptors complete a faculty developed online preceptor program prior to beginning in the role of CNS preceptor. Students formally evaluate preceptors and the setting; data are aggregated and shared with preceptor and CNS program faculty. All preceptors are reviewed annually, and names and contact information are kept in a school database. Annual meetings between CNS program faculty and preceptors facilitate dialogue about ongoing curricular and practice needs and concerns.
Interpretation/Conclusion: Faculty members are responsible for developing clinical preceptor programs that meet the learning needs of students and prepare them to achieve the core CNS practice competencies. Preceptors provide on-site clinical supervision for CNS students and are partners in delivering curriculum. Faculty must be attentive to addressing the development of preceptors and to ongoing communication.
Implications for Practice: The Triadic Partnership Model that explicates partnership between faculty, preceptor, and student can serve as a guiding framework for supporting CNS students in achieving clinical competency.
Knisely M, Indiana University, Indianapolis
Purpose/Objectives: This presentation will explore a student's perspective of an effective student-preceptor relationship. Strategies for selecting and working with a preceptor to achieve learning outcomes through a successful clinical experience are examined.
Significance: Clinical experiences provide opportunities for learning future CNS practice. Experienced clinicians serving as preceptors are critical to the students' learning. A positive triadic partnership and an organized approach in the clinical setting can lead to meaningful role preparation.
Background/Rationale: To achieve the core CNS practice competencies, students must complete a minimum of 500 supervised clinical practice hours with a qualified CNS preceptor. Clinical experiences in a CNS program are conceptualized as a triadic, balanced partnership among the faculty, preceptor, and the student where the student has equal responsibility for achieving learning outcomes. In this partnership, students take responsibility for codeveloping learning goals, communicating expectations to preceptors, and evaluating course and clinical achievements.
Description: Student responsibilities for the clinical learning experience include self-reflection for identifying desired outcomes of the experience including determining characteristics of a preceptor to maximize learning, negotiating with a preceptor to create the clinical experience, seeking and providing timely feedback during the experience, and thoughtful evaluation of the experience once completed.
Outcomes: The student should (1) plan, write, and communicate objectives to achieve during the clinical experience; (2) identify important characteristics sought in a preceptor; (3) promote open communication and feedback with preceptor; (4) create and negotiate a schedule with preceptor and identify desired clinical experiences; and (5) evaluate preceptor, clinical experience, and self at the conclusion of the clinical experience.
Interpretation/Conclusion: The CNS student must take responsibility in developing learning goals, communicating expectations to preceptors, and completing a thoughtful evaluation of the clinical experience. Fulfilling these responsibilities will lead to successful completion of clinical hours, achieving desired goals, and facilitating a positive student-preceptor relationship.
Implications for Practice: Both the student and CNS preceptor must assume an active role in the learning process. Effective clinical experiences for the student will prepare them to succeed in future CNS roles.
Klinkner G, University of Wisconsin Hospital & Clinics, Madison
This symposium is intended to highlight the influence that clinical nurse specialists (CNSs) have on patients, nurses, and organizations. Learners will hear about the innovative and collaborative efforts of CNSs to illustrate their impact on departmental and organizational goals. Clinical nurse specialists lead improvement initiatives that focus on organizational and population health goals. System-wide projects reveal additional areas for improvement such as new nursing practices and interdisciplinary collaboration. This symposium presentation includes a focus on a system-wide approach of tracking CNS outcomes work. Additionally, 2 specific project examples will recognize CNSs' unwavering commitment to patients, families, and communities.
Purpose/Objective: The purpose of this work was to pilot a patient-centered diabetes concerns assessment for hospitalized patients who have a self-reported history of diabetes.
Significance: Currently, no assessment tools addressing diabetes psychosocial needs exist for use in an acute care setting.
Background/Rationale: Acute care nurses report that diabetes education is time-consuming and challenging to provide because of a number of factors including lack of time to teach, lack of knowledge or skills to teach, and patient factors (ie, too sick, learning barriers). The DAWN (Diabetes Attitudes, Wishes and Needs) study revealed the following: a more patient-centered approach to diabetes care positively influences self-management outcomes, and assessment tools should be used that elicit patients' needs and concerns related to living with diabetes so that providers can better understand and address barriers to diabetes self-management.
Description: An assessment tool previously published for use in ambulatory care settings was modified, with permission for use, in an acute care setting. A general medicine unit was selected to pilot the assessment tool. Nurses were educated about the rationale for the Diabetes Concerns Assessment and how to implement the tool. Nursing staff were surveyed before and after the intervention, and patient responses to assessment questions were evaluated.
Outcome: Nurses reported increased comfort when using the tool to assess diabetes concerns. They reported greater certainty about the focus of patients' concerns and were more certain that these concerns had been addressed. Nurses also had a greater awareness of documentation tools available in the electronic medical record. The Diabetes Concerns Assessment tool elicited rich responses from patients about their concerns related to living with diabetes.
Conclusion: Assessing concerns about living with diabetes uncovers potential barriers to self-management; however, patients may not be comfortable discussing concerns. When patients are willing to share their concerns, structured processes must be in place to address those concerns. Lastly, it is important to incorporate a diabetes-focused assessment that can be done quickly and within nurses' usual workflow.
Implications for Practice: Clinical nurse specialists impact nursing practice and patient outcomes by merging their clinical expertise and knowledge of the evidence with patient preferences and values. Assessing patients' psychosocial needs related to living with diabetes not only helps patients, but also may significantly help nurses to focus on patients' priorities and barriers to improved outcomes. Additional work is needed to incorporate such assessment tools into electronic health records.
Klinkner G, Arsenault K, Hunter J, Purvis S, University of Wisconsin Hospital & Clinics Madison, Wisconsin
Purpose/Objective: The purpose of this work was to design a tool to communicate CNS outcomes.
Significance: Clinical nurse specialists have always been innovators of healthcare change. As patient and system outcomes are increasingly being scrutinized and evaluated, CNSs must be able to quantify and communicate their contributions to high-quality, safe patient care.
Background/Rationale: More than 30 CNSs are employed at this Magnet-accredited level I trauma center and academic medical center. Despite various reporting tools used by individual CNSs to capture activities and outcomes, there was not a single document to represent outcomes of all CNSs. The lack of a centralized reporting tool creates challenges for goal setting and communication about how CNSs contribute to organizational goals. Furthermore, nursing executive leadership may have difficulty articulating CNS practice achievements to nonnursing colleagues without such a document.
Description: A subset of CNSs, from a variety of settings, collaborated to design a tool that could capture CNS activities and related outcomes utilizing the framework of CNS core competencies. Process and outcome measures along with any known financial implications were included for each clinical example inserted. After multiple workgroup meetings, the larger CNS group provided feedback about how to progress to next steps. Decisions were made about content to include and exclude as well as how to organize the document. All CNSs had the opportunity to insert their own activities for the fiscal year. The comprehensive document was then summarized and shared with nursing executive leadership.
Outcome: The outcomes of this project included a unique tracking tool and summary document used to capture CNS outcomes across the organization. This work led to discussions among CNS colleagues about role differences and similarities as well as the lack of resources to quantify the financial impact of CNS work. Clinical nurse specialists learned from each other and became more motivated to utilize the tracking tool. Clinical nurse specialists are also more actively considering how to quantify outcomes for future projects.
Conclusion: Despite the large number of CNSs and the incredibly varied environments and job duties of CNSs in the group, many commonalities were found in terms of goals and objectives. A collective CNS outcomes document brings these commonalities into focus and helps to clarify the extensive contributions of the CNS group. Initial feedback from nursing executives has been very positive, especially with regard to linking CNS outcomes to strategic goals. Clinical nurse specialists will have access to the document throughout the year and be expected to add content so that a yearly report can be summarized. Improvements will be made as the tool is utilized and critiqued.
Implications for Practice: Creating a framework for quantifying CNS outcomes can support improved goal setting by individual CNSs and by the CNS group as a whole. Cohesion of CNSs may also improve by working together to summarize outcomes related to the 3 spheres of CNS influence. Clinical nurse specialists who participate in such work may find that despite varied specialties, professional activities, and outcomes, commonalities can be found and more succinctly communicated to organizational leaders.
Schoenwetter K, University of Wisconsin Hospital & Clinics, Madison
Purpose/Objective: The purpose of this work was to provide education to skilled nursing facility staff to enable them to care for medically stable patients with chest tubes.
Significance: Clinical nurse specialists are in a position to decrease hospital costs and shorten hospital length of stay (LOS) by sharing their clinical expertise with colleagues outside the hospital setting.
Background/Rationale: It is not uncommon for patients to develop persistent air leaks or excessive fluid drainage following thoracic surgery. Studies have shown that medically stable patients with chest tubes can effectively be cared for at home, especially if chest tube management was the only need for hospitalization. Prior to project implementation, no skilled nursing facilities in the state would accept patients with chest tubes. Therefore, many patients remained hospitalized until their air leak resolved or until their drainage decreased enough to remove the chest tube. This led to prolonged hospital days, increased costs, and patient and surgeon dissatisfaction.
Description: The cardiothoracic case manager attended a conference during which representatives from multiple in-state skilled nursing facilities were asked if they would consider taking patients with chest tubes if proper education was provided. Those interested were subsequently contacted by the thoracic CNS. The CNS scheduled education sessions with each facility during which both interactive and written education opportunities were provided.
Outcomes: Within a 6-month period of time, the thoracic CNS met with different skilled nursing facilities, and now Wisconsin has 23 skilled facilities that are willing to accept medically stable patients with a chest tube. Between June 1, 2011, and June 1, 2012, 56 people were discharged with a chest tube following thoracic surgery. Of those 56 patients, 6 (11%) were successfully discharged to a skilled nursing facility; 0% of those patients were readmitted to the hospital. Discharging to skilled nursing facilities is estimated to save on average 5 hospital days, which can translate to a savings close to $6000 per person. Patient and surgeon satisfaction also increased.
Conclusions/Interpretations: The CNS role is essential to facilitate improved patient care and system processes. By reaching out to skilled facilities statewide and offering education on chest tube management for medically stable patients, hospital LOS was decreased with an average cost savings of $1200 per day per patient. Patient and surgeon satisfaction increased as LOS was decreased, and patients were able to transition care closer to home.
Implications: As hospitals work to decrease LOS and provide more cost-effective healthcare, collaboration between hospitals and skilled nursing facilities is essential. The CNS has the unique ability to ease transitions in care by identifying gaps in practice and by providing education and expertise to bridge those gaps.
Richardson J, Atherton S, Holmquist J, Loudon T, Portland VA Medical Center, Oregon
Overview/Abstract: In the current climate of healthcare reform, members of the healthcare team are increasingly encouraged to visualize patient care across the entire care continuum: from the outpatient medical home in primary and specialty care, through the various levels of an inpatient admission, possibly through a rehabilitative stay, and then back to the medical home. Although patient care and practice improvements have been traditionally segmented into specific care areas, it is critical to recognize that it is not only within these care areas but between them that quality improvement efforts must be focused. These care transitions represent not only a physical change in venue but usually a change in care providers as well. Unfortunately, adverse events have been associated with these handoffs in care, and there are a multitude of staff and system-related causes. Deficits in communication and information transfer have been identified as increasing the potential for errors. Often, the patient is not included in developing the plan of care and may have different goals from the healthcare team. And staff from specific care areas debate over who has responsibility for this transitional care. The clinical nurse specialist (CNS) is uniquely positioned to develop, implement, and sustain a structured, comprehensive approach to improve patient outcomes during these handoffs in patient care. Within this symposium, 3 CNSs with diverse responsibilities from an integrated healthcare system will each address how they have been able to impact patient outcomes across a specific care transition. Highlighted CNS projects include implementation of the Modified Early Warning System in the inpatient setting (critical care CNS), transmission prevention of Clostridium difficile and methicillin-resistant Staphylococcus aureus in acute and long-term care (infection prevention CNS), and postdischarge follow-up (primary care CNS).
