1. Fulton, Janet S. PhD, RN, ACNS-BC, FAAN

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Clinical nurse specialists (CNSs) often are described, in part, as providers of care for "complex patients." This notion of complex patients, or more accurately patients with complex health needs, generally is equated with caring for individuals with multiple physiological failures and thus requiring knowledgeable and skilled nurses with specialty expertise of a CNS. Clinical nurse specialists are nursing's go-to providers particularly for hospitalized patients with difficult care problems. Clinical nurse specialists develop care plans and provide bedside leadership for supporting staff in delivering and evaluating complex care routines. With the trend to move healthcare delivery out of the costly acute care hospital and patients and their families assuming greater responsibility for managing complex care in the home environment, it's timely to take a new look at what caring for patients with complex care means.


Take the example of a factious patient I'll call Harry. At 48 years old, an overweight Harry was diagnosed with diabetes. Now 54, he has added cardiac disease, renal insufficiency, and peripheral neuropathy to his pathophysiologic conditions. In addition to multiple hospitalizations for evaluation and intervention, Harry is a frequent visitor to the local emergency room for management of acute symptoms. A data review of emergency department costs tags Harry as a problem.


Harry is a patient with complex disease-related care needs. He isn't very compliant with prescribed care, continues to gain weight, and misses clinic appointments, all factors contributing to advancing disease and compounding symptoms. I've been supervising CNS students in clinical courses for some time, and I have read all too many case studies in the genre of Harry. Part of the solution to slowing disease progression and keeping Harry out of the emergency department involves education about diabetes management and wellness maintenance, and students are quick to note that nurses are frontline patient educators, and they can easily recognize situations where patients would benefit from education. But who are we educating? Who is Harry, not the collection of deficits in physiologic function compounded by deficits in self-management, but Harry, the person?


Health assessments are focused on selective questions intended to contribute to diagnostic conclusions and include few probative questions about the context of patients' lives. We offer medical treatments, nursing interventions, and lifestyle advice with minimal understanding of the patient's history, beliefs, and practices. One reason for Harry's continuing disease progression and weight gain is because, as an electrician for a major contractor, he spends hours on job sites. The crew he works with has made it a goal to find the cheapest lunch deal, so a fast-food double bacon burger with a large fries and drink is often the winner! Harry understands that a lunch of a sandwich, fruit, and water is a better choice, but really, how can he eat a simple sack lunch in the midst of the enticing smells of burgers and fries. And eating with the crew is critical for finding out about additional income opportunities like overtime and side jobs. Harry has a child with special needs from his current marriage and 2 teenagers from a previous marriage. He works as much as possible to cover expenses and saves his paid time off for summer vacation visits with his oldest 2 children. With the clinic open during times he needs to work, and job sites often far away, he sees skipping appointments is the only option. He is a good electrician, and no one notices that his reading level is low. Every healthcare encounter brings more written instructions, all neatly stacked on the corner of his kitchen counter.


Yes, Harry is a patient with complex healthcare needs because he is a patient with a complex life. If we are to make progress in improving patient outcomes and reducing healthcare costs, healthcare providers must address patients in the context of their lives. As the advanced practice nurses historically charged with addressing complex care needs, CNSs must expand their practice focus to include the complexity of lives in which patients are now being asked to self-manage disease. Without this expanded view, we will continue to provide expensive, technologically driven care to alter the pathophysiology of disease with little attention to the person in which the disease resides. As the future with healthcare reform unfolds, meeting complex health needs of patients is increasingly about understanding the complexity of patients' lives. Patients act in accordance with their own self-interests. In lieu of probing deeper for an understanding of a patient's behavior, we are quick to use a label of noncompliance. Noncompliance on the part of the patient signals nonunderstanding on the part of the provider. As CNSs, our responsibility is to gain a deeper understand of patients' lives. Our current boiler plate assessments fall far short of garnering the level of understanding needed to adapt interventions for the patient's life. In the future, the best possible level of health outcomes will be defined by patients in the context of their complex lives.