Showing papers in "Clinical Nurse Specialist in 2010"

Nursing identification of delirium.

Abstract: PURPOSE Describe nurses' ability to recognize delirium on both intensive care unit and medical-surgical units. DESIGN This is a descriptive cross-sectional study using a convenience sample. SAMPLE AND SETTING Sixty-one registered nurses (RNs) were recruited from both medical-surgical and intensive care units from 2 midsized hospitals in the Midwest. METHODS : For this study, a survey was developed using true/false and Likert-type scale questions to assess (1) nurse knowledge of symptoms associated with delirium, (2) negative sequelae associated with delirium, and (3) confidence levels regarding assessing for delirium. CONCLUSION Tremendous opportunity exists in nursing education for learning about negative outcomes associated with delirium and the importance of routine assessment. Clarification of negative sequelae related to delirium will lead nurses to value and understand the importance of early detection. Appropriate use of a standard cognitive assessment and an instrument designed to detect delirium is vital in a successful delirium prevention program. Providing nurses with educational resources and opportunities to apply knowledge will increase confidence in identification and management of delirium.

Qualitative research findings as evidence: utility in nursing practice.

Abstract: Background—The use of qualitative research methods in nursing research is common. There is a need for Clinical Nurse Specialists (CNSs) to become informed regarding how such qualitative findings can serve as evidence for nursing practice changes. Purpose—To inform CNSs of the meaning and utility of qualitative research findings. Implications for qualitative research findings as evidence in nursing practice are particularly discussed.

Knowledge, Attitudes, and Use of Complementary and Alternative Therapies Among Clinical Nurse Specialists in an Academic Medical Center

Abstract: Background: There has been an increase in the use and awareness of complementary and integrative therapies in the United States over the last 10 years. Clinical nurse specialists (CNSs) are in an ideal place to influence this paradigm shift in medicine to provide holistic care. Purpose: This study was designed to describe the knowledge, attitudes, and use of complementary and alternative medicine (CAM) by CNSs in a large Midwest medical center. Design: This study used a descriptive exploratory correlational design. Sample/Setting: Seventy-six CNSs who work in various inpatient and outpatient units within this medical facility were surveyed electronically, in the fall of 2008, using a 26-item questionnaire developed by the research team. Method: Data were analyzed using descriptive statistics. Findings: The results demonstrate that CNSs at this academic medical center use several CAM therapies for their personal use and for professional practice with patients. The top therapies that CNSs personally used were humor, massage, spirituality/prayer, music therapy, and relaxed breathing. The top therapies requested most by patients were massage, spirituality/prayer, healing touch, acupuncture, and music therapy. The results indicated that most CNSs thought CAM therapies were beneficial and that there was some evidence for use of these therapies for use by patients or by CNSs. Implications: The results of this study will help to determine educational needs and clinical practice of CAM therapies with CNSs at this academic medical center. The survey used and the research results from this study can be a template for other CNSs to use to begin to address this topic of CAM use in other hospitals and clinical settings. This survey could be used to explore CAM use by patients in specialty areas for practice enhancement.

Health care providers' attitudes regarding family presence during resuscitation of adults: an integrated review of the literature.

Abstract: Purpose Family presence (FP) during resuscitation is a controversial practice that leads to disagreement among health care professionals. A systematic review of the literature was performed to answer the question: What are the attitudes of health care providers regarding family presence during resuscitation of adults? Methods MEDLINE, PubMed, and CINAHL databases were searched using the following terms: family, family presence, family witnessed, cardiopulmonary resuscitation, nurses, personnel, patient, attitudes, attitude of health personnel, and ethics. Criteria for inclusion consisted of research studies addressing health care providers' attitudes toward family presence during adult resuscitation conducted in the United States that were published between 1998 and 2008. Results The literature search produced 480 titles. Thirteen full-text articles met criteria for inclusion in the evidence tables. Findings of this integrated literature indicate that: between and within discipline differences in attitudes, perceived burden on staff, perceived effects on family, lack of medical knowledge of family, and existence of a hospital policy influence provider attitudes toward FP. Conclusions and implications More research is needed to determine if FP is evidence based; however, there is sufficient evidence to consider implementing FP. There is wide variation in support for FP among health care professionals, although nurses generally are more favorable. If an institution elects to implement an FP policy or evidence-based practice guideline, it must carefully consider the many provider, patient, family, and system-level factors that can hinder or promote the success of this initiative.

