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Exponential increases in healthcare knowledge are resulting in a mind-boggling amount of information to be absorbed and used in patient care. Accessing and using this new knowledge present real challenges for clinicians, particularly advanced practice nurses (APNs). The two articles by Duffy and Schulmeister and Vrabel in this section of Clinical Nurse Specialist offer concrete suggestions for managing two aspects of the knowledge explosion, namely the use of nurse-sensitive quality indicators and accessing the literature.


Escalating concerns regarding quality and a sustained research focus on patient outcomes during the last two decades are beginning to bear fruit. Rapid growth is occurring in resources available to guide clinical practice and in research-based literature evaluating outcomes. Increasingly, national data sources and evidence-based practice guidelines are available from the Internet. Examples include the National Guideline Clearinghouse database of evidence-based clinical practice guidelines ( and two nationally developed performance measures for evaluating healthcare quality, the Foundation for Accountability quality measures ( and the National Committee for Quality Assurance's Health Plan Employer Data and Information Set (HEDIS)( Sorting through the universe of indicators to achieve a realistic and usable subset of quality measures to gauge outcome attainment is indeed a challenge. As Duffy notes, the goal is to identify indicators that are nurse-sensitive 1 yet not overly burdensome to implement given existing resources. The critical indicator matrix she describes can be a means to accomplish this goal. Clinical nurse specialists who take a leadership role in identifying outcomes and related indicators can save their institutions valuable time and money.


A number of authors 2-4 have summarized the growing evidence of the impact of APN practice on patient outcomes. In particular, the last few years have brought exciting progress in the area of studying the relationship between structures, processes, and outcomes. 3 Two recent examples deserve special mention. Naylor and colleagues 5 studied the impact of an APN-directed discharge planning intervention for elderly patients who were hospitalized. They found fewer hospitalizations, a longer interval between discharge and rehospitalization, and significantly lower costs in the patient group receiving the APN intervention compared with the group not receiving the intervention. McCorkle and colleagues 6 studied an APN-directed home care intervention for older postsurgical patients with cancer. Overall, patients in the intervention group had higher survival rates than did patients in the control group. Of particular significance was the finding that patients with late-stage cancer receiving the APN intervention had 2-year survival rates twice those of patients in the usual care group. These encouraging studies demonstrate the powerful affect of APNs on patient well-being and even survival, and provide good examples of nurse-sensitive outcome indicators. As Duffy notes in this issue, continuing to refine nursing-sensitive outcomes for their patient population is an important leadership activity of CNSs.


It has been my belief for 20 years that all APNs must gather outcome data on their practices. Graduate nursing programs play a critical role in enculturating APN students to the necessity of outcome evaluation. At the University of Virginia, students link outcomes to care processes in several courses. For example, the research course culminates with an evidence-based project that identifies and critiques the research literature on a clinical problem, proposes an evidence-based intervention, and details the outcomes to be measured in evaluating the success of the intervention. The APN's ability to evaluate the outcomes of care is an important value-added benefit of advanced nursing practice. Students should showcase their abilities in this area in their portfolios and speak to this strength when interviewing for positions after graduation.


Accessing this burgeoning literature also presents new challenges. There is a growing revolution in the means of accessing literature and clinical guidelines, particularly in the use of electronic data searching, the Internet, and personal digital assistants (PDAs). Schulmeister's tips for searching PubMed are helpful for any electronic database. Graduate education is also changing in response to these new technologies. As one example, we now send incoming students an assessment tool to evaluate their knowledge and comfort with computer technology and programs, PDAs, and literature searching using electronic databases. Students with limited experience in these areas attend summer technology sessions to familiarize themselves with the tools and technology expectations of the graduate program. These sessions better prepare students to meet the growing expectations for use of technology in learning environments.


There is no sign that the current explosive growth in knowledge is abating; quite the contrary! APNs can and must be leaders in harnessing this growing knowledge base for the benefit of their patients and the nursing profession.




1. Brooten D, Naylor MD. Nurses' effect on changing patient outcomes. Image J Nurs Scholar. 1995; 27:95-99. [Context Link]


2. Girouard SA. Evaluating advanced nursing practice. In: Hamric AB, Spross JA, Hanson CM, eds. Advanced Nursing Practice: An Integrative Approach. Philadelphia: WB Saunders; 1996:569-600. [Context Link]


3. Girouard SA. New directions for the advanced practice nurse in health care quality. In: Hamric AB, Spross JA, Hanson CM, eds. Advanced Nursing Practice: An Integrative Approach. Philadelphia: WB Saunders; 2000:755-794. [Context Link]


4. Urden LD. Outcome evaluation: an essential component for CNS practice. Clin Nurse Spec. 1999; 13:39-46. [Context Link]


5. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999; 281:613-620. [Context Link]


6. McCorkle R, Strumpf NE, Nuamah IF, et al. A specialized home care intervention improves survival among older post-surgical cancer patients. J Am Geriatr Soc. 2000; 48:1707-1713. [Context Link]