Atherton S, Holmquist J, Portland VA Medical Center, Oregon
Significance: Implementing isolation precautions for patients colonized or infected with multidrug-resistant organisms (MDROs) such as methicillin-resistant Staphylococcus aureus (MRSA) or Clostridium difficile infection (CDI) is necessary to prevent healthcare-associated infections (HAIs). Processes for assessing need for isolation precautions and implementation of those precautions at each transition of care, paired with reliable communication systems, enhance safety of other patients.
Background: In an integrated healthcare system located over a large area in 2 states, with care ranging from primary, inpatient, specialty, to long-term care, communication of patient's MDRO or HAI status and isolation requirements were a challenge. As new MDROs emerged in the healthcare system, transmission prevention approaches varied. National policy required screening for MRSA on admission, transfer, and discharge in acute-care and long-term-care settings. Isolation requirements for CDI were more stringent, requiring soap and water for hand hygiene and bleach-based cleaning product to eradicate the spores from the environment. The severity of CDI and risk of outbreaks necessitated isolation initiation immediately on suspicion of infection and continuation until symptoms resolved.
Methods: The Infection Prevention and Control (IPC) program for the healthcare system was developed by clinical nurse specialists (CNSs). Nurse-driven procedures for collection of surveillance cultures to detect MRSA colonization and CDI are a key feature. Nurses have authority to implement isolation based on patient report of diarrhea or symptoms suggesting infection. Laboratory notifies nurses of MDRO-positive specimens for immediate isolation initiation and IPC for flag entry on the patient's electronic medical record. The flag was designed by IPC CNSs to provide MDRO details and isolation instructions for each transition of care that requires a different procedure. Only IPC staff have the authority to discontinue flags per set criteria. This is done in response to consults and at routine intervals to ensure isolation precautions are not utilized unnecessarily.
Outcomes: The annual inpatient rate of MRSA infections has remained 0.1 per 1000 patient care days, and the same measure for long-term care is steady at 0.2. The higher rate in long-term care reflects transmission risks of the homelike setting. Transmission rates are reported at the unit level allowing for customization of isolation procedures aligned with patient care goals of the setting. This facilitates ongoing process evaluation and rapid quality improvement if transmission or infection rates increase. If CDI transmission is identified, supplemental transmission prevention policies are instituted to enhance patient safety. Flag content promotes communication between staff, patients, and families; identifies educational needs; and is used to communicate MDRO or HAI status to external agencies. Infection Prevention and Control averages approximately 750 flags for the 72 000 patients who utilize the integrated healthcare system.
Conclusions: Clinical nurse specialist developed infection prevention procedures utilizing nurse-driven interventions and effective healthcare system communication tools enhance patient safety during transitions of care across a large healthcare continuum.
Implications: Nurse-driven policies and reliable communication systems should be considered to enhance patient safety during transitions in care.
Richardson J, Portland VA Medical Center, Oregon
Significance: The traditional model of individual physician-based primary care is no longer sustainable; an increasing number of patients along with an inadequate number of primary care physicians have created a healthcare access deadlock. In addition, the renewed emphasis on patient-centric disease prevention and chronic disease management in primary care has increased the workload and made traditional care even less tenable. The patient-centered medical home model provides comprehensive, coordinated care across the continuum and is a potential solution to these challenges. However, it does not always provide resources to care for patients as they cross transitions: from emergency department to home, from hospital to skilled care facility, and from inpatient to outpatient. These transitions in care have been associated with adverse events including medication errors, missed laboratory and imaging results, and even fatalities.
Background: A team-based "medical home" care model has been implemented at a metropolitan teaching hospital This new model incorporates nurse practitioners as providers and registered nurses (RNs) as critical members of the team with significant autonomy. Nontraditional care is encouraged via independent nursing visits, telephone appointments, group visits, and protocolized medication management. This type of culture transformation does not happen quickly or easily. Protocols must be developed, policies and procedures written, and group visit curriculum created. The clinical nurse specialist (CNS) is uniquely qualified to assist with this culture transformation. One of the current CNS-led "coordination of care" initiatives involves RNs providing telephone visits for patients transitioning from the inpatient to the outpatient setting. The goal of this project was to improve overall care quality by increasing the percentage of patients contacted after discharge and potentially averting adverse events and/or decreasing readmissions. In April 2011, the RNs were contacting 17% of all discharged Veteran patients by 2 business days after discharge.
Methods: The primary care CNS led development and implementation of the Postdischarge Phone Call project. She provided documentation and transitional care education for the RNs in 11 clinics; content of the calls includes a general patient assessment, medication reconciliation, and determination of the need for future appointments. The CNS worked with information technology to automate the "alert" process when a patient has been discharged and collaborated with multiple departmental staff. She authored a policy to guide the staff on when and how to conduct and document the calls and mentored individual RNs to champion the project in their clinics. Staff are provided with data on a monthly basis.
Outcomes: As of July 2012, RNs are reaching 74% of discharged patients within 2 business days. Additionally, an association may exist between those patients who received the contact within 2 business days and a decrease in readmissions within 30 days of discharge. Further statistical analysis is in progress.
Conclusions: This project indicates that targeted nursing interventions can increase the percentage of patients contacted after hospital discharge and may be associated with decreased readmissions.
Implications: Primary care nurses can impact patient care through team-based practices including postdischarge phone calls.
Loudon T, Portland VA Medical Center, Oregon
Significance: It is well established that delay in detection and recognition of clinical deterioration leads to higher severity of illness and higher mortality. Rapid Response literature addresses failure to recognize, failure to act, and inappropriate placement as the main contributors for failure to rescue. Intensive care unit mortality is highest in the population of patients who are transferred from medical-surgical wards to intensive care. Implementation of systems that support early intervention and controlled transition of care may contribute to better outcomes.
Background: Organizational leadership desired a more robust Rapid Response program supporting initiatives to avoid preventable code events. Our percentage of patients who survived code events was high, but our percentage of patients who survived to discharge was discouraging: 51% in fiscal year (FY) 2010. The Institute for Healthcare improvement (IHI) was offering an education Expedition on Rapid Response, which included Modified Early Warning System (MEWS). Our facility participated in the Expedition, took the tools offered in the course, and modified them to fit our patient population per IHI recommendations. The MEWS tool utilizes vital sign parameters, (heart rate, respiratory rate, blood pressure, and temperature) along with level of consciousness and changing oxygen requirements. Each parameter is assigned a point value ranging from 0 to 3, depending on the degree of deviation from expected normal parameters. The points are then totaled and categorized into level of concern/alarm.
Methods: We assessed our population of patients per IHI recommendations and modified the MEWS tool to fit our population. The tool was trialed for ease of use, appropriate intervention recommendations, and modified per staff feedback. MEWS was implemented after staff in-services, which included the use of SimLab scenarios including MEWS calculations. Laminated pocket cards, computer workstation cards, and computer tools in the drop-down menu were developed. An action algorithm was created for each level of alarm, including recommended follow-up, notification, escalation of care, and rescoring of the MEWS.
Outcomes: Our survival to discharge improved in FY 2011 and FY 2012: 66% and 73%, respectively. An unintended outcome of implementation of the MEWS was support of transition to higher level of care. When a patient's condition does not warrant admission to intensive care, but the MEWS score is elevated, transition to a higher level of care or assignment modification has been facilitated. Elevated MEWS scores of 5 or greater have a recommended reassessment interval of every 30 minutes and increased frequency of interventions; this reassessment interval cannot be supported on medical/surgical wards.
Conclusions: Nursing staff verbalize satisfaction with MEWS and report the tool is helpful with decision making and articulation of concerns to providers about their patients. Providers report satisfaction with the objective information communicated by the nurse when status update calls are placed. Although our survival rates from code to discharge have improved, we cannot directly attribute these findings to the MEWS.
Implications: MEWS facilitates translation of data into information for nurses, providers, and organizations. The MEWS tool supports patient-centered care, early interventions, and transition to a higher level of care.
Smith S, Baylor Health Care System, McKinney, Texas; Leeper B, Baylor Health Care System, Dallas, Texas; Siela D, Ball State University, Muncie, Indiana; VanHoy S, Sparks, Maryland
Adult patients with obesity pose unique challenges to nurses who care for them in the acute and critical care settings. The increasing numbers of patients who are obese make this an important area of study. A patient's body mass index has implications for both drug and nutrition management. The impact of obesity on the patient, nursing staff and hospital resources is significant. Nurses must learn to alter their approaches to assessment, goal setting, care planning, interventions, and evaluation based on the presence of obesity. Measures must be used to prevent injury and provide safe care. Clinical nurse specialists are well positioned to ensure the use of evidence-based strategies to manage patients and to further study obesity to generate new knowledge about this special population. To provide nursing care that is rooted in evidence-based practices helps to ensure better outcomes for obese patients. Obese patients have many challenging pulmonary problems. It is important to understand the pathophysiology in the pulmonary system related to obesity with resulting changes in physical assessment and diagnostics. Awareness of interventions to manage pulmonary problems related to obesity is key. Many clinicians perceive obesity, particularly severe or morbid obesity, to be associated with increased risk for mortality and morbidity following coronary artery by pass graft surgery. Mortality and morbidity, including the impact of diabetes, risk for acute respiratory failure, and sternal wound infection associated with obese patients undergoing coronary artery bypass graft surgery, will be reviewed. The negative impact of obesity on outcomes of trauma patients including the relationship between obesity and injury pattern, increased complications related to surgical procedures, and increased mortality and morbidity rates is important to consider when developing a plan of care. Implications of obesity in trauma patients and guidelines for care of obese trauma patients will be delineated.
Leeper B, Baylor Health Care System, Dallas, Texas
Obesity is a major health problem in the United States and is well known to be a risk factor for the development of cardiovascular disease. Many clinicians perceive obesity, particularly severe and/or morbid obesity to be associated with increased risk for mortality and morbidity following coronary artery bypass graft surgery. There is an estimated 97 million overweight or obese adults (67% of adults) in the United States which has increased by 50% since the 1960's. The direct cost of obesity is estimated to be $56.1 billion, 17% or $6.99 billion can be attributed to cardiac costs.
Significance: The increased incidence and direct costs of obesity represent a significant challenge to our healthcare community. Furthermore, nurses caring for these patients are often fearful of potential injury to themselves due to heavy lifting, etc.
Purpose/Objectives: The purpose of this presentation is to provide a review of the latest evidence related to morbidity and mortality outcomes in the morbidly obese patient undergoing coronary artery bypass surgery.
Description: Specific content will include a discussion on the impact of diabetes, risk for acute respiratory failure and sternal wound infection associated with obese patients undergoing coronary artery bypass graft (CABG) surgery. Additional content will include implications for nursing practice including the management of obstructive sleep apnea (OSA) and use of BiPAP, pain management and concerns related to early mobilization and ambulation protocols in this high risk patient population.
Outcome/Conclusions: The Clinical Nurse Specialist is in a unique position to implement strategies addressing OSA outside the ICU, pain management issues and increased activity levels in this group of patients resulting in a reduction of acute respiratory distress due to stacking of pain medications/sleeping medications. Collaboration with the nursing staff and physical therapists helps to establish strategies to increase the patient's activity levels and reduce nursing's anxiety about potential back injuries, etc. Case examples will be presented to demonstrate important points.
Implications for Practice: The American Heart Association predicts that 40% of people in the US will be morbidly obese by 2030. This group of patients has unique challenges and is at high risk for serious adverse events, particularly respiratory depression. A CNS led multidisciplinary team has the unique opportunity to establish strategies addressing these unique needs.