Patient safety: examining the adequacy of the 5 rights of medication administration.

Abstract: Purpose The purpose of this article was to examine the adequacy of the 5 rights (5 R's) for nurses and for including patients in medication administration while considering patient safety. Patient safety related to medication adverse events will be discussed; the 5 R's will be examined and critiqued and the importance of patient-centered care and patient participation in care will be presented. A path forward is offered based on the expressive-collaborative model. Suggestions for introduction of the model are outlined, and implications for practice, research, and education are discussed. Background Nurses have been guided by the 5 R's of medication administration in both education and practice for many decades. Many have found the 5 R's to be lacking and proceeded to propose the addition of a variety of rights from right indication to the rights of nurses to have legible orders and timely access to information. Patients are no longer passive recipients of care and are choosing to play increasingly greater roles in the process of care. Innovation In a collaborative patient-centered environment, an expressive-collaborative model of approaching systems of care is needed. In this model, individuals negotiate with one another to find out what people need to know and to strategize on the means to acquiring the necessary information. Providers are no longer expected to be all knowing. Conclusion Medication administration is no longer simply the 5 R's. Medication administration is a process with many interconnected players including patients. We need to collaboratively restructure medication use in this era in which all involved in the process share the responsibility for a safe medication use system.

Clinical nurse specialist practice patterns.

Abstract: Purpose The study purpose was to describe clinical nurse specialist (CNS) practice patterns (activities, outcomes, and practice barriers). Design A cross-sectional survey design was used for this research study. Setting and sample California Board of Registered Nursing certified CNSs (N = 1,523). Method Surveys were mailed to CNSs and included the CNS Activity Questionnaire, the Clinical Nurse Specialist Outcomes and Barriers Analysis Survey, and a demographic survey. Descriptive (means, percentages) and inferential (t tests and one-way analyses of variance) statistics were used to analyze the data. Conclusions Practicing CNSs (n = 947) demonstrated a role preference for expert clinical practice. Practice patterns (activities, outcomes, and barriers) differed in terms of CNS specialty, years of experience, number of units covered, and CNS reporting structure. Clinical nurse specialists are spending time in the 5 broad role components expert (clinical practice, consultation, education, clinical leadership, and research) utilized by the California Board of Registered Nursing as an organizing framework for practice; however, CNS practice patterns from this study reflect more discrete and functional activities that may be better encompassed under the CNS spheres of influence practice model. A number of barriers to practice exist, the most commonly reported being reporting structure. Years of experience in the role result in differences in both practice patterns and perceptions of barriers. Recommendations for CNSs and organizations include evaluating CNS reporting structures, developing advanced practice outcome-based job descriptions and competencies, and designing performance evaluations that recognize differences between inexperienced and experienced CNSs.

Healthcare experiences of women with visual impairment.

Abstract: Purpose This investigation was a secondary analysis of focus group transcripts to address the question of how women with low vision or blindness have experienced healthcare. Design Secondary analysis of qualitative data was performed on transcripts from 2 focus groups. Setting These focus groups were conducted at an agency serving visually impaired people in Philadelphia. Sample The 2 focus groups included 7 and 11 women, respectively, having low-vision or who are blind who had been part of an original study of reaching hard-to-reach women with disabilities. Methods Content analysis for the identification of thematic clusters was performed on transcriptions of the focus group data. Findings Findings are consistent with existing research on the health needs of women with disabilities but add specific understanding related to visual impairment. Six thematic categories were identified: health professionals' awareness, information access, healthcare access, isolation, the need for self-advocacy, and perception by others. Conclusions and implications Secondary analysis of qualitative data affords in-depth understanding of a particular subset of participants within a larger study. Clinical nurse specialists and other health professionals need to increase their sensitivity to the challenges faced by women with visual impairment, and plan and provide care accordingly. Health professions students need to be prepared to interact with people who are visually impaired and healthcare settings need to respond to their needs.

