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Descriptive Research

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:

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Descriptive Research

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  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

  2. Acknowledgements This research was partially supported by: • Nurses Foundation of Wisconsin Grant • Helene Denne Schulte Research Assistantship, UW-Madison School of Nursing

  3. Acknowledgements • 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

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

  5. 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

  6. Background • Safety & quality are critical issues in health care • CNSs have great potential to influence safety & quality in acute care

  7. 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)

  8. Advanced Practice NursesNational Sample Survey of RNs, 2004http://bhpr.hrsa.gov/healthworkforce/reports/rnpopulation/preliminaryfindings.htm

  9. 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)

  10. Framework for CNS Practice • NACNS, 2004 Direct Patient / Client Care Nurses And Nursing Practice Organizations And Systems

  11. 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)

  12. 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%

  13. Design and Methods • Descriptive Mixed Method Study • Data Sources • Multidimensional Work Sampling (MDWS) • CNS Questionnaire • Administrator Questionnaire • CNS Job Descriptions

  14. 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)

  15. 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)

  16. 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)

  17. 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%)

  18. 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

  19. 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

  20. 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

  21. 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)

  22. 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

  23. CNS Work Activity

  24. CNS Activity with Patients

  25. CNS Activity with Nurses

  26. CNS Activity with the Organization/System

  27. Other CNS Activity

  28. CNS Contacts

  29. CNS Work by Organization

  30. 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 Activities(Likert Scale: 1=not at all important; 5=highly important

  31. 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) Most Important CNS Outcomes(Likert Scale: 1=not at all important; 5=highly important)

  32. 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.

  33. 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

  34. 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.

  35. Questions?Comments? Thank you! Julie Darmody MSN, RN, ACNS-BC darmodyj@uwm.edu Doctoral Candidate, UW-Madison School of Nursing Clinical Assistant Professor, UW-Milwaukee College of Nursing

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