Siela D, Ball State University, Muncie, Indiana
Significance: Obese patients are likely to enter and be admitted to critical care nursing units because they are much more susceptible than other patients to thromboembolic disease, myocardial infarction, respiratory failure requiring mechanical ventilation, sepsis, and wound complications.
Design (Background/Rationale): Once they are admitted to a critical care unit, patients who are obese or have a body mass index greater than 30 kg/m2 are more likely to experience complications and mortality than those who have a body mass index less than 30 kg/m2. One of the biggest challenges of providing care for morbidly obese patients who are critically ill are the challenging problems and issues related to the pulmonary system. To determine and facilitate appropriate care for critically ill obese patients, clinical nurse specialists (CNSs) must understand pulmonary pathophysiology, assessment, pulmonary function, and diagnostics. In addition, CNSs must be aware of evidence-based medical and nursing intervention strategies to treat or prevent symptoms or pulmonary problems related to obesity for critically ill patients.
Description of Methods: The presentation will include discussion of pulmonary pathophysiology, assessment, pulmonary function, diagnostics, and evidence-based strategies related to obese critically ill patients.
Outcomes/Conclusions: This session will enhance the knowledge base of CNSs, who coordinate and facilitate the pulmonary care of critically ill obese patients.
Implications: Clinical nurse specialists will be able to impact pulmonary care outcomes of obese critically ill patients.
VanHoy S, Sinai Hospital of Baltimore, Sparks, Maryland
Significance: Obesity poses a major risk for many health conditions, including trauma. Consequently, every bodily system and anatomic structure can be affected by obesity. When combining trauma and obesity, the consequences can be grave. As prevalence of obesity in the trauma population increases, nurses are confronted with the chalenges and complexities associated with effective management of these patients. It is essential that nurses caring for obese trauma patients have an understanding of their anatomic, physical, and psychological needs and any special equipment or requirements for the patients.
Background/Rationale: Obesity has reached epidemic proportions internationally, and the problem is no less significant in the United States. Trauma remains the fifth leading cause of death in the United States. Recently, the impact of obesity on the outcomes of trauma patients has been the focus of several investigations, with several addressing the impact of obesity on trauma patients. When trauma occurs in the overweight or obese population, it presents many challenges that negatively impact outcomes and increase mortality rate.
Description of Methods: Among the principal challenges for nurses and providers are obtaining a comprehensive assessment, meeting patients' physiologic requirements, providing timely and effective intervention, and maintaining vigilance in ongoing evaluation and discharge. Paramount to providing optimal nursing care is recognition for early planning and preparation, if possible before arrival to a trauma center and maintained throughout the continuum of care.
Findings/Outcomes: Obesity is generally defined as having an abnormally increased proportion of adipose tissue or body fat in relation to muscle mass. Injury results when the body is exposed to an excessive form of energy, such as kinetic (crash, fall, bullet), chemical, thermal, electrical, or radiation, or from a lack of essential agents, such as oxygen or heat (drowning or frostbite). Mechanics of injury are related to the type of injury force and subsequent tissue response. The degree of injury varies according to the presence of accompanying factors, such as severity of injury, age, gender, geography, alcohol, and obesity. Studies have identified a relationship between obesity and injury pattern, increased complications in outcomes related to surgical procedures, and increased mortality and morbidity rates in obese trauma patients. A thorough understanding of mechanism of injury can help explain the type of injury, predict outcome, and identify common combinations of injuries. Acquiring such knowledge can improve nursing management and care of the obese trauma patient.
Conclusions/Interpretation: Changes in practice guidelines need to include considerations of obese patients that will focus on decreased length of stay, mortality, and morbidity. As obesity and bariatric programs become more prevalent, nurses will need to remain current in unique practice methods, including available products, equipment, and evidence-based recommendations.
Implications: Literature in nursing management in this patient population is virtually nonexistent and vague. Further research is needed to examine the impact of recommended practice guidelines on the outcome of obese trauma patients. In addition, more studies are needed to investigate the impact of implementation of recommended guidelines on attitudes of nurses, safety, and quality of care.
Bedwell SM, Oklahoma University Medical Systems, Edmond
In 2010, Oklahoma University Medical Systems gathered an interdisciplinary team of healthcare providers to explore initiative that would reduce unexpected deaths of patients cared for in their facility. The Risk-Adjusted Mortality Index, which measures actual mortality to expected mortality, was used as a crude indicator for overall patient quality as it could be readily benchmarked both internally and externally. As part of the exploration, the team reviewed the top DRGs related to unexpected deaths. As in many facilities, sepsis was the most prevalent DRG across all patient populations. Armed with this information, the team formed a subgroup to determine how to create a system for early identification, stratification, and intervention for patients with signs of sepsis. The result was 3 sepsis algorithms that cover the lifespan from newborn to adults.
Newton J, Oklahoma University Medical Systems, Oklahoma City
Significance: Sepsis is an insidious condition that manifests itself as an overwhelming systemic infection. The emergency department is the primary entry to the hospital for septic patients. The initial symptoms of sepsis may appear relatively benign and result in seriously ill patients admitted to a medicine specialty floor. Patients admitted to the hospital with stable sepsis can rapidly deteriorate. Thirty-eight percent of our overall deaths had sepsis as the principal DRG or leading comorbid DRG. An early warning algorithm was needed to assist in identifying patients at risk.
Background: Patient safety is a high priority in every healthcare professional's environment. The frequency of patient handover has led to the inattention to patient vital signs that signify the patient's transition from SIRS to sepsis. A review of the literature revealed that healthcare providers had been searching for a preemptive tool that would help to screen patients who were at risk for sepsis. By definition, a patient with sepsis has a known or suspected infection. Infections require antibiotic treatment.
Design: As part of the hospital-wide sepsis prevention initiative, the adult critical care team was tasked with developing an adult algorithm to detect early warning signs of sepsis. The adult critical care interdisciplinary team combined the physician order for antibiotics and the monitoring of physiological parameters for SIRS as a trigger to identify the early signs of sepsis. The latest update for the early goal-directed therapies was incorporated to streamline the stratification and intervention phase of the adult sepsis algorithm.
Methods: The adult algorithm identification phase was triggered by 2 methods: the physician ordered an antibiotic (perioperative antibiotics were exempt unless continued >48 hours), or the patient developed a new infection, hypotension, altered mental status, hypoxia, or significant temperature changes. Either of these triggers activated the sepsis monitoring criteria with physician notification. The algorithm was submitted to and endorsed by the adult physician services at Oklahoma University Medical Center.
Conclusion: The algorithm is currently being tested in clinical practice to determine the tools effectiveness for early recognition and treatment of adult sepsis. All emergency department admissions and rapid response data are being analyzed to determine compliance with the algorithm.
Implications: The use of an adult sepsis algorithm tool can assist healthcare providers to recognize and treat sepsis earlier. Further research is needed to determine if early recognition and treatment can reduce morbidity and mortality associated with sepsis.
Significance: Premature and sick newborns are one of the highest-risk populations for sepsis. Early intervention can decrease morbidity and mortality for these vulnerable patients.
Background: Nosocomial infections or late-onset sepsis affect approximately 6% to 33% of neonates, depending on the reporting center. Late-onset sepsis is defined as any infection occurring after 48 hours of life. Septicemia occurring prior to this time is assumed to have been transmitted by the mother to the infant. The risk for late-onset sepsis is inversely proportional to gestational age at birth mainly due to an immature immune system and frequent invasive procedures. With increased survival of extremely premature infants, there has been little improvement in national rates in the last few years despite widely published prevention strategies and bundles. Recognition of early signs and symptoms of sepsis is vital to preventing increased morbidity and mortality among extremely premature infants.
Design: As part of the hospital-wide sepsis prevention initiative, the neonatal Interdisciplinary team was tasked with developing a neonatal algorithm to detect early warning signs of sepsis. The neonatal interdisciplinary team combined various sepsis indicators from research literature to develop the Neonatal Late-Onset Sepsis Algorithm.
Methods: The Neonatal Late-Onset Sepsis Algorithm synthesized risk factors, clinical signs and symptoms, and interventions from several neonatal sepsis research articles to develop a comprehensive late-onset sepsis algorithm for the neonatal population. Common risk factors were identified and used to trigger the algorithm. If a risk factor is present, the nurse assesses the infant every 4 hours for 3 or more signs of sepsis. The presence of 3 or more signs of sepsis initiates a sepsis workup. Signs of sepsis include physical findings, such as sudden-onset feeding intolerance, increased lethargy or hypotonia, distended abdomen, and altered peripheral circulation and more subtle signs, such as heart rate, temperature, blood pressure, glucose, and apnea trends. The algorithm was used to review known sepsis cases to determine reliability and validity of the tool.
Conclusion: Of the 15 cases reviewed, 14 exhibited signs of sepsis from the sepsis algorithm up to 48 hours prior to the recognition of sepsis by the practitioner. The algorithm is currently being tested in clinical practice to determine the tools effectiveness for early recognition and treatment of neonatal sepsis.
Implications: The use of a neonatal specific sepsis algorithm tool can assist healthcare providers to recognize and treat neonatal late-onset sepsis earlier. Further research is needed to determine if early recognition and treatment can reduce morbidity and mortality associated with neonatal sepsis.
Perron L, Oklahoma University Medical System, Edmond
Significance: Early intervention can decrease morbidity and mortality for pediatric patients.
Background: Recognition of early signs and symptoms of sepsis is vital to preventing increased morbidity and mortality. The Bridge Group in Northern California demonstrated a 40% reduction in sepsis death and decrease in morbidity with aggressive early identification and initiation of a sepsis bundle. Currently, there are no published algorithms for pediatric sepsis.
Design: As part of the hospital-wide sepsis prevention initiative, the pediatric interdisciplinary team at The Children's Hospital at Oklahoma University Medical Center was tasked with developing an algorithm to detect early warning signs of sepsis. The pediatric interdisciplinary team combined various sepsis indicators from research literature to develop the Pediatric Sepsis Algorithm.
Methods: The Pediatric Sepsis Algorithm is based on identification, stratification, and intervention. Patients who present with signs of sepsis or have underlying risk factors are screened for additional indicators. If the child has 3 of the following symptoms (temperature >38.5[degrees]C or <35.5[degrees]C, tachycardia, tachypnea, hypotension, an sPO2 <90%, or altered mental status) or any risk factors, then a full evaluation and treatment for sepsis are initiated. If laboratory work indicates sepsis is present, the child is stratified by the lactate level to determine admission status. The Pediatric Algorithm was submitted to and endorsed by all pediatric services with The Children's Hospital at Oklahoma University Medical Center.
Conclusion: With the endorsement of the Pediatric Algorithm, the tool is now being tested within the emergency department and inpatient units to determine effectiveness for initiation of early intervention for sepsis. All emergency department admission and pediatric rapid responses are being reviewed for compliance with the algorithm.
Implications: The use of a pediatric specific sepsis algorithm tool can assist healthcare providers to recognize and treat sepsis earlier. Further research is needed to determine if early recognition and treatment can reduce morbidity and mortality associated with pediatric sepsis.
Mittelsteadt PB, US Army Institute of Surgical Research, San Antonio, Texas; Hayes E, Mann-Salinas E, Phillips S, Robbins J, Serio-Melvin ML, Shingleton SK, Tubera D, US Army Institute of Surgical Research, San Antonio, Texas.