Assessing the health literacy levels of patients using selected hospital services.

Abstract: PURPOSE The aim of this study was to assess the health literacy abilities of patients in an urban and suburban hospital. BACKGROUND Inadequate health literacy is a widespread problem that is associated with insufficient self-care knowledge and behavior, inappropriate use of emergency services, higher rates of hospitalization, and increased healthcare costs. Knowledge of patients' reading ability is necessary to ensure that appropriately leveled printed health education materials are available. METHODS The health literacy of a convenience sample of 21 inpatients and 34 outpatients from an urban and suburban hospital was measured using the Test of Functional Health Literacy in Adults and the Rapid Estimate of Adult Literacy in Medicine. Variables for analysis included demographic characteristics, perceived health status, highest grade of school completed, socioeconomic status, healthcare costs, and number of inpatient and outpatient admissions over the previous year. RESULTS Based on the Rapid Estimate of Adult Literacy in Medicine, 33% of patients had health literacy levels that were eighth grade or below, whereas according to the Test of Functional Health Literacy in Adults, 23% had marginal or inadequate functional health literacy. Literacy was significantly related to socioeconomic status (P < .001) and education (P < .001), although 30% of participants had a reading level below the highest grade completed. No other significant correlations were found. IMPLICATIONS Clinical nurse specialists should ensure that health information materials are written at appropriate levels and educate nurses and other healthcare professionals to use effective communication and teaching strategies.

Sustaining excellence: clinical nurse specialist practice and magnet designation.

Abstract: Clinical nurse specialist practice is essential in providing the clinical expertise, leadership, and organizational influence necessary for attaining the excellence in care reflected by the American Nurses Credentialing Center's Magnet designation. Clinical nurse specialists, prepared as advanced practice nurses, bring clinical expertise, knowledge of advanced physiology, and pathology and a system-wide vision for process improvements. This unique curriculum specifically prepares clinical nurse specialists (CNSs) to immediately practice as leaders of interdisciplinary groups to improve outcomes. Clinical nurse specialist graduates possess an understanding of complex adaptive systems theory, advanced physical assessment, and pathophysiology and knowledge of optimal learning modalities, all applicable to improving the health care environment. Their practice specifically links complex clinical data with multidisciplinary partnering and understanding of organizational systems. The basis for optimal clinical practice change and sustained process improvement, foundational to Magnet designation, is grounded in the combined educational preparation and systems impact of CNS practice. This article describes the role of the CNS in achieving and sustaining Magnet designation in an urban, academic quaternary care center. Using the National Association of Clinical Nurse Specialists model of spheres of influence, focus is on the CNS's contribution to improving clinical outcomes, nurse satisfaction, and patient satisfaction. Exemplars demonstrating use of a champion model to implement practice improvement and rapid adoption of optimal practice guidelines are provided. These exemplars reflect improved and sustained patient care outcomes, and implementation strategies used to achieve these improvements are discussed.

A unique collaborative nursing evidence-based practice initiative using the Iowa model: a clinical nurse specialist, a health science librarian, and a staff nurse's success story.

