Clinical Nurse Specialist Acute Care

							    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
                                         Needs Assessment Algorithm
                                    Identify Stakeholders
                             •current or potential consumers       Identify Skills and
                             •service providers                   Competencies to Meet
                             •professional organizations             Desired Goals
                             •decision makers


                                   Identify Population          Examine Potential Solutions
                                •outline social indicators
                                •characteristics of clients


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


(Found in CNS Toolkit on
         page 7)              Identify Informal and Formal
                              Patterns of Service Utilization         Implementation
                           •develop algorithms to demonstrate



                              Assess Needs (Met and Unmet)                Evaluation
                           •Key Informant Survey to ask their
                           perceptions on:
                                  •who has the need?
                                  •how many have the need?
                                  •why does the need exist?      Revision / Ongoing Evaluation
                                  •is the need met adequately
                                  with current services?


                                                                       Process Complete

                              Determine Potential Goals and
                                Outcomes to Meet the Needs
                           •Prioritize them
          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)
               The Strong Model of Advanced Practice
        Direct
     comprehensive                        Support of
         care                              systems


                                                   Collaboration
Scholarship

                            Patient
                                                   Publication
                                                       and
   Education
                                                   professional
                                                    leadership

                                            Empowerment
                          Research

     Novice                                       Expert
 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 Project
Leadership: 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