Our military and civilian burn center serves as a regional, national, and intergovernmental asset. Clinical nurse specialists (CNSs) are uniquely qualified to assess, plan, implement, and evaluate a broad spectrum of nursing-centered activities. Many of these initiatives fall outside the norm of daily clinical operations at other burn centers. We will discuss similarities and differences within the definition of 3 specific CNS pillars: The clinical expertise pillar is defined by CNS-led, evidence-based, multidisciplinary problem solving, emphasizing bedside care. Unique aspects of this role include researching and implementing military-specific clinical topics; managing complex polytrauma with superimposed burn injuries is a largely unique function within a military center. Synergy with the CNS education pillar is required since 3 branches of the military train clinically at the bedside and with the wound pillar since all patients require some clinical nursing intervention to achieve maximal wound healing. The CNS education pillar provides the structural framework for implementing complex clinical care competency, research, and community outreach. The concept of military community outreach extends literally worldwide. Clinical nurse specialist-leveraged education trains hundreds of triservice military medical providers before combat deployment. Clinical nurse specialist education initiatives drive the successful effort to transport burn and polytrauma military casualties up to 8000 miles within 72 hours of injuries. All this has been accomplished with no appreciable difference in outcomes when matched against civilian patients from the local community. The CNS wound expert pillar incorporates cutting-edge technologies to better define wound staging. Clinical nurse specialist expertise is essential to translate what is traditionally a pen-and-paper endeavor to a new paradigm of digital media imaging, collection, and data interpretation. This wound pillar impacts both the clinical and education pillars on a daily basis. More importantly, it sets the stage for long-term understanding of the specialized field of burn wounds.
Robbins J, US Army Institute of Surgical Research, San Antonio, Texas; Mann-Salinas E, Mittelsteadt P, Phillips S, Serio-Melvin ML, Shingleton SK, Tubera D, US Army Institute of Surgical Research, Fort Sam Houston, Texas
Purpose/Objectives: The purpose of this seminar is to describe the clinical roles of a clinical nurse specialist (CNS) in the care of the burn patient.
Significance: Trauma patients may sustain any combination of penetrating, blunt, burn, or other injuries depending on the mechanism. Care of the polytrauma burn patient is highly complex and requires a multidisciplined and multisystem approach to administer safe and effective care. Orchestrating comprehensive care, facilitating collaboration with patients and their families, supporting the needs of nursing staff, and interacting with the multidisciplinary team are components of maximizing patient outcomes.
Background: The CNS in a burn center caring for polytrauma patients is an expert practitioner and change agent who provides clinical expertise by developing and bringing evidence-based practice to the bedside. The CNS in the clinical pillar leads translation of evidence into practice. The CNS within the intensive care and intermediate care units collaborate daily with a multidisciplinary team to include physicians, dieticians, physical and occupational therapists, respiratory therapists, behavioral health providers, staff nurses, and other CNSs to optimize patient care and outcomes in the polytrauma burn population.
Description: There are currently 2 clinical CNSs serving as clinical experts in our burn center: one is primarily focused in the intensive care setting and the other in the burn intermediate care unit. Working together, both CNSs are able to facilitate care of the polytrauma patient across the care continuum to discharge. Clinical expertise of the CNS directly impacts bedside nursing care, training, and competency. Development of evidence-based system-focused programs includes preceptorship, skills validation, performance improvement projects, infection control, and education. Recently, a CNS-led team received a federal grant to develop and implement an evidence-based precepting program to transition experienced nurses to the specialty of burn care.
Outcome: The CNS fulfils multiple roles in facilitating and leading care of the polytrauma burn patient that promotes synergy across the CNS spheres of influence. Nurse to nurse, the CNS is instrumental in ensuring competency and translation of best practice to the bedside nurse; nurse to patient, the CNS facilitates coordination of the interdisciplinary care team to meet the patient's evolving needs during recovery; and the CNS is the most essential team member to ensure the needs of both the patient and staff nurse are supported by an efficient and effective system.
Interpretation/Conclusion: A CNS with an expert clinical background in the care of the polytrauma burn patient can influence, develop, and translate evidence into practice to advance highly effective care across the continuum and promote even greater outcomes among patients, families, nurses, and across systems.
Implication for Practice: A need exists for the clinical expertise of advanced practice nurses in the polytrauma setting. The CNS can facilitate and drive the care of the most complex burn patient resulting in positive outcomes and synergy for the patient across the spheres of CNS influence.
Phillips S, US Army Institute of Surgical Research, San Antonio, Texas; Mann-Salinas E, Mittelsteadt P, Robbins J, Serio-Melvin ML, Shingleton SK, Tubera D, US Army Institute of Surgical Research, Fort Sam Houston, Texas
Purpose/Objectives: To describe the comprehensive education and training roles of the clinical nurse specialist in support of the burned polytrauma patient.
Significance: Our client, the burned patient, experiences highly complex injuries that many times are complicated by polytrauma. Military casualties have unique needs that are served by education in multiple echelons of healthcare, across a care continuum that stretches around the globe, and is provided predominately by non-burn care specialists on multiple transportation and healthcare platforms. This Burn Center is the only military organic burn center able to provide comprehensive training in burns for the entire Department of Defense; our center supports definitive care for all burned military service members and serves as a regional burn center.
Background: The Burn Center Education Department provides several key functions: staff and student education and training, predeployment training, nursing preceptor development, ongoing competency sustainment and assessment, and burn prevention and community outreach. Education provides the foundation for the services received by our end users: our staff members, patients, and families within our system and students who require basic understanding of burn care. This education service is overseen by a team of a clinical nurse specialist (CNS) and clinical nurse leader (CNL).
Description: The Education Department facilitates 100% of initial unit in-processing for all disciplines to ensure consistency in the introduction to the unique mission of the Burn Center. Education, training, and competency validation are provided for 100% of the nursing staff, utilizing an evidence-based precepting and ongoing education program. The Education CNS/CNL team coordinates training and provides direct education to over 800 clinical staff members, students, and predeployers annually. Training is provided for surgery and medical interns and residents, respiratory therapists, nurses, occupational therapists, and physical therapists. Annual training includes Advanced Burn Life Support certification classes, a burn symposium capturing 100% of newly assigned permanent staff in 2 or more offerings, and clinical skills fair validation training. The Education Department offers burn prevention outreach to over 1000 community members each year.
Outcome: Smooth coordination, personalized collaborative communication, and provision of evidence-based education promote excellent staff and student support, ultimately benefiting our patients and families. The efforts of the Education Department directly support the ongoing American Burn Association Accreditation the Burn Center has maintained since 2004. In support of combat operations overseas, every deployed Army, Air Force, and Naval healthcare provider and casualty directly benefits from the educational opportunities provided by the Burn Center personnel.
Interpretation/Conclusion: The Education CNS/CNL team collaborates with all members of the healthcare team, and their leadership provides needed training to a highly demanding burn population, maximizing training resources.
Implication for Practice: The CNS/CNL educator impacts each of the CNS spheres of influence: nurse/nurse sphere in training and education, nurse/patient sphere in outreach efforts and assurance of competent staff, and in the systems sphere facilitating excellent care in worldwide burn patient management for our military casualties.
Shingleton S, US Army Institute of Surgical Research, San Antonio, Texas; Mann-Salinas E, MP, Phillips S, Robbins J, Seriomelvin ML, Tubera D, US Army Institute of Surgical Research, Fort Sam Houston, Texas
Purpose/Objectives: The purpose of this seminar is to describe the multiple roles of a wound-focused clinical nurse specialist (CNS) in a military burn center.
Significance: Our verified, regional burn center averages approximately 52 admissions per month. We care for civilian and military patients and their families experiencing burns, complex polytrauma, and skin-related conditions that require complex care and extensive rehabilitation. Wound healing remains the keystone to successful outcomes in this patient population.
Background: The wound-focused CNS operates within the 3 spheres of influence. The CNS leads a 3-member wound care team (WCT) that provides expert wound care and consultation, patient and family education, training for new staff, students and predeployers, and ongoing education and skill building for staff. The wound-focused CNS also collaborates on a daily basis with a multidisciplinary team, including physicians, other CNSs, therapists, social workers, case managers, and nutritionists, to facilitate individualized care and maximize outcomes in this critical patient population.
Description: The WCT at the burn center expanded from 1 licensed vocational nurse to 2 licensed vocational nurses and a CNS in May 2010. The CNS-led team focuses largely on providing expert wound care and collaboration with nursing, physician assistant, and physician colleagues to maximize the ideal wound healing environment. While the bedside nurses remain primarily responsible for wound care, the WCT is frequently consulted for wound assessment and complex dressing changes. The WCT is a primary user of an electronic wound mapping system developed by this organization to graphically display wounds, and the CNS is instrumental in facilitating the daily use of the system by the interdisciplinary burn care team. Wound photographs are primarily obtained by the WCT and uploaded to the system to ease access for the nursing staff and multidisciplinary team. The CNS also focuses on pressure ulcer prevention in these high-risk patients and leads a pressure ulcer team that performs weekly surveillance of patients in the burn intensive care unit. Surveillance data are used to assess prevalence and incidence of pressure ulcers and to identify trends that allow the CNS to develop targeted interventions and educational programs. The CNS-led team also focuses on providing wound education to staff and a variety of trainees, supporting an evidence-based preceptorship program through curriculum development and competency validation.
Findings/Outcomes: Numerous programs, interventions, and practice changes have been implemented by the CNS. Standard order sets for wound care, postoperative dressings,and pressure ulcer prevention have been sustained after implementation. Ongoing data analysis is underway with the aim of better defining pressure ulcer risk in burn patients and identifying differences among military versus civilian patients. Finally, the electronic wound mapping program is being embraced by bedside nurses who find the technology enhances their ability to provide the best possible care to their patients.
Conclusions: Optimal wound healing requires expert wound care, the collaboration of a multidisciplinary team, innovation, and outcome-focused educational strategies.
Implications: The CNS operates within the spheres of influence to serve this complex patient population and diverse team responsible for their care.
Tamburri L; Joiner JM, Royal S, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
Clinical nurse specialists (CNSs) are leaders in implementing organizational change related to clinical practice innovations and improving patient outcomes. In order for any clinical change to be effective and enduring, it is imperative that staff nurses be engaged in the change process. The importance of this staff nurse engagement is evident in standards set by professional organizations that recognize nursing excellence such as the American Nurses Credentialing Center's Magnet Recognition Program and the American Association of Critical-Care Nurses' Beacon Award for Excellence. Fostering staff engagement requires an organizational structure that supports this process and creative strategies implemented by CNSs that encourage and reward staff participation in clinical change projects. This symposium will describe one hospital's framework for fostering staff engagement and will present several examples of practice innovations and improved patient outcomes that resulted from a variety of staff engagement activities. An emphasis will be placed on specific actions that participants can replicate in their own organizations.
Tamburri L, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
Significance: Staff members who are engaged in their work are more involved, enthusiastic, and productive than those who are not engaged. They also have a positive impact on outcomes. Fostering staff engagement requires an organizational framework and leaders to support the process.
Design (Rationale): Professional organizations that recognize nursing excellence acknowledge the value of staff engagement in creating meaningful change. The American Nurses Credentialing Center's Magnet Recognition Program "recognizes healthcare organizations for quality patient care, nursing excellence and innovations in professional nursing practice." The vital role of staff nurse engagement is evident in Magnet standards including structural empowerment, exemplary professional practice, and new knowledge, innovations, and improvement. The American Association of Critical-Care Nurses' (AACN's) Beacon Award for Excellence also has criteria addressing staff engagement. In addition, AACN established standards for developing healthy work environments, which reflect the need for staff engagement in communication, collaboration, and decision making in order to ensure excellent patient outcomes. Staff engagement is also an expectation in Joint Commission standards for accrediting healthcare organizations and designating specialty centers.