Abstract: Purpose/objectives The purpose of this article was to share how the collaboration of a clinical nurse specialist (CNS), a health science librarian, and a staff nurse can heighten staff nurses' awareness of the evidence-based practice (EBP) process. Background/rationale The staff nurse is expected to incorporate EBP into daily patient care. This expectation is fueled by the guidelines established by professional, accrediting, and regulatory bodies. Barriers to incorporating EBP into practice have been well documented in the literature. Description of the project/innovation A CNS, a health science librarian, and a staff nurse collaborated to develop an EBP educational program for staff nurses. The staff nurse provides the real-time practice issues, the CNS gives extensive knowledge of translating research into practice, and the health science librarian is an expert at retrieving the information from the literature. Interpretation/conclusion The resulting collaboration at this academic medical center has increased staff nurse exposure to and knowledge about EBP principles and techniques. The collaborative relationship among the CNS, health science librarian, and staff nurse effectively addresses a variety of barriers to EBP. Implications This successful collaborative approach can be utilized by other medical centers seeking to educate staff nurses about the EBP process.

Interruptions and medication errors: part I.

Abstract: The human brain is heralded for its amazing complexity and information processing capacity. Purportedly containing about a hundred-billion neurons and several-hundred-trillion synaptic connections, the brain processes information in a matter of milliseconds. However, for all of this processing power, we can barely attend to more than a few things and have difficulty performing more than 1 task at a time! The technological era forces constant stimuli on us all. What happens in the brain when we are distracted or interrupted? Recent media alerts about the dangers of texting or talking on cell phones while driving are alarming, yet many professional people pride themselves on the ability to multitask and deal with interruptions, perhaps failing to recognize the parallel circumstances. The aim of this manuscript is to review brain physiology associated with interruptions and prompt clinical nurse specialists (CNSs) to consider implications within their own areas of practice. (This article is a companion to an article published in volume 24, issue 6, of this journalVInterruptions and Medication Errors, Part I). A plethora of studies have reported medication errors partially linked to interruptions. A variety of concepts in the literature describe similar phenomena that have the potential to influence medication errors and patient safety. These concepts and terms include interruptions, multitasking, lack of focus, task switching, and distractions (Table 1). Along with other professionals (including physicians and attorneys), nurses are considered ‘‘knowledge workers’’V people who are valued in society for their education, knowledge, and experience in a specific subject area. Cooper has described knowledge workers as people who ‘‘think for a living.’’ High-quality cognitive processing activity is critically important for health professionals. Patients may think that clinicians are not focusing on themat timeswhen our brains are busy cognitively juggling dozens of clinical issues, fearful of dropping a critical one. The resulting neuronal overload may cause us to appear to be distracted and have patients interpret that as our not listening or caring about their communication.

A clinical nurse specialist-led intervention to enhance medication adherence using the plan-do-check-act cycle for continuous self-improvement.

Abstract: Purpose A clinical nurse specialist-led intervention to improve medication adherence in chronically ill adults using renal transplant recipients as an exemplar population is proposed. Background/rationale Meta-analyses and systematic reviews of chronically ill and transplant patients indicate that patient-specific characteristics not only are poor and inconsistent predictors for medication nonadherence but also are not amenable to intervention. Adherence has not meaningfully improved, despite meta-analyses and systematic narrative reviews of randomized controlled trials (RCTs) dealing with medication nonadherence in acutely and chronically ill persons and RCTs dealing with transplant patients. Interventions with a superior potential to enhance medication adherence must be developed. Description of the intervention Use of a clinical nurse specialist-led continuous self-improvement intervention with adult renal transplant recipients is proposed. Continuous self-improvement focuses on improving personal systems thinking and behavior using the plan-do-check-act process. Electronic medication monitoring reports, one of several objective measures of medication adherence, are used by the clinician to provide patient feedback during the check process on medication-taking patterns. Conclusion Continuous self-improvement as an intervention holds promise in supporting patient self-management and diminishing the blame that clinicians place on patients for medication nonadherence. Using an objective measure of medication adherence such as an electronic monitoring report fosters collaborative patient-clinician discussions of daily medication-taking patterns. Through collaboration, ideas for improving medication taking can be explored. Changes can be followed and evaluated for effectiveness through the continuous self-improvement process. Implications Future studies should include RCTs comparing educational and/or behavioral interventions to improve medication adherence.

