Transcript Slide 1

Descriptive Research
The Work of
Clinical Nurse Specialists
in the Acute Care Setting
Julie Darmody MSN, RN, ACNS-BC
Doctoral Candidate, UW-Madison School of Nursing
Clinical Assistant Professor, UW-Milwaukee College of Nursing
Acknowledgements
This research was partially supported by:
• Nurses Foundation of Wisconsin Grant
• Helene Denne Schulte Research
Assistantship, UW-Madison School of
Nursing
Acknowledgements
• Mary Ellen Murray PhD RN (Advisor)
• Murray Research Team
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Mary Hook PhD, RN
Roberta Pawlak MS, RN
Yulia Semeniuk MS, RN
Judy Westphal MSN, RN
Nicole Bennett MS, RN
Karin Kunz BS, RN
Purpose
Conduct a broad exploratory
study that will describe the
work of the CNS in acute care
from multiple perspectives.
Objectives
Collect data on the following:
• organization characteristics
• job descriptions
• CNS activities and time
• perceptions of CNSs & Administrators about
most important CNS activities and outcomes
Background
• Safety & quality are critical issues in
health care
• CNSs have great potential to influence
safety & quality in acute care
Significance
• Current increase in employment
opportunities for the CNS in acute care
(Gerard & Walker, 2003; Sole, 2004)
• Challenges include a lack of
understanding about the effect of CNS
practice on patients, nurses, and systems
(Walker, et al, 2003)
Advanced Practice Nurses
National Sample Survey of RNs, 2004
http://bhpr.hrsa.gov/healthworkforce/reports/rnpopulation/preliminaryfindings.htm
CNS Practice
• The Clinical Nurse Specialist (CNS) is a
masters-prepared advanced practice nurse
who is a clinical expert in evidence-based
nursing practice within a specialty area
(ANA, 2004)
• The Clinical Nurse Specialist (CNS)
influences patients, nurses, and the
organization to achieve quality, cost-effective
outcomes (NACNS, 2004)
Framework for CNS Practice
• NACNS, 2004
Direct Patient / Client Care
Nurses
And
Nursing Practice
Organizations
And
Systems
Review of Literature:
Foundations of CNS Practice
• Foundation or core of CNS practice is
clinical expertise with patients in a specialty
area (Sechrist & Berlin, 1998; Wilson-Barnett & Beech, 1994)
• Common features of developing practice
models are that the CNS is a clinical expert
who utilizes influence to improve patient
outcomes (Ball, 1999; Ball & Cox, 2003; Ball & Cox, 2004; NACNS, 1998;
NACNS, 2004)
Observing the work of the Clinical Nurse
Specialist: A Pilot Study (Darmody, 2005)
• Purpose: develop a tool for recording the
activities of CNSs using the NACNS Model
• Sample: n=5 CNSs in one acute care setting
• Method: Direct observation (4 hours/CNS =20 hrs)
• Results: CNS activity/time with
– Patients=30%
– Nursing personnel=44%
– Organization=10%
– Other Activities=16%
Design and Methods
• Descriptive Mixed Method Study
• Data Sources
– Multidimensional Work Sampling
(MDWS)
– CNS Questionnaire
– Administrator Questionnaire
– CNS Job Descriptions
Setting and Sample
• Four Health Care Organizations in the Midwest
• CNS Participants (n=30)
Masters prepared and employed in an acute care setting in a
position titled CNS
• Administrator Participants (n=7)
Responsible for supervision and evaluation of CNSs in the
organization
• Job descriptions (n=12)
Organization Characteristics
• Who do CNSs report to?