Methods: The nursing division in our organization created structures and processes that embrace staff engagement. Through this framework, clinical nurse specialists (CNSs) are leaders in fostering staff engagement and creating change. Individual unit Practice Councils are our system of shared governance and the avenue for staff to make unit-based changes. Clinical nurse specialist-led councils focus on improving patient outcomes, especially nurse-sensitive indicators. Clinical nurse specialists mentor staff as they progress in our clinical ladder. Staff must demonstrate their contributions in the areas of clinical excellence, customer service, community outreach, evidence-based practice, committee participation, and continuing education. Through this process, they contribute to improving patient outcomes while receiving recognition and rewards for their achievements. Other processes contributing to staff engagement include our nursing conceptual model, which is woven into all aspects of professional nursing care; staff nurses who collect and analyze unit-based PI data; nurse champions of innovative change projects who serve as pilot testers, peer educators, and unit resources; and our performance appraisal, which considers achievement of individual and unit-based goals in calculating a nurse's performance score.
Outcomes: A high level of staff engagement produced significant outcomes for our nurses, our patients, and the organization. Staff participation and advancement in the clinical ladder are consistently increasing. Performance on many nurse-sensitive indicators has met or surpassed benchmarks. We have received several honors including Magnet designation 4 times, the AACN Gold Beacon Award, and the National Database of Nursing Quality Indicators award for nursing quality.
Conclusions: Recognizing the importance of staff engagement is a crucial component for successfully implementing change. Developing a framework that supports staff engagement can be accomplished on unit and organizational levels, and CNSs are the leaders in this process.
Implications: Staff engagement contributes to the implementation of innovative clinical practices and improved patient outcomes.
Royal S, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
Significance: Patient safety is of the utmost concern for healthcare providers. Several professional organizations have developed national standards regarding patient safety. The National Database of Nursing Quality Indicators is the safety and quality arm of the American Nurses Association and has an established database of nurse-sensitive indicators including patient falls and pressure ulcers. The National Healthcare Safety Network identifies benchmarks for monitoring infection rates. Healthcare organizations use these and other measures to track quality outcomes and make changes toward excellence.
Design (Background/Rationale): Using national benchmarks of nurse-sensitive indicators, our institution identified areas for improvement. As direct care providers, nurses have a significant impact on these indicators, and it was crucial that they be engaged in the improvement process.
Description of Methods: The fall prevention initiative has become one of our institution's most robust programs. Unit-based fall champions actively participate in the hospital fall committee. They then disseminate information to their colleagues at the unit level during practice councils and staff meetings. Staff nurse-led meetings occur at every shift change to identify patients at risk for falls, and interventions provided. Pressure ulcer prevention is another area where staff has a significant impact. Staff nurse performance improvement representatives participate in bedside observation tracer methodology. Bedside observation tracer methodology promotes staff nurses working collaboratively with the CNS/CNE and their RN colleagues to assess all patients and identify appropriate treatment/interventions. Staff nurses take this opportunity to give real-time feedback to their colleagues on pressure ulcer prevention and treatment. Direct care nurses take responsibility and ownership of all nurse-sensitive indicators. Infection rates are discussed at all nurse practice councils. Additionally, M&M's, or mistakes and mishaps, are discussions led by the CNS/CNE to review infections in real time with staff. Staff also monitors unit progress by reviewing the monthly impact and effectiveness report. These reports identify nurse-sensitive indicator rates on a monthly basis.
Findings/Outcomes: Examples will be provided of notable improvements in patient outcomes such as fall and pressure ulcer rates that have met and exceeded the national benchmarks. In addition, outstanding infection rates including central line-acquired bloodstream infections and ventilator-acquired pneumonia in critical care areas will be discussed.
Implications: While critical care is identified as the practice area, the benefits of staff engagement can be applied in any practice area.
Conclusion Interpretations: The hospital was recently awarded the American Nurses Association National Database of Nursing Quality Indicators award for nursing quality in the category of academic medical center. The CNS/CNE group led the initiative to engage and challenge the staff to become change agents. As a result, they were able to see the direct impact of their care.
Joiner JM, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
Significance: Presenting new and highly complex projects to staff nurses can be a challenging part of the CNS role. Having engaged staff who participate in the development, planning, and rollout of new innovations inpractice makes it easier to gain the acceptance of additional staff, especially if the projects are multifaceted or complex.
Background/Rationale: As a 4-time designated Magnet facility, we are expected to present a strong shared governance model and maintain a high level of staff engagement. We recruit staff to participate in new projects through the roles of cochair and nurse champion. Having staff involved at such high levels throughout the organization generates enthusiasm and greater acceptance of change. Success is widely attributed to the presence of highly engaged staff.
Description: When a new model for continuous renal replacement therapy was brought to our facility, staff RNs attended a nurse champion course, assisted with teaching at least 2 training classes, provided support during the conversion, and were resources on the units. For our mild therapeutic hypothermia program, having nurse champions on the off-shift for initiating and troubleshooting was vital to a successful program. Automating an algorithm that addresses pain, sedation and delirium is a multifaceted, long-term project. Recruitment of nurse champions across the critical care division led to greater staff buy-in and confidence in their ability to manage these complex patients. The professional advancement system (clinical ladder) encourages the staff nurse to consider becoming a cochair of a committee. The CNS works with staff cochairs on a variety of committees across the hospital. Examples include the Evidence-Based Practice Journal Clubs and the Staff Organ Donor Team. The unit-based Nursing Practice Councils are also run by the staff nurse with the assistance of the CNS. The CNS utilizes simulation for a variety of programs for staff education. Historically, the technology was used primarily by the CNS. At this time, staff utilizes simulation in their clinical ladder projects alongside the CNS. Examples include competency validation, a Maternal Fetal Medicine program, and "Simulation Week," in which a variety of topics involving interdisciplinary teams and simulation are presented.
Outcomes: The continuous renal replacement therapy nurse champions assisted with providing education to over 200 critical care nurses during a 3-week period. They also assisted with the development of policies, order forms, and documentation forms. National success rates for mild therapeutic hypothermia average 12%; our facility has a 36% success rate. The Staff Nurse Donor Team has met or exceeded national benchmarking targets for donor referral, effective request, and conversion rates.
Interpretation/Conclusion: Using a shared governance model, the clinical nurse specialist can provide staff with safe, effective, and efficient high-quality programs by helping to facilitate rollout of projects alongside staff nurses.
Implications for Practice: Identifying appropriate projects where staff can assist can greatly impact your relationship with staff and provide creative learning opportunities.
Vincent R, Mayo LM, WakeMed Health & Hospitals, Raleigh; and Reguin-Hartman KL, WakeMed Health & Hospitals, Apex, North Carolina
Symposium Objective: Identify ways to create and promote the role of the CNS within a healthcare organization.
Individual Abstract Objectives: * Discuss ways to create a clinical nurse specialist position within an organization. * Identify elements needed to successfully incorporate the new CNS into an organization. * Discuss current methods for evaluation of the clinical nurse specialist role.
Overview: Clinical nurse specialists ensure that practice changes based on best evidence are identified and implemented collaboratively between nursing, other disciplines, and administration with a goal to improve safety, quality, and cost-effectiveness. The purpose of this presentation is to describe a process to assist the novice clinical nurse specialist in establishing a solid foundation within a hospital system beginning with the creation of a job description, development of an orientation program, and evaluation of the role. This symposium consists of 3 sections. The initial presenter will discuss the creation of a new CNS position from job proposal, development of a job description, to finding your niche. The second presenter will provide a proven strategy for paving the way into the organization, including orientation and organizational assessment. The third presenter will provide examples of CNS outcomes and methods of documentation and measurement of success. These discussion points can be used for professional role development.
Vincent R, WakeMed Health & Hospitals, Raleigh, North Carolina
Significance: Selecting a patient population, identifying population-specific outcomes, and detailing the impact the clinical nurse specialist (CNS) will have on daily nursing practice are cornerstones for writing a successful job proposal and job description. The successful CNS must be a skilled communicator, adept at identifying patterns and using inquiry and logic to make patient care decisions. These attributes are important in creating and defining the CNS role, more especially so in a new role within an organization.
Design: This presentation will demonstrate how a clearly articulated job proposal and job description can proscribe the expectation of the CNS role using a variety of perspectives to include the patient population, divisional, or program based.
Description of methods: The job proposal begins with carefully reviewing organizational information and data as well as the nursing strategic plan. Creating any job requires a clear commitment from the organization and, in this case, an understanding of what a CNS is and does. Identification of outcomes is a primary focus for creating a CNS position: from the impact on nurses at the bedside to reduction in readmission rates for a specific patient population. Transitional roles are an effective means of creating a placeholder for the future CNS. In our organization, existing CNSs identified and prioritized gaps for future positions, identified expert staff in school to become CNSs, and, in some cases, were able to move those graduate students into transitional roles until they graduated and became certified. Writing a job description using national guideline set forth by the professional organization is important to maintain the role standard, but also to uphold the hiring organization's mission, vision, and values. Utilizing the CNS spheres of influence to shape the position and aligning those with the organization's nursing strategic plan help ensure the achievement of outcomes of importance to the hiring organization. A well-written job description should provide guidance for CNS activities, but not be prescriptive.
Outcomes: The CNS is well positioned to have an impact on nursing practice by articulating nursing's unique contribution within the context of multidisciplinary teams, promoting the vision of the organization, mentoring others, and engaging in just-in-time education opportunities while working with staff at the bedside. These are all reasons to grow a CNS program within an organization. Our organization has increased our number of CNSs from 1 in 2008 to 5 today, and we anticipate future growth.
Conclusions: Proposing a new role within an organization sets the stage for the impact the CNS has within all 3 spheres of influence, and an emphasis on outcomes must be associated with each. Linking the CNS role to the nursing strategic plan can underscore the value of the role. Identification of the CNS impact on the nursing strategic plan solidifies commitment to the organization and its values.
Reguin-Hartman K, WakeMed Health & Hospital, Apex, North Carolina
Significance: The role of the clinical nurse specialist (CNS) can be ambiguous, making it challenging to design a consistent orientation program. For a new CNS, the early transition months are essential for paving the way to a successful CNS role. There are many challenges associated with CNS orientation including limited research and guidelines for the process.
Design: This presentation will combine the limited available research with recommendations from the CNS Toolkit to demonstrate how a new CNS created a unique orientation plan for an acute care organization and rehabilitation facility. This 800-bed healthcare system has a small number of CNSs but seeks to grow the role.
Description of Methods: Steps to successful orientation include doing a thorough organizational assessment, meeting with key stakeholders, orientation to bedside care and processes, competency validation, and careful consideration in the selection of early projects. Organizational assessment included meeting with divisional managers, key stakeholders, support services, review of nurse quality indicators, and Hospital Consumer Assessment of Health Providers and Systems scores. Orientation to bedside care and processes was completed through charge nurse and progression rounds, rounding with the clinical administrator, and bedside orientation. A CNS initial competency checklist was created by the organization's CNS group. The components of the checklist aligned with elements of the NACNS's framework for CNS Core Competencies and can provide a reference for orientation. The selections of first CNS projects were carefully considered analyzing for quick wins, visibility, learning organizational processes, and measurable outcomes. Early projects included work on a partially developed tracheostomy care team, creation of an Evidence-Based Practice Council, and an evidence-based practice project on vancomycin administration.
Outcomes: Our outcome is the establishment of a consistent yet individualized orientation plan. One challenge for our facility was the different reporting structures for the CNS team. One CNS reports to a divisional director, one to a program manager, and others to the director of research and evidence-based practice. This requires individualization of each orientation plan. Other challenges included consistency with similar job titles, defining the coverage area of the new CNS position in a multicampus organization, and varied experience in utilizing CNSs throughout the organization.
Conclusions: A consistent orientation program ensures uniformity in CNS role expectations in a facility where the role is still evolving. This requires planning, support, and resources. Multiple elements to include in the orientation plan are organizational assessment, meeting key stakeholders, orientation to bedside care, competency validation, and careful consideration of early projects.