Advanced practice nursing: meeting the caregiving challenges for families of persons with frontotemporal dementia.

Abstract: Frontotemporal dementia (FTD), once thought to be a rare cause for dementia, is now acknowledged to be the most common presenile (before age 65 years) cause of dementia. Frontotemporal dementia is associated with profound changes in behavior, personality, emotions, and cognition. The purpose of this article is to describe 2 cases of patients with FTD to illustrate salient aspects of the caregiving experience. Issues faced by caregivers are organized into 6 categories: diagnosis, behavioral symptoms, function, communication, long-term management and care, and maintenance of the caregiver's emotional and physical health. Examples of interventions directed by advanced practice nurses are described. We suggest that management of FTD requires expertise as scientific advances and discoveries about FTD continually change the landscape of care.

The clinical nurse specialist role in developing a geropalliative model of care.

Abstract: Purpose The purpose of this article was to share the experiences and knowledge gained of the clinical nurse specialist's (CNS's) role in the development and implementation of an interdisciplinary geropalliative model of care. Background Across healthcare settings, patients with life-threatening or life-limiting illnesses often experience unwarranted suffering and inattention to their wishes. Studies demonstrate that a palliative approach to care can provide the structure for improved symptom management and earlier identification of patients' goals of care. Description A palliative model of care was adopted at a 721-bed healthcare facility that encompasses long-term, subacute care, and acute care. The model incorporated a consult team into an embedded approach that provided basic palliative skills in all care. Watson's Caring-Healing Theory guided the model. Outcome Nursing knowledge of palliative care improved, families expressed satisfaction with care, and the staff responded that palliative care positively impacted patient/family outcomes. Conclusion The structure, processes, and outcomes of care can be positively impacted by the CNS during the development and implementation of a palliative model of care. This occurred through CNS activities such as direct consultation, educational initiatives, mentoring, and disseminating assessment and care planning tools. Implications A geropalliative model of care can be integrated into a variety of healthcare settings. Clinical support and expertise contributed to positive outcomes. Questions for research include the need to identify a symptom assessment tool that is valid, reliable, and easy to use in the chronically ill, geriatric setting, as well as discerning innovative ways to disseminate knowledge to nurses.

Fast-track colorectal surgery program reduces hospital length of stay.

Abstract: Purpose This study compared outcomes of a fast-track postoperative program implemented for patients undergoing laparoscopic colorectal surgery on 2 surgical units to patients receiving traditional postoperative care following laparoscopic colorectal surgery prior to implementation of the fast-track program. Aims The primary aim was to determine if there was a significant difference in length of stay and 30-day readmission rates between the 2 groups. The secondary aim was to examine whether patients on the fast-track program were able to successfully tolerate early diet, early ambulation, and minimal use of drains. Setting The study was conducted at a large Midwestern hospital. Method A retrospective medical record review was done on 100 patients who underwent laparoscopic colorectal surgery on the fast-track program for data pertaining to the research questions. Additionally, a medical record review was done for comparison on 100 matched controls based on age, sex, surgeon, and surgical procedure who received traditional postoperative care following laparoscopic colorectal surgery. Findings A statistical significant difference of 1 day was found between patients receiving traditional care and patients on the fast-track program. Readmission rates between the 2 groups were not statistically significantly different. Conclusion : Overall, patients undergoing laparoscopic colorectal surgery on a fast-track program discharged 1 day sooner than patients on traditional recovery programs. Patients successfully followed the fast-track program. Implications Fast-track programs in colorectal surgery reduce length of stay and could be considered for other surgical populations.

Clinical nurse specialists as leaders in rapid response.