System-wide (n=1), hospital-wide (n=1), or multiple (n=2)
• Job Descriptions
Single (n=2) or Multiple (n=2)
• Structure of CNS Responsibility
– Majority are unit-based (n=1)
– Majority are population-based (n=2)
– Combination of unit and population-based (n=1)
CNS Characteristics (n=30)
• Age Range
30-39: 7 (23.3%)
40-49: 12 (40%)
> 50 : 11 (36.7%)
• Average years of
experience as CNS: 9.63
years
• Average years in current
CNS position: 6.08 years
• Work Status (FTE)
Full-time: 22 (73.3%)
Part-time (0.5 to 0.9): 8 (26.6%)
• Responsibility
– Unit-based: 16 (53%)
– Population-based: 14 (47%)
CNS Characteristics (n=30)
• Specialty Patient Population
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Critical Care/Emergency: 4 (13.3%)
Diabetes: 4 (13.3%)
Geriatric: 3 (10%)
Medical-Surgical: 13 (43.3%)
Obstetric/Neonatal/Pediatric: 4 (13.3%)
Pain & Palliative Care: 2 (6.7%)
• Certification as Advanced Practice Nurse:
Yes: 19 (63.3%) No: 11 (36.7%)
Administrator Characteristics
(n=7)
• Position Titles: Varied including Director,
Assistant Vice-President, Vice President
• Education: All Masters prepared in Nursing
or Business Administration
• Representation: At least 1 Administrator
participant from each of the 4 organizations
with several organizations having more than
1 participant
Recruitment & Data Collection
(Sept 2006 thru Jan 2008)
– E-mail recruitment messages to eligible CNS
and Administrator Participants
– Group or individual meeting with researcher
– Return questionnaires and consents by mail
• Enrolled CNSs = 30 (33%)
• Enrolled Administrators = 7 (41%)
– CNS participants
• Training appointment
• Quiz #1 after training and Quiz #2 two weeks later
• Work sampling data collection until 240 data points
Job Descriptions (n=12)
• Framework
– NACNS model (17%)
– Sub-role or other framework (83%)
• Literature-based themes present
– Quality & Evidence-based practice consistently present
– Clinical & fiscal outcomes usually described in general
terms
– Safety not included in majority of job descriptions
Random Work Sampling
• CNSs carried Random Reminder
Instrument (Divilbiss Electronics)
• Recorded work activity on checklist each
time a random signal was received
• CNS Activity Checklist was developed in
a pilot study (Darmody, 2005)
Random Work Sampling Results
• CNSs self reported 7,564 data points or
observations during 518 work days and
4,216 hours
• CNS work days averaged 8.14 hours in
length
• Each CNS subject recorded an average of
252 data points during 17.3 days and 140.6
hours of work
CNS Work Activity
CNS Work
Activity
Frequency Percent
Patients
Nursing
2,172
1,715
28.7%
22.7%
Organization
Other
Total
2,517
1,160
7,564
33.3%
15.3%
100%
95% Confidence
Interval
± 1.02% (27.7-29.7%)
± 0.94% (21.7-23.6%)
± 1.06% (32.2-34.3%)
± 0.81% (14.5-16.1%)
CNS Activity with Patients
Patient Activity
Frequency
Percent
Interdisciplinary Rounds
417
5.51%
Patient Consultation
305
4.03%
Coordination of Care
287
3.79%
Direct Patient Care
285
3.77%
Chart Review
256
3.38%
Patient Teaching
180
2.38%
Care Communication
129
1.71%
Documentation
123
1.63%
Brief Interaction
86
1.14%
Nursing Rounds
56
0.74%
Discharge Planning
Total Patient Activity
48
2,172
0.63%
28.71%
CNS Activity with Nurses
Nursing Activity
Frequency Percent
Nursing Education
853
11.28%
Nursing Orientation
309
4.09%
Nursing Question
286
3.78%
Nursing Communication
186
2.46%
Performance Evaluation
81
1.07%
Total Nursing Activity
1,715
22.67%
CNS Activity with the Organization/System
Organization Activity
Frequency
Percent
Committee Meeting
Quality Improvement
Problem solving
725
593
370
9.58%
7.84%
4.89%
Protocol/Guideline Development
CNS Group Meeting
Organization Question
315
208
161
4.16%
2.75%
2.13%
Safety
Education: Interdisciplinary