Mayo LM, WakeMed Health & Hospitals, Raleigh, North Carolina
Significance: A clear and sound understanding of the CNS role is required to appreciate the impact on outcomes. Knowledge of the CNS spheres of influence and role function is critical to understanding the mechanisms underlying the impact of CNS care on patient, nurse, and system outcomes. In order to clearly articulate how the CNS impacts patients, nursing practice, and system outcomes, it helps to be able to delineate the ways in which the role is conceptualized.
Design: The purpose of this presentation is to demonstrate a variety of ways to quantify productivity of CNS practice. A review of the available literature will be presented followed by discussion of work logs, quantification tools, and data collection. An emphasis is placed on aligning the 3 spheres of influence with CNS practice.
Description of Methods: Several years ago, our small CNS group rewrote our job description using the 3 spheres of influence of the CNS as described. Since that time, we have developed methods by which to marry the 3 spheres with proof of our effectiveness. Work logs have proven to be useful to quantify the relevance of projects to each of the 3 spheres. Examples of outcomes managed by our CNS team include reviewing all trauma charts for adverse events and deaths to evaluate for organizational changes that need to be implemented, leading interdisciplinary spinal cord injury rounds and focus on decreasing adverse outcomes and complications, and CNS-led product improvement efforts for the healthcare system.
Outcomes: Unique roles and reporting structures within the organization make standardized quantification of the CNS role challenging. Further, as every CNS knows, it can be difficult to track the intangible aspect of the CNS role such as professional influence and role modeling; however, recording the outcomes associated with these interactions is important.
Conclusions: Outcome management is an important yet complicated aspect of the CNS role and is unique to each patient population, unit, and individual. Collaboration among CNSs about methodologies to quantify outcomes is essential to promotion and success of the role.
Quatrara BD, University of Virginia Health System, Troy
The development of nurses along a continuum was first described by Dr Patricia Benner in her 1982 work "Novice to Expert Theory." It is a theory that has held true throughout the decades. It resonates with clinicians in various roles, including the role of the advanced practice nurse. Clinical nurse specialists (CNSs) are not immune to the need for growth and development. The same pattern of professional advancement occurs with the CNS realm. As a result of experiences and education, the CNS may expand the role beyond the individual practice setting. The CNS may move from implementing the role within a unique practice setting to operationalizing it throughout the institution or demonstrating the role at a national level. The pace and degree of transition vary, but the path from Novice to Expert is the same. Recognizing and validating the evolution of a CNS are important. The clinical career ladder (CCL) is one framework that acknowledges this progression. The CCL articulates expectations and sets the bar for innovation and outcomes. The CCL supports the development of skill acquisition and recognizes the phases of professional advancement that may be achieved. Competencies are expected at each level and may be actualized differently at each level of the ladder. The CCL also provides stability and flexibility. As the term ladder suggests, vertical movements in either direction are feasible. This symposium will provide an overview of a 3-step advanced practice nurse CCL as well as the competencies and spheres of influence demonstrated by the CNS at each step. This symposium will illustrate the innovations and outcomes of CNS practice at each level.
Rea KM, Elgin K, University of Virginia Health System, Charlottesville
The advanced practice nurse CCL provides structure to the Advanced Practice Nurse 1-Clinical Nurse Specialist (APN 1-CNS). It provides a framework for growth and development and a measurement of progression. It serves as a guidepost for goal development and a reflective marker for self-evaluation. The requirements for the (APN 1-CNS) include management of the care of a defined patient population, using a holistic perspective, as a dominant aspect of the role with recognition as an interdisciplinary leader within the service area. Consistent demonstration of core competencies of APN practice is foundational to the APN CCL. Accountability for each of these competencies is established through a rigorous evaluation of outcomes and peer-review process. The application of CNS spheres of influence within APN 1-CNS practice varies across settings and patient populations; however, the patient sphere of direct care of patients or clients is predominant. Examples of APN 1-CNS behaviors that demonstrate the clinical competencies and application of this sphere of influence are development of a surgical intermediate care unit to facilitate patient progression, creation of a clinical pathway for a distinct population, or advanced direct care planning for patients with long lengths of stay. The Nursing and Nursing Practice sphere is demonstrated through coaching, guiding, and role modeling evidence-based practice. Facilitating the adoption of evidence-based practice impacts this sphere, and examples of APN 1-CNS practice will be described in this symposium. Influence in the Organizations and Systems sphere occurs as the APN 1-CNS identifies the need for practice changes within their setting and/or population. This may include leadership in the development of systems to optimize direct patient care or the implementation of clinical innovation.
Mahanes D, University of Virginia Health System, Charlottesville; Wilkins, KD, University of Virginia Health System, Palmyra
As the advanced practice nurses evolve and develops, there is opportunity to demonstrate their CNS impact across the spheres of influence at a broader level. The APN 2-CNS role within the clinical career ladder (CCL) incorporates a larger organization and systems leadership component to the patient population focused practice. The advanced practice nurse CCL provides opportunity for the CNS to be promoted and recognized. APN 2-CNS candidate creates a professional portfolio inclusive of self-evaluation, peer review and outcomes demonstration. The advancement portfolio is reviewed by APN peers. The panel's decision for advancement is recommended to the CNO and approved or denied. As the APN 2-CNS is validated at their new level of practice, it is expected that they are already demonstrating these behaviors. The spheres of influence and core competencies are firmly established, and the CNS remains grounded in direct clinical practice within their specialty. Within the Direct Care of Patients or Clients sphere they expand on their consultation and coaching skills. The APN 2-CNS facilitates innovation and resolution of systems issues. Examples to illustrate this include CNS leadership of new protocol development and creation of clinical guidelines. Innovative approaches to reducing catheter-associated bloodstream infections and ventilator-associated pneumonia are driven by APN 2-CNS. The assertive interdisciplinary leadership of the CNS at this level occurs within and across practice settings. The Nursing and Nursing Practice sphere is influenced through expert coaching, guiding, and mentorship. Within the Organizations and Systems sphere, the APN 2-CNS uses data to evaluate nursing practice and patient outcomes and drive change. Examples of all 3 spheres of influence and outcomes of APN 2-CNS practice will be presented in this symposium. The APN 2-CNS is validated by peers every 3 years, and their performance is evaluated annually.
The advanced practice nurse clinical career ladder (CCL) provides an opportunity for the CNS to be recognized for advanced leadership and scholarly achievement. The Advanced Practice Nurse 3-Clinical Nurse Specialist (APN 3-CNS) is achieving professional growth and development on an individual level and making an indelible mark for patients, nurses, and organizations at every level. The requirements for the (APN 3-CNS) include those previously mentioned in the APN 1 and APN 2 CNS discussions. Moreover, the APN 3-CNS role includes an emphasis on contributing to nursing knowledge within a defined specialty through research studies, publications, and presentations. The expectation is set for this clinician to disseminate knowledge and share findings outside of the local healthcare institution. At this step on the clinical career ladder, the CNS is actively engaged as an advanced practice nurse at a national level. The individual's contributions are reaching beyond the walls of the institution. The exact mechanism for implementing the APN 3-CNS role may differ among clinicians, but the key components are the same. APN 3-CNS achieves recognition of expert clinical competencies and the broadest impact across all spheres of influence. There is an emphasis on research, collaboration, and systems leadership. The spheres of influence, although ever present, evolve as the CNS advances on the CCL. The spheres of influence must be operationalized on a larger scale by the APN 3-CNS. The Direct Care of Patients or Clients sphere can be applied to an individual or a local population, but it may also be reflective of a national patient population. An example would be how the APN 3 applies expert knowledge to partner with healthcare industry manufacturers to research and change products for postoperative surgical venous thrombosis prophylaxis. A similar pattern occurs within the Nursing and Nursing Practice sphere of influence. Nurses continue to be guided as individuals and small groups, but they are also mentored in larger groups across great distances through academic and scholarly work. The same occurs with the Organizations and Systems sphere of influence. The system is enlarged beyond an individual practice organization and becomes a bigger entity, an entity that reaches across the country. These spheres are influenced throughout a variety of venues including affiliations with professional specialty organizations, oral presentations, and written works. Examples of APN 3-CNS behaviors that optimize the clinical competencies of research, collaboration, and system leadership and demonstrate the spheres of influence will be provided in this symposium.
Idemoto BK, Avallone D, University Hospitals Case Medical Center, Cleveland, Ohio
This Creating Novel Solutions symposium emphasizes the efforts of CNSs to implement professional development and educational programs that resulted in an Advanced Practice Nurse (APN) Council, a peer-reviewed Advanced Practice Promotion Program (APPP), a writing improvement workshop, interprofessional education and practice, and several research/evidence-based projects and professional publications. The APNs at this academic teaching hospital historically met as individual specialty groups. None had representation, recognition, or authority in the hospital leadership structure, or guidelines for evaluation and promotion. To remedy these deficiencies, a self-governance Council was formalized, a Charter completed, a resource Web site designed, and voting membership to the nursing governance structures granted. A "peer-reviewed" advancement model utilizing Benner's novice to expert concepts, and similar to the format utilized for academic physicians, was established as part of the organizing charter. The Council and Advancement Model have been sustained for 6 years; achievements include a 67% promotion rate and 88.5% retention rate. A writing workshop to for publication endeavors and participation in an interprofessional, grant-supported educational program are Magnet-based accomplishments. The CNS role enhances patient care outcomes, provides recruitment and retention incentives, and increases the hospital's reputation through presentations, research, and publications.
Avallone DA, University Hospitals Case Medical Center; Forsythe PL, Rainbow Babies and Children's Hospital; Idemoto BK, Kloos JA, University Hospitals Case Medical Center, Cleveland, Ohio
Purpose: This Creating Novel Solutions symposium emphasizes the efforts of CNSs, in collaboration with nurse colleagues, to implement an Advanced Practice Nursing Council.
Significance: The advance practice nurses (APNs) at this academic teaching hospital had a long history of nursing specialty group networking activities and educational opportunities. Some met monthly, others a few times per year, each with separate agendas and varying structures. None had representation, recognition, or authority within the hospital's leadership structure, or provided opportunities for communication between the individual groups.
Background: Concurrent with the formalization of the APN Promotion Program, the individual APN specialty groups merged into one integrated structure, the APN Council. Clinical nurse specialists were the driving force in the development and establishment of this cross discipline, collaborative, professional council within the nursing organization hierarchy.
Description: The APN Council represents and encompasses all APN titles and disciplines. A formal Charter was developed that sanctioned the council as a voting member of the hospital's Nursing Coordinating Council-the governing and decision-making council for nursing and professional practice issues. Meetings occur monthly, which are structured and goal oriented while still providing ample opportunity to make contacts, exchange ideas, and discuss professional or practice issues. Representatives from the APN Council are active, voting members on a variety of hospital committees such as Pharmacy and Therapeutics, Electronic Medical Record Development, Code Violet, Retention and Recruitment, and others. While the APN Council primarily has a professional clinical focus, it also has a role in departmental operations issues, particularly those that cross-management centers and different levels of practice.
Outcomes: The Council is recognized as the authority for resolving issues that have historically frustrated individual practitioners: for example, enhancing laboratory result reporting features of the electronic medical record, facilitating prescriptive authority issues, and developing a formal process to preceptor APN students. Collaborative projects that were an outgrowth of the synergy among APN council members include development of a hospital APN Web page, refinement of the peer-reviewed promotion process, and APN Mentorship for Senior Clinical Nurse Promotion.
Conclusion/Implications for Practice: The power, expertise, and energy of the nurses attending council meetings provide a synergy that results in accomplishments not likely to be achieved by individuals or small networking groups.