Abstract: The purposes of this article were to provide background information about rapid response teams (RRTs), to describe the actual and potential outcomes of RRTs, to define the potential role of the clinical nurse specialist in leading RRTs, and to provide recommendations for implementation of RRTs. Rapid response teams provide the opportunity for early intervention for patients demonstrating clinical decline before they reach a point of no return. The long-standing practice of waiting for intensive intervention (code blue) until the patient experiences cardiopulmonary arrest has shown poor outcomes, bringing this practice into question. Although research results are mixed, there is evidence to suggest that the successful use of RRTs results in clinically significant patient outcomes as evidenced by decreased cardiopulmonary arrests and decreased rates in mortality. Other positive patient, nursing, and organizational outcomes can result from RRTs and are discussed. Clinical nurse specialists are uniquely qualified to provide leadership in the development and implementation of RRTs and the monitoring of outcomes. As RRTs become a more common standard practice, further research is needed to examine their benefits and to further refine effective early intervention for high-risk patients.

Using Simulation in Psychiatric/Mental Health Nursing Education: The Time Has Come!

Abstract: Background/Rationale: Teaching scenarios include: an elderly fall victim who must be assessed for alcohol use and abuse; a veteran with war injuries including a below the knee amputation, chronic pain, PTSD, and suicidal ideation; and many manifestations of anxiety disorders. The simulator is used to manipulate vital signs and other physiologic responses as students experience the consequences of their actions, or inactions, in a controlled setting.

A literature review of intensive insulin therapy and mortality in critically ill patients

Abstract: Background: Since Van den Berghe et al published their study on tight glucose control in 2001, intensive insulin therapy (IIT) has been increasingly used for critically ill patients worldwide. However, recent studies reported a significantly increased risk of hypoglycemia without a significant reduction in mortality. Objective: The purpose of this article was to evaluate the effect of IIT with a target glucose of 110 mg/dL or less on mortality in adult critically ill patients and to determine whether it is appropriate to generalize IIT for all critically ill patients. Methods: Ovid, MEDLINE, and PubMed databases were searched for studies that compared "conventional" vs "intensive" insulin therapy in adult critically ill patients. Results: Eleven articles were included for this review. There was no significant difference in intensive care unit mortality between tight glucose control group and conventional glucose control group in 5 of 6 studies. Only 1 study showed a significant difference in hospital mortality between the 2 groups. Seven studies showed a significant increase in the incidence of hypoglycemia. Conclusions: Intensive insulin therapy was not associated with significant reduction in mortality in adult critically ill patients but was related to a significant increase in the incidence of hypoglycemia. Therefore, it is inappropriate to generalize IIT for all critically ill patients, even though it significantly improved blood glucose control.

Nurse-directed care model in a psychiatric hospital: a model for clinical accountability.

Abstract: Purpose The focus on recovery for persons with severe and persistent mental illness is leading state psychiatric hospitals to transform their method of care delivery. This article describes a quality improvement project involving a hospital's administration and multidisciplinary state-university affiliation that collaborated in the development and implementation of a nursing care delivery model in a state psychiatric hospital. Description of the project The quality improvement project team instituted a new model to promote the hospital's vision of wellness and recovery through utilization of the therapeutic relationship and greater clinical accountability. Implementation of the model was accomplished in 2 phases: first, the establishment of a structure to lay the groundwork for accountability and, second, the development of a mechanism to provide a clinical supervision process for staff in their work with clients. Effectiveness of the model was assessed by surveys conducted at baseline and after implementation. Outcome Results indicated improvement in clinical practices and client living environment. As a secondary outcome, these improvements appeared to be associated with increased safety on the units evidenced by reduction in incidents of seclusion and restraint. Conclusions Restructuring of the service delivery system of care so that clients are the center of clinical focus improves safety and can enhance the staff's attention to work with clients on their recovery. Implications The role of the advanced practice nurse can influence the recovery of clients in state psychiatric hospitals. Future research should consider the impact on clients and their perceptions of the new service models.