Product/Equipment Review
Program Development
123
13
6
3
1.63%
0.17%
0.08%
0.04%
Total Organization Activity
2,517
33.28%
Other CNS Activity
Other CNS Activity
Frequency
Percent
Personal Time
Schedule/Calendar
Continuing Education (Self)
613
399
64
8.1%
5.27%
0.85%
E-Mail Management
Scholarship: Write/Present
40
20
0.53%
0.26%
Research
Professional Organization
Total Other Activity
14
10
1,160
0.19%
0.13%
15.34%
CNS Contacts
CNS Contact
Frequency
Percent
Self (working alone)
Group Meeting
Nurse
2,843
1,704
1,263
37.59%
22.53%
16.7%
Patient
Manager
376
372
4.97%
4.92%
Provider (any non-nursing provider)
All other contacts
Total CNS Contacts
239
767
7,564
3.16%
10.13%
100%
CNS Work by Organization
Site Sample Patients Nursing Organization Other
Org
A
n=9
23.4%
28.2%
32.5%
15.8%
Org
B
n=6
47.8%
11.7%
27.9%
12.5%
Org
C
n=9
17.7%
29.8%
38.8%
13.7%
Org
D
n=6
35.4%
14.2%
31.0%
19.4%
Most Important CNS Activities
(Likert Scale: 1=not at all important; 5=highly important
• CNS Perception (n=30)
• Develop clinical protocols &
guidelines (4.467)
• Quality improvement
projects (4.433)
• Nursing education (4.433)**
• Coordination of care (4.067)
• Nursing orientation (4.000)
** statistical significance
• Administrator Perception
(n=7)
• Develop clinical protocols &
guidelines (4.571)
• Rounds: Interdisciplinary
(4.429)
• Quality improvement projects
(4.286)
• Rounds: Nursing (4.143)
• Coordination of care (3.857)
Most Important CNS Outcomes
(Likert Scale: 1=not at all important; 5=highly important)
• CNS Perception (n=30)
• Evidence-based nursing
care (4.967)
• Skilled & competent
nursing staff (4.800)**
• Patient satisfaction
(4.533)
**statistical significance
• Administrator
Perception (n=7)
• Skilled & competent
nursing staff (5.000)**
• Evidence-based nursing
care (4.857)
• Patient satisfaction
(4.429)
Summary & Conclusions
Random work sampling
• The NACNS model provides a useful framework
• Average proportions of CNS time spent in major work
categories in the NACNS Framework:
•
patients 28.7%
•
nursing personnel 22.7%
•
organization/system 33.3%
•
other activities 15.3%
• Population-based CNSs spent a greater percent of time in
activities with patients while unit-based CNSs spent a greater
percent of time with nursing personnel.
Summary & Conclusions (cont)
Organization Characteristics
• This study revealed variations between organizations on
CNS job descriptions, reporting relationships, and how CNS
responsibility is structured within the organization.
Perceived Importance of Activities and Outcomes
• Overall the most important activities and outcomes as
perceived by CNSs and administrators were similar.
– CNSs placed significantly greater importance on the activity of
nursing education and the outcome of patient knowledge
– Administrators placed significantly more importance on the outcome
of skilled and competent nursing staff
Implications
• Link work activity to clinical and fiscal outcomes
“Explicit descriptions of the work of APNs are essential to
understanding the process of care and empirically linking
this to outcomes.”
Cunningham, R. (2004). Advanced practice nursing outcomes: A review of selected empirical literature.
Oncology Nursing Forum, 31(2), 219-230.
• Articulate the value of CNS practice
“Articulating how, why, and for whom they add value is
critical to the future viability of the APN role and the
delivery of quality healthcare services to the public.”
Cunningham, R. (2004). Advanced practice nursing outcomes: A review of selected empirical literature.
Oncology Nursing Forum, 31(2), 219-230.
Questions?
Comments?
Thank you!
Julie Darmody MSN, RN, ACNS-BC
[email protected]
Doctoral Candidate, UW-Madison School of Nursing
Clinical Assistant Professor, UW-Milwaukee College of Nursing