Kloos JA, University Hospitals Case Medical Center, Cleveland, Ohio
Significance/Purpose: Promotion is a critical component in building a professional career. Similarly, recruitment and retention incentives are vital functions of employee-friendly organizations. This presentation describes the development and implementation of an advanced practice nurse clinical ladder promotion program and the growth-producing experiences the leadership group has experienced as they pioneered and championed this professional endeavor.
Background: The development of a promotional program based on a clinical ladder concept was an outgrowth of an advanced practice nurse (APN) evaluation process limited by a lack of resources and professional advancement guidelines. In addition, a literature search was conducted that demonstrated a lack of existing evidence regarding advanced practice promotional processes, pathways, or tools.
Description: Clinical nurse specialists (CNSs) in collaboration with nurse colleagues and administrators at this urban academic teaching hospital recognized, implemented, and have supported for the past 5 years an APN Council and a Peer Reviewed Advancement Program (APPP) to achieve these results. In conjunction with the establishment of the APN Council, a "peer-reviewed" clinical ladder advancement model, similar to the format utilized for academic physicians, was developed and implemented. Based on Benner's concepts, the advancement model recognizes 3 levels of practitioners, novice, proficient, and expert, and promotion to each elevated tier is based on tenure and key criteria in 4 major role categories of practice-clinical, education, professional, and leadership/administration involvement. Each tier has identified achievements, competencies, and clinical acumen that must be attained for advancement and promotion to that level. The Advancement Committee, cochaired by a CNS and nurse practitioner, meets biannually to review and evaluate applicant packets and decide, based on documented accomplishments, whether to support the requested promotion. A decision not to support the requested promotion is accompanied by a written action plan with suggestions to resolve the identified practitioner deficits. Promotion criteria are continuously reviewed, refined, and republished.
Outcomes: To date, two-thirds of the APNs have been promoted utilizing the clinical ladder with a demonstrated retention rate of 88.5%. An additional outcome is the strong collegial relationships that have been forged as the program evolved.
Conclusion/Implications for Practice: APPP is well established as an objective, self-directed professional development program that challenges each APN to evolve as a practitioner.
Idemoto BK, University Hospitals Case Medical Center, Cleveland, Ohio
Purpose: Encouraging interprofessional practice and education is important in fostering solutions to challenges in all fields of healthcare.
Significance: Clinical nurse specialists (CNSs) promote the highest level of patient care and quality outcomes while mentoring staff in professional development and growth. To improve understanding of the complexities of healthcare today, interprofessional or collaborative education and practice must play a prominent role in evolving healthcare models.
Background: The Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, includes recommendations for nursing and advises collaborative practice with all healthcare disciplines. The Joint Commission mandates interprofessional "meaningful use" process changes to improve patient outcomes in a wide variety of topics that are now being led by CNSs. NICHE (Nurses Improving Care for Healthsystem Elders) offers innovative interprofessional gerontologic care models that require input and training that surpasses the expertise of any single provider. One model, "Acute Care of the Elderly" or ACE program, originated in 1994 at this Midwest teaching hospital and has subsequently been disseminated throughout the United States.
Description: Whether it is protocol development or process improvement, CNSs in this institution are always at the "table" in a leadership role. Meaningful use and venous thromboembolism prevention is an example of a required model of care that has shown remarkable process changes in this setting, resulting in outstanding patient outcomes. The exemplary process concepts of the ACE unit consistently demonstrate improved care in the acute setting, with CNSs leading the weekly interdisciplinary rounds in both the ACE unit and the intensive care unit. In addition, CNSs at this academic teaching hospital have had the opportunity to participate in interprofessional educational practice group offerings supported through a funded NIH grant awarded to affiliated schools of dentistry, medicine, nursing, and social work. Following a training session in Motivational Interviewing, 4 CNSs representing differing specialty areas of the hospital (pediatrics, oncology, obstetrics, and medical/surgical) facilitated small groups consisting of first-year dental, medical, social work, and graduate nursing students in 4-hour networking sessions. The next session topic will focus on obesity issues.
Outcomes: Improved patient outcomes utilizing targeted interventions are demonstrated consistently as a result of interdisciplinary protocols such as meaningful use, NICHE, and ACE. Additionally, the student evaluations for the interprofessional educational networking sessions were positive, with participants indicating interest in further collaborative group work.
Conclusion/Implications for Practice: Clinical nurse specialists lead and role model interprofessional practice principles and behaviors that produce improved patient outcomes and utilize this experience and expertise to provide insight and direction to interprofessional educational offerings with the goal of incorporating successful concepts into acute hospital practices in the future.
Forsythe PL, Rainbow Babies and Children's Hospital, Cleveland, Ohio
Significance/Purpose: The ability to express oneself in written form is an important professional skill required to demonstrate accomplishments and represent acumen to colleagues. Clinical nurse specialist expertise was used to develop writing skills, provide colleague motivation, and mentor staff to author manuscripts for submission and acceptance in peer-reviewed journals.
Background: Communication has 2 basic expressions, verbal and nonverbal skills. The development of effective communication skills is most often focused on improving the verbal components-the what and the how words are spoken-with less attention on the written forms of communication. Ineffective writing skills were identified at this academic teaching hospital as a barrier preventing staff nurses from authoring and submitting manuscripts for publication.
Description: In 2011, CNSs assumed the responsibility of developing and presenting a writing workshop for all levels of nurses, with the goal of motivating staff to publish their ideas. The workshop, introduced in a Nursing Grand Rounds format to present the goals, an overview of the content, and intended outcomes of the program, was attended by 30 nurses. On a monthly basis, a series of interactive sessions followed, with each presentation focused on 1 of the 3 major components of good writing-ideation supported by literature search evidence, composition, and revision. Several how-to issues were discussed, such identifying and utilizing processed evidence to support ideas, in addition to the basic tenets of effective writing. Participants submitted "works in progress" for their peers to review. The series concluded in early 2012 with 2 Nursing Grand Rounds presentations focused on the logistics of creating power point slides, completing a manuscript, composing an abstract and descriptive title, and the submission process for publication to professional journals.
Outcomes: Approximately 25 nurses completed the Write It Right series. Participants requested support for current and new article ideas. One participant authored an article that was critiqued in one of the sessions and was accepted for publication in a professional journal; a second participant has submitted 3 articles currently under review. The writing content, recognized as a growth-producing experience, is now incorporated in the hospital's career advancement preparation programs and taught in conjunction with evidence-based practice education during the nurse residency programs.
Conclusion/Implications for Practice: Clinical nurse specialist role modeling and mentoring assisted aspiring nurse authors to successfully develop professional behaviors and raised the bar of expectations for writing as an effective mode of communication for all staff nurses. This ongoing mentoring process can support a variety of projects. Future endeavors include focusing on the development of evidence-based staff specific ideas/projects and facilitating the composition and publication of these identified topics. This presentation focuses on the program's development and processes utilized to sustain staff engagement in professional endeavors.
White AJ, Cleveland Clinic, Ohio
Various clinical rounding techniques exist in the acute care environment. Implementation of clinical rounding techniques have long been a focus of the clinical nurse specialists (CNSs) who facilitate the implementation of rounds, influence change, and improve clinical outcomes. Rounds are vitally important, given the complexity of healthcare today, which includes the delivery and exchange of patient-centered information at multiple levels at multiple handoff times. Without such coordination of care, patients are at risk for poor outcomes. Causes of communication breakdown are varied as in the following examples: hierarchical-based care focused on one discipline's information as the only truth, novice nurse communication techniques and knowledge, and noninvolvement of the other disciplines in an organized fashion. When this information is kept in "silos," patient compromise can occur. Clinical nurse specialists have the ability to influence change in the outcome of patients by targeting different silos of care in the healthcare team and bridging the gap to promote coordination of the plan of care. There are many techniques in effective clinical rounding that may be utilized to effect this change. This panel will identify 4 successful CNS-involved rounding techniques utilized in a hospital system: clinical nurse specialist/RN focused-rounds, patient-focused rounds, interdisciplinary, and transition-of-care rounds and review the approach, methods, and measure of each technique in a panel discussion.
McLaughlin-Davis M, Cleveland Clinic-Lakewood Hospital, Lakewood, Ohio
Significance: The importance of seamless transitions of care cannot be overemphasized. Case managers are theoretically responsible for patient's discharges and transfer to the next level of care. Unfortunately, it is another "silo" in hospitals, so much so that often other team members do not know the discharge plan for patients under their care. The elderly are particularly vulnerable to emotional, mental, and physical harm when care transitions are not optimal.
Design: Strong interprofessional discharge rounds identify nutritional, skin, pharmacological, and behavioral needs that require intervention prior to discharge and (or) at the next level of care. In addition to these considerations, hospitals face a reduction in prospective payments for an excess of readmissions. Heart failure, pneumonia (PN), and myocardial infarctions (MI) are diagnoses targeted as those having unnecessary readmissions that take a significant physical toll on patients and a substantial financial toll on hospitals and ultimately the Medicare Trust Fund. Failure to manage care transitions in the hospital contributes to readmissions and additional Medicare spending. Twenty percent of all hospitalizations are rehospitalizations within 30 days at significant cost per case. Under the auspices of the Value-Based Purchasing Rule, hospitals are reimbursed based on grading for clinical process of care, outcomes, and patient experience domains.
Description: An education program provided to the intraprofessional team prepared them for the daily rounding process. This is part of the routine on the nursing unit and is favored by all team members.
Findings/Outcomes: Length of stay remained constant and under hospital benchmark. Patient satisfaction scores under the nurse communication and discharge information are on an upward trajectory. The professional team is committed to the process.
Conclusions: Improved patient and employee satisfaction with daily rounding.
Implications: Discharge information and communication with doctors and nurses are graded outcome measures. Tools for effective discharge rounding and communication aid in the process of rounding, care transitions, and improvement in outcome measures.
Significance: The CNS role in mentoring bedside nurses on quality patient outcomes can be difficult using graphs and tables in a fast-paced critical care environment. Quality improvement, decreased length of stay, mortality, and hospital cost have been associated with rounding. Rounding with a purpose focusing on patient-centered quality outcomes with bedside nurses is a way to positively influence change.
Design (Background/Rationale): The CNS on the 43-bed medical intensive care unit (MICU) in a tertiary teaching hospital with high nursing turnover identified an opportunity to improve nursing-related quality measures: National Database of Nursing Quality Indicators data, infection control outcomes, and quality nurse data. Interdisciplinary healthcare team involvement and participation were planned with CNS rounding with the bedside nurse. In an effort to improve nursing quality of care and increase educational awareness and positive application of care, a patient quality-focused method of rounding with the bedside nurse was chosen.
Description of Methods: This pilot project involved CNS qualitative needs assessment via interviews of nursing management, medical staff, staff nurses, the quality nurse, and review of data. A fishbone diagram identified areas of improvement and future rounding topics. One topic per week was shared with bedside nurses verbally and posted in the break rooms for viewing. The healthcare team was invited to join in the rounding focus of the week. Rounding occurred on every patient and nurse focusing on the topic of the week and its application to that nurse's patient. This pilot was conducted in October, November, and December 2011 and again in February and March 2012. The anticipated outcome would be an increase in nursing and patient quality measures sequentially each quarter.
Findings/Outcomes: The MICU grew to 53 beds in January 2012 and therefore increased the number of patients and nurses. Baseline data comparing fourth quarter 2011 to first and second quarters 2012 revealed the following percent change: pain assessment, negligible in 2 units with 10% gain in the other 2 units; restraint usage, 36% rate reduction; catheter-acquired urinary tract infection, 55% rate reduction; central line-associated bloodstream infection (CLABSI), 100% increase; ventilator-acquired pneumonia, 98% rate reduction; and unit-acquired pressure ulcer, 56% rate reduction.
