Clinical Nurse Specialist: Acute Care

Doris Sawatzky-Dickson RN MN RLC

Neonatal Intensive Care,

Children’s Hospital

Outline

• Needs Assessment

• Model of Advanced Practice Nursing

• Role of CNS in acute care

Identify Stakeholders•current or potential consumers•service providers•professional organizations•decision makers

Needs Assessment Algorithm

Identify Population•outline social indicators•characteristics of clients

Define Service Provided•Type and range of service•use and demand for service•sources of referrals•accessibility and affordability•waiting lists

Identify Informal and Formal Patterns of Service Utilization

•develop algorithms to demonstrate

Assess Needs (Met and Unmet)•Key Informant Survey to ask their perceptions on:

•who has the need?•how many have the need?•why does the need exist?•is the need met adequately with current services?

Determine Potential Goals and Outcomes to Meet the Needs

•Prioritize them

Identify Skills and Competencies to Meet

Desired Goals

Examine Potential Solutions

Decision and Program /

Service Planning

Evaluation

Process Complete

Implementation

Revision / Ongoing Evaluation

(Found in CNS Toolkit on page 7)

Needs Assessment(Outlined in the CNS Guide starting on page 4, NP Guide starting on

page 9)

• Stakeholders – if you don’t involve them you may be setting up failure

• Population – some obvious, others must choose priority group

• Service Utilization – formal and informal patterns – find out what is really happening

Needs Assessment• Assessment of needs – use

stakeholders to identify the gaps

• Goals – prioritize, be clear on what you want to accomplish

• Solutions – match the skills needed with the skills potentially available – use this workshop to help determine what the options are

Needs Assessment

Planning

Implementation

Evaluation

Concurrent sessions this afternoon will deal with some of those issues

Role Options

• Nurse

• Physician

• Clinical Nurse Specialist

• Nurse Practitioner / RN (Extended Practice)

• Clinical Assistant / Physician Assistant

Advanced Practice Nurses

• An overall term that encompasses both Clinical Nurse Specialists and Nurse Practitioners

Strong Model of Advanced Practice Nursing

• Model adopted by the WRHA Advanced Practice Nursing Steering Committee

• Incorporated by all advanced practice nurses at the Health Sciences Centre over the past 2 years

(Full description of this model starts on page 16 of the CNS Guide and page 22 of the NP Guide)

Novice Expert

Research

Education

Publication and

professional leadership

Support of systems

Direct comprehensive

care

Patient

ScholarshipCollaboration

Empowerment

The Strong Model of Advanced Practice

Clinical Nurse Specialist

• Functions fully within the scope of nursing practice

• At HSC and with the proposed WRHA job description, requires Master’s degree

• Takes the nursing role beyond the bedside

CNS in NICU • Intensive Care for newborn

infants up to 45 weeks post conceptual age

• Approx. 500 admissions a year

• 80 staff nurses• 1 patient care manager• 1 nurse educator• 3 clinical resource nurses• CNS role started in 1998

Needs Assessment• Priority needs:

– Decrease length of stay– Coordinate complex patients– Improve outcomes, decrease

complication rates: • infection, • brain hemorrhage, • blindness from prematurity• developmental delay

Direct Comprehensive Care• 20% of time• Consults, care coordination, parent

support, skill-specific patient care (lactation support, PICC line insertion, wound care)

• Case load does not focus on management of medical issues or provision of direct care, but on facilitation of issues and discharge planning

Support of Systems• 20% of time• Various management committees at

unit, program,facility, regional and national level

• Facilitate review, revision and development of Neonatal Practice Guidelines

• Develop new programs and initiatives– Neonatal / Child Health Family Support Program

Education

• 15% of time• Nursing Education• Family Education• nil appointment with U of M –

provide guest lectures and faculty advisor for students

Research

• 10% of time

• Principal or co-investigator on at least one project at any one time

• Evidence-Based Practice initiatives and application of research

Publication and Professional Leadership

• 20% of time• Various committees, working

groups at all levels to keep nursing moving forward, in step, providing better service

• Publication of projects and research

• Presentation at conferences local, national, international

Time?

The other 15% spent doing:• Administrative duties (no

admin support for most CNS positions)

• Traveling to and from meetings• Professional development

(attending workshops, conferences, etc)

Project Example: high infection rate

System support: facilitate project to address the issue. Develop a better tracking process and practice change plan

Research: literature review. Evaluation survey.

Infection Rate Project

Direct Care: work through nursing practices and procedures that could be adapted

Education: develop learning package, video, lectures for education days. Do one-on-one sessions with staff. Mentor a student working with project

Infection Rate ProjectLeadership: present at

conferences. Publish results

Results: Infection rate cut by half after one year. Nurses highly supportive of practice changes!

Fewer infections = shorter intensive care stays, potential lives saved!

Clinical Example

• Infant born with multiple problems resulting in prolonged hospitalization in NICU and will likely go home with tracheostomy esophagostomy and gastrostomy feeding

CNS Contributions to Care

• Wrote educational packages for parents

• Monitored literature for best ways to care for tracheostomy, esophagostomy and gastrostomy tubes

• Insert PICC line during early hospitalization

• Consult for mom on breast milk management issues

CNS Contributions to Care

• Consult for infant on skin care issues related to gastrostomy

• Coordinate team meetings with multiple disciplines to make decisions regarding treatment options

• Facilitate communication with community and hospital team to ensure home team is ready when baby is ready

CNS Goals

• Decisions made in the infant and family’s best interest in full partnership with them

• Discharge not a day too early or a day too long

• Family satisfaction with service