Descriptive ResearchDescriptive Research

The Work of Clinical Nurse Specialists in the Acute Care Setting

Julie Darmody MSN, RN, ACNS-BCDoctoral Candidate, UW-Madison School of Nursing

Clinical Assistant Professor, UW-Milwaukee College of Nursing

AcknowledgementsAcknowledgements

This research was partially supported by:

• Nurses Foundation of Wisconsin Grant

• Helene Denne Schulte Research Assistantship, UW-Madison School of

Nursing

AcknowledgementsAcknowledgements

• Mary Ellen Murray PhD RN (Advisor)

• Murray Research Team

– Mary Hook PhD, RN– Roberta Pawlak MS, RN– Yulia Semeniuk MS, RN– Judy Westphal MSN, RN– Nicole Bennett MS, RN– Karin Kunz BS, RN

PurposePurpose

Conduct a broad exploratory study that will describe the work of the CNS in acute care from multiple perspectives.

ObjectivesObjectives

Collect data on the following:

• organization characteristics

• job descriptions

• CNS activities and time

• perceptions of CNSs & Administrators about most important CNS activities and outcomes

BackgroundBackground

• Safety & quality are critical issues in health care

• CNSs have great potential to influence safety & quality in acute care

SignificanceSignificance

• 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 NursesAdvanced Practice NursesNational Sample Survey of RNs, 2004National Sample Survey of RNs, 2004

http://bhpr.hrsa.gov/healthworkforce/reports/rnpopulation/preliminaryfindings.htmhttp://bhpr.hrsa.gov/healthworkforce/reports/rnpopulation/preliminaryfindings.htm

CNS PracticeCNS 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 PracticeFramework for CNS Practice

• NACNS, 2004

Direct Patient / Client Care

Organizations

And Systems

Nurses And

Nursing Practice

Review of Literature:Review of Literature:Foundations of CNS PracticeFoundations 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 Observing the work of the Clinical Nurse Specialist: A Pilot Study Nurse Specialist: A Pilot Study (Darmody, (Darmody,

2005)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 MethodsDesign and Methods

• Descriptive Mixed Method Study

• Data Sources

– Multidimensional Work Sampling (MDWS)

– CNS Questionnaire– Administrator Questionnaire – CNS Job Descriptions

Setting and SampleSetting 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 CharacteristicsOrganization Characteristics

• Who do CNSs report to? System-wide (n=1), hospital-wide (n=1), or multiple (n=2)

• Job DescriptionsSingle (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)CNS Characteristics (n=30)

• Age Range

30-39: 7 (23.3%)40-49: 12 (40%)> 50 : 11 (36.7%)

• Work Status (FTE)

Full-time: 22 (73.3%)Part-time (0.5 to 0.9): 8

(26.6%)

• Average years of experience as CNS: 9.63 years

• Average years in current CNS position: 6.08 years

• Responsibility – Unit-based: 16 (53%)– Population-based: 14

(47%)

CNS Characteristics (n=30)CNS Characteristics (n=30)

• Specialty Patient Population

– 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 Administrator Characteristics (n=7)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 Recruitment & Data CollectionCollection

(Sept 2006 thru Jan 2008)(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)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 SamplingRandom 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 Random Work Sampling ResultsResults

• 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

CNS Work Activity

Frequency

Percent

95% Confidence Interval

Patients 2,172 28.7% ± 1.02% (27.7-29.7%)

Nursing 1,715 22.7% ± 0.94% (21.7-23.6%)

Organization

2,517 33.3% ± 1.06% (32.2-34.3%)

Other 1,160 15.3% ± 0.81% (14.5-16.1%)

Total 7,564 100%

CNS Activity with PatientsCNS Activity with PatientsPatient Activity Frequenc

yPercent

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 48 0.63%

Total Patient Activity 2,172 28.71%

CNS Activity with NursesCNS 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 CNS Activity with the Organization/SystemOrganization/System

Organization Activity Frequency

Percent

Committee Meeting 725 9.58%

Quality Improvement 593 7.84%

Problem solving 370 4.89%

Protocol/Guideline Development 315 4.16%

CNS Group Meeting 208 2.75%

Organization Question 161 2.13%

Safety 123 1.63%

Education: Interdisciplinary 13 0.17%

Product/Equipment Review 6 0.08%

Program Development 3 0.04%

Total Organization Activity 2,517 33.28%

Other CNS ActivityOther CNS Activity

Other CNS Activity Frequency

Percent

Personal Time 613 8.1%

Schedule/Calendar 399 5.27%

Continuing Education (Self) 64 0.85%

E-Mail Management 40 0.53%

Scholarship: Write/Present 20 0.26%

Research 14 0.19%

Professional Organization 10 0.13%

Total Other Activity 1,160 15.34%

CNS ContactsCNS Contacts

CNS Contact Frequency

Percent

Self (working alone) 2,843 37.59%

Group Meeting 1,704 22.53%

Nurse 1,263 16.7%

Patient 376 4.97%

Manager 372 4.92%

Provider (any non-nursing provider)

239 3.16%

All other contacts 767 10.13%

Total CNS Contacts 7,564 100%

CNS Work by CNS Work by OrganizationOrganization

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 Most Important CNS ActivitiesActivities

(Likert Scale: 1=not at all important; 5=highly important(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 Most Important CNS OutcomesOutcomes

(Likert Scale: 1=not at all important; 5=highly important)(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 & ConclusionsSummary & 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 Summary & Conclusions (cont)(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

ImplicationsImplications

• 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?Questions?Comments?Comments?

Thank you!

Julie Darmody MSN, RN, ACNS-BC

darmodyj@uwm.eduDoctoral Candidate, UW-Madison School of Nursing

Clinical Assistant Professor, UW-Milwaukee College of Nursing