Conclusions/Interpretations: The nurses responded positively to the rounds. Restraint usage, catheter-acquired urinary tract infection, VAP, and UAPU all noted rate reduction. Overall benefits were great and continue to show improvement, which is thought to be due to mentoring of all staff inclusive of the coaches.
Implications: Clinical nurse specialist nurse/patient-focused rounding is useful when a need for rapid cycle improvement is warranted. This pilot has led to the development of the CNS/Pulmonary Day incorporating simulation in training of the MICU nursing staff.
Claus S, Cleveland Clinic-Fairview Hospital, Ohio
Significance: The fast-paced environment of healthcare presents both challenges and opportunities for effective communication and patient safety. Multidisciplinary rounding as a strategy to unite the healthcare team has been shown to be effective in decreasing length of stay, mortality, hospital cost, and improved patient outcomes. Multidisciplinary rounding with the patient-centered focus is also a mechanism to improve the patient experience.
Background: Leadership on one 50-bed neuroscience nursing unit with a variety of surgical and nonsurgical patients from numerous services identified an opportunity to improve Hospital Consumer Assessment of Healthcare Providers and Systems scores specifically in the domains of physician, nursing, and medication communication. The general neurology service and the clinical nurse specialist made a commitment to support a pilot project designed to offer consistent and predictable rounding times for both patients and nurses.
Description of Methods: A pilot group of general neurology physicians, a clinical nurse specialist, unit nursing leadership, and staff nurse representatives met and rounded at a consistent and predictable time. Rounds were conducted daily on all of the general neurology service patients. Patients were informed of the process by the nursing staff and given a table tent with a business card holder with the specific rounding time. Physician and nursing rounds occurred in addition to the physician teaching rounds but allowed for sharing of information among the medical team and patient. The pilot was conducted over 6 weeks. Over the 6 weeks, the team evolved to include the pharmacist and care manager.
Outcomes: The pilot was considered a success at the end of the 6-week period and was deemed a best practice that should be continued. Measurable outcomes included an increase in the Hospital Consumer Assessment of Healthcare Providers and Systems scores for general neurology in the overall assessment, nursing communication, nurses' explanation, and medication communication.
Conclusions: The physician and nurse rounds were considered important and essential to providing care and enhancing communication.
Implications: Daily physician and nursing rounds in the format described have the potential to not only impact patient experience and satisfaction scores but also improve the quality of care that is provided to patients.
Revta B, Cleveland Clinic-Fairview Hospital, Ohio
Significance: Outcomes for stroke patients are better when providers comply to Stroke Core Measures. Literature suggests adherence to patient care measures is enhanced when an interdisciplinary team is used. Literature review shows evidence related to the effectiveness of interdisciplinary teams in many clinical areas, yet no study has documented the impact of daily stroke rounds by an interdisciplinary team led by the clinical nurse specialist on compliance to Stroke Core Measures.
Design: Compliance to Stroke Core measures was compared at 4 points, corresponding to the addition of professionals to the Interdisciplinary Stroke Team.
Description of Methods: Prior to August 2009, our facility had no designated person or team assigned to monitor Stroke Care Practice within the facility. In August 2009, 1 clinical nurse specialist (CNS) began to oversee Stroke Care for the facility. The team later added a neurologist and then finally a pharmacist. To examine the impact of the development of an Interdisciplinary Stroke Team on patient outcomes, we compared the total adherence rates for 8 Stroke Core Measures for each of 4 time frames (baseline, CNS only, CNS and neurologist, and CNS, neurologist, and pharmacist). A large registry provided the data for this study. Compliance to the stroke measures is calculated as a percentage of total stroke measures that were completed.
Outcomes: Baseline data (n = 108) showed that between August 2008 and July 2009 compliance to Stroke Core measures was 79.22%. Clinical nurse specialist-only data (n = 286) showed that between August 2009 and January 2011 compliance to Stroke Core measures was 81.75%. Clinical nurse specialist plus neurologist data (n = 114) showed that between February 2011 and August 2011 compliance to Stroke Core measures was 93%. Finally CNS, neurologist, and pharmacist data (n = 207) showed that between September 2011and June 2012 the compliance to Stroke Core measures was 97%.
Conclusion: Interdisciplinary stroke team composed of CNS, neurologist, and pharmacist was most effective in improving overall compliance to Stroke Core measures in our facility.
Gunn S, Clinical Nurse Specialist, Dallas, Texas
Delirium in the older adult patient population is a significant issue, with incidence of delirium cited in the literature as high as 90%. Delirium increases costs, mortality, lengths of stay, and ventilator days. Delirium is associated with long-term cognitive dysfunction, decreased quality of life, and increased utilization of long-term-care facilities in geriatric patients. In the past, delirium has been an underemphasized complication for older adult patients in acute and critical care settings, but as evidence about appropriate prevention, recognition, treatment, and long-term effects continues to emerge, nurses play a valuable role in affecting patient outcomes. This is an area with many opportunities for CNSs to make a difference in patient outcomes both in terms of financial and human costs. Our goal during this symposium is to highlight tactics CNSs can take to influence nursing and interdisciplinary practices related to delirium. The symposium will provide background information on how geriatric patients are particularly at risk for delirium and adverse outcomes associated with delirium. During this introductory session, opportunities for CNSs to implement practice change, track process measures, and impact long-term outcomes will be addressed. The second part of the symposium will provide the audience with an example of a pilot implemented on a general medical unit specifically addressing the incidence of delirium in the geriatric patient population. This session will include elements of change management, lessons learned, results of the pilot, and strategies to prompt spreading best practices. The symposium will end with an overview of a CNS-led research project in 2 facilities, tracking delirium in the geriatric patient and how technologies such as interactive video games, volunteer activities, and mobility were implemented as research variables. An overview of the research study, the role of the CNS, and lessons learned will be highlighted.
Gunn S, CNS Internal Medicine, Dallas, Texas
Purpose: The purpose of this presentation is to provide an overview of geriatric demographics, delirium outcomes, and implications for CNS practice.
Significance: As the US population ages and places increased burden on healthcare costs, CNSs are in a prime position to demonstrate their expertise to influence outcomes in the geriatric patient population. Patients older than 65 years account for 50% of our hospital days and healthcare costs. Delirium is a largely preventable condition that costs the United States more than $150 billion annually. Persons older than 65 years are particularly vulnerable to developing delirium. Patients who become delirious in the acute care setting have increased mortality, length of stay, complications, readmission rates, and long-term cognitive decline. Additionally, the older adult with delirium is more likely to be discharged to a long-term-care facility instead of going home.
Rationale: Implementing delirium screening, introducing and reinforcing evidence-based nursing practices to prevent or minimize the incidence of delirium, and tracking subsequent outcomes is a great way for any CNS to demonstrate their value to the organization.
Methods: This abstract will provide a brief overview of delirium. An explanation of why the geriatric patient population is a focus will be presented. Nursing practices to prevent or minimize delirium will be described. This information was gleaned from an extensive review of current literature on this topic.
Findings/Conclusions: The methods and approaches we have taken regarding this topic have revealed ample opportunity for CNSs to work within all 3 spheres of influence using their roles as expert clinician, consultant, and change agent.
Implications: This overview provides the foundational content for the rest of this symposium. It also explains how to identify areas of opportunity, collect appropriate evidence, and translate evidence into practice at the bedside.
Wheeler M, Baylor Healthcare System, Dallas, Texas
Purpose The purpose of the study presented is to explore the impact on cognitive, functional, quality, financial, and satisfaction outcomes of a delirium prevention program inclusive of interactive gaming technology on hospitalized patients 70 years or older. Goals of this study are to prevent delirium, decrease length of stay, improve physical function, decrease cost per case, and help the patient transition from hospital to their preadmission level of care easily.
Significance: Delirium in older adults has revealed negative outcomes and is a significant problem. The use of technology to prevent/treat delirium is an innovative approach to care, but there is not much research conducted in this area, especially within the acute care setting.
Background: Prevention of delirium in hospitalized patients is becoming a large focus in the care of older adults. A clinical nurse specialist (CNS)-led research study was performed to compare a well-known delirium prevention program with the addition of interactive gaming technology. The use of interactive gaming to prevent delirium has not been studied in formal research trials. We wanted to determine if this innovative approach would affect patient outcomes positively. The CNS roles of researcher, consultant, change agent, and expert clinician are exemplified through study tasks such as screening and enrolling patients, evaluating them on a regular basis, and adjusting intervention protocols as needed. This is a perfect example of how a CNS also works within all 3 spheres of influence to integrate and standardize cutting-edge care. The study involved collaboration with an interprofessional team, including volunteers, physical therapy, physicians, nurses, social work, and care coordination.
Methods: A randomized, 2-group before/after design with an additional historical comparison group was used. A control group was selected from historical data that are routinely collected as standard of care. This control group was used since the delirium prevention program has been shown to provide benefits to participants, and it would be unethical not to provide an intervention. Potential participants in the randomized groups were screened, gave informed consent, and then randomized to the delirium prevention program or the delirium prevention program with interactive gaming technology.
Findings: This study has not yet been completed. Outcome measures include initial episode of delirium, cognitive status, and functional status.
Conclusions: Findings from the study will be discussed as part of the symposium presentation.
Implications for Practice: Decreasing delirium episodes promotes quality of life for elderly patients, allowing more of them to live independently. Innovations in interactive gaming technology will only assist the CNS in caring for older adults. Further implications for CNS practice will be discussed, and an opportunity for question-and-answer audience participation will be provided.
Flanders S, Baylor University Medical Center, Dallas, Texas
Purpose/Significance: Delirium has been recognized as a clinically significant problem in acute and critical care units. Patients may be at risk to develop delirium due to predisposing factors existing prior to their hospital stays, precipitating factors related to care delivered, or both. Delirium prevention and early recognition and treatment are crucial because development of delirium can lead to short- and long-term negative patient outcomes, increase hospitals' costs and lengths of stay, and require more nursing resources. As recent research on delirium has demonstrated the importance of addressing this significant clinical issue to all 3 spheres of clinical nurse specialist (CNS) influence, CNSs are optimally positioned to lead change by ensuring the interdisciplinary team is prepared to minimize delirium's impact on at-risk patients.
Background/Description: In our hospital, patients in critical care units were being screened for delirium, but patients in our acute care medical-surgical units were not. One of the medical units with a high proportion of older adult patients was selected by the CNS to pilot the feasibility of implementing delirium screening, prevention, and interventions. The nurse manager agreed, and the CNS mentored 2 staff nurses to lead components of the pilot through an evidence-based practice professional project as an innovative approach to enhance staff nurse buy-in. The CNS collaborated with physicians to adapt the critical care delirium order set to the non-critical care acute care units and engaged interdisciplinary staff including physical and occupational therapists, pharmacists, chaplains, and patient care technicians in the initiative. Staff education was conducted on delirium prevention, screening, and interventions. Family education was also developed so families could stay informed and be encouraged to partner with staff in the plan of care. Shift supervisors assisted by reminding staff to complete delirium screenings each shift and following up to ensure assessments were documented. Data were collected related to completion of screenings, positive screens, and actions taken.
Outcomes: Outcomes demonstrated staff became more consistent in completing screens as the pilot progressed, and when a patient screened positive for delirium, timely provider notification occurred.
Conclusions: Nurses verbalized delirium screening took very little time and were positive about the project. Because of the successful implementation in the pilot unit, the CNS pulled together a broad group of stakeholders with the endorsement of senior nursing leaders and key physicians. The group included nurse managers, CNSs, and educators, who aligned with the CNS's proposal that delirium screening become integrated into care for inpatient adult medical, surgical, cardiovascular, and oncology populations.
Implications: Nurses on all involved units have been educated about delirium, and it is anticipated this change in practice will reduce risks of developing delirium to the patients under our care.
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