1. Sitterding, Mary MSN, CNS

Article Content


To succeed, a CNS innovator will disturb the present. A kaleidoscope, not a computer, is the ultimate weapon to help CNSs meet the challenges of the 21st century. Factors that drive the business case for the CNS innovator in the hospital include the following: patient/family expectations; public expectations based upon public-reported indicators and outcomes; changing workforce; clinician dissatisfaction; and a drive for excellence. Innovation emerges as the CNS works with teams to apply basic principles of complexity science. The opportunity was for the CNS to utilize a complex adaptive systems (CCASs) approach to achieve and sustain excellence regarding public-reported surgical site infection process indicators that include antibiotic administration within 60 minutes of first incision; antibiotic selection; and the duration of antibiotic prophylaxis.



Complex adaptive systems are collections of individuals or agents who act in ways that are not always totally predictable, and whose actions are interconnected so that one agents actions change the context for other agents (Plsek & Greenhalgh, 2001). The CNS worked with the Surgical Site Infection Prevention Team to identify and modify structures, processes, and patterns influencing achievement and sustainability. Utilizing a complexity lens, surgical site infection process improvement was led by senior leadership who positioned surgical site infection as a strategic priority. The CNS used the CAS framework to engage bedside nurses using a "few simple rules" (Plsek, 2000). Simple rules include (1) all of our work is patient-centered; (2) all of our work is evidence-based; and (3) solutions are derived from the bedside nurse. A good enough vision regarding surgical site infection prevention improvement initiative was clearly and frequently communicated informally and formally at nursing unit nursing practice councils as well as within leadership forums. With the initial improvements implemented, resistance to practice change was anticipated. The CNS designed strategies aimed at decreasing resistance, ie, incentive, information, intervention, indoctrination, and involvement (Hammer and Staton, 1995).



Among retrospective records reviewed, 90% to 100% of persons receiving an elective total joint replacement and coronary artery bypass graft CABG receive antibiotic administration within 60 minutes of first incision. In addition, 90% to 100% of records reviewed suggest evidence-based selection of antibiotics for this population. Surgical site infection rates have decreased among target populations. Initial achievement was realized in 2001 and has been sustained as the team attempts spread across other eligible populations served.



Providers and hospitals are CASs. In complex systems, unpredictability and paradox are inherent. The machine metaphor doesn't allow us to understand fully the influence of nondisease-based patterns influencing system outcomes. The CNS is well positioned to diagnose and manage nondiseased-based patterns (knowledge deficit, self-efficacy, outcome efficacy, values, influencing provider practice. Understanding and applying basic concepts of CASs broadens the CNS capacity to meet the expected patient, provider, and system outcomes.


Implications for Practice

The CNS is well positioned to positively influence CMS public reported outcomes such as surgical site infection prevention process indicators by applying a CASs approach to diagnosing, modifying, and/or eliminating structures, processes, and patterns influencing patient, provider, and system outcomes. CNS competencies demonstrated within this innovation include, but are not limited to, the following: (1) design system-level assessment methods and instruments to identify organization structures and functions that impact nursing practice and nurse-sensitive patient care outcomes; (2) diagnose variations in organizational culture (values, beliefs, or attitudes) that can positively or negatively affect outcomes; (3) plan for achieving intended system-wide outcomes, while avoiding or minimizing unintended consequences; and (4) design methods/strategies to sustain and spread change and innovation.


Section Description

This year's annual NACNS conference is planned for Orlando, Fla, March 9-12, 2005. Over 300 clinical nurse specialists (CNSs) are expected to attend, and as with past conferences, attendees will also include graduate faculty from CNS programs, nurse administrators, and nurse researchers. The theme of the conference, CNS Leadership: Navigating the Healthcare Environment Toward Excellence, was selected to showcase the many ways CNSs acquire and disseminate knowledge and innovative practices in their specialty areas. Two preconference sessions are scheduled. One session, sponsored by NACNS Legislative/Regulatory Committee, targets information for CNSs interested in understanding the legislative/regulatory process as it deals with the practice of nursing, and will also help build skills CNSs need to engage in the process. The second session, sponsored by NACNS Education Committee, focuses on CNS education issues, and as with the education preconferences of past years, anticipates informative dialogue and much sharing among CNS educators around curriculum design, teaching strategies, and indicators of quality in the curriculum that link to the NACNS education standards to program review and excellence. The conference planning committee is proud and pleased to have Jeanette Ives Erickson, MS, RN, CNA, Senior Vice President for Patient Care Services and Chief Nurse Executive of Massachusetts General Hospital as the opening keynote speaker. She will begin the conference by highlighting the importance of CNS practice on patient safety. The planning committee is equally proud and pleased to have NACNS past-president Rhonda Scott, PhD, RN, Chief Nursing Officer of Grady Health System as the closing speaker. Dr Scott will challenge attendees to use the information from the conference to shape quality care delivered in a safe environment and to advance the profession of nursing through direct care to clients, influencing standards of care delivered by other nurses, and influencing the healthcare delivery system to be to support innovative, cost-effective, quality nursing care. A total of 64 abstracts for podium and poster presentations were selected in addition to graduate student posters. The abstracts address the 3 spheres of CNS practice with a strong emphasis on clinical practice improvements. As you will note from the abstracts published in this issue of the journal, specialty practice areas represented in the abstracts include children, adults, and gerontological patient groups; hospital, outpatient, and home care settings, and community health. In addition, a wide variety of specialty topics including smoking cessation programs, end-of-life care issues, and protocols outlining nursing approaches to improved diabetes, cardiovascular and ventilator management. A number of the abstracts described hospital and healthcare system level innovations that resulted from CNS practice. Collectively, these abstracts reflect the breadth, depth, and richness of CNS contributions to the well-being of individuals, families, groups, and communities. The following abstracts are from those presenters who elected to have their work published in the journal so those who are unable to attend this year's conference can share in the knowledge of the conference. As you read each abstract, consider the talent and clinical scholarship of your CNS colleagues who are advancing the practice of nursing and contributing to improved outcomes for patients and healthcare organizations. You may want to contact individual presenters to network, collaborate, consult, or share your own ideas about these topics. Watch for next year's call for abstracts and consider submitting an abstract for presentation at NACNS's next conference in Salt Lake City, Utah, March 15-18, 2006.