Using mobile health technology to enhance patient-centered care.

Abstract: Mobile health (m-health) initiatives are those that use Bmobile communicationsVsuch as PDAs and mobile phonesVfor health services and information.[ M-health has been described as a patient-centered approach to care; however, further research is required to assess relevant tools, identify appropriate populations, and accelerate behavior change. The amount of health information available via the Internet is vast but fragmented, with quality, relevance, and reliability often uncertain. The purpose of this article is to explore an example of an m-health intervention that takes full advantage of social media tools and communication preferences of the adolescent client. Eysenback described these developments made possible by Web 2.0 capabilities as Medicine 2.0, which consists of social networking, participation, apomediation, collaboration, and openness. Specifically, he describes social networking as Ba potentially powerful tool to engage users, in that it provides Fsocial_ incentives to enter, update, and manage personal information.[ Two recent reports by the Pew Internet and American Life Project provide the context for this approach, using social media and mobile telephone short-message service (SMS, more commonly known as text messaging). The reports indicate that 93% of teens between the ages of 12 and 17 years access the Internet. Of these, 73% of American teens are using social network Web sites. Furthermore, 31% of teens use the Internet for health, diet, or fitness information, and 17% of teens report using the Internet to gather information about sensitive topics concerning sexual health and drugs. With regard to mobile phone technology, 75% of 12to 17-year-olds report owning a cell phone, and 88% of them use text messaging. Therefore, creating an intervention to attract adolescents to primary care by combining social networking and text messaging is an appropriate approach. In a review of clinical preventive services (CPSs) for adolescents, Solberg and colleagues note that adolescents are generally healthy; however, more than 70% of morbidity and mortality within this developmental phase is an outcome of high-risk behaviors: alcohol use, unsafe sex, and violence. They made 3 key recommendations:

Clinical nurse specialist-led evaluation of temporal artery thermometers in acute care.

Abstract: Purpose: A systematic review of literature and intensive evaluation were conducted using a quality process to assess temporal artery thermometer (TAT) accuracy in an acute-care setting. Background: Inaccurate temperature measurements were reported following adoption of the TAT. Concern for patient safety and outcomes generated a need to reevaluate use of the TAT. Description of the Project: Using components of evidence-based practice and intensive evaluation processes, a clinical nurse specialist (CNS)-led team evaluated existing research, assessed current practice, and obtained additional clinical data. Outcomes: Existing research provides inadequate evidence to support use of the TAT for acutely ill hospitalized patients. Findings from an intensive evaluation indicated low interrater reliability in controlled testing, inaccurate technique by staff despite retraining, lack of nurse confidence in the accuracy of the device, and a need for continuous costly retraining. These findings are consistent with findings in a University HealthSystem Consortium report. Summary and Conclusions: A multifaceted evaluation process was needed for the team to compile data, identify issues, and make decisions. A recommendation was made to discontinue use of the TAT. Implications: Clinical nurse specialists have the knowledge and ability to provide clinical leadership at a system level. When usual processes result in safety concerns, the CNS provides leadership to identify patterns, provide direction, creatively integrate evaluation processes, synthesize findings, and uses his/her influence within the system to change practice.

Hemodialysis arteriovenous fistula self-cannulation: moving theory to practice in developing patient-teaching resources.

Abstract: Purpose/objectives This article discusses how Orem's theory was applied to the revision of supporting documents in the patient-teaching process and subsequently the nurse's role in the patient's learning experience. Background/rationale Teaching based on didactic, provider-focused objectives is ineffective in meeting patient's learning needs. There is a lack of conclusive research on the development of appropriate patient-teaching endeavors for the acquisition of knowledge and skills related to the performance of hemodialysis arteriovenous fistula self-cannulation. Description of the project/innovation To prepare patients for home hemodialysis, Orem's self-care-deficit nursing theory was used to guide the revisions of a patient assessment and learning documentation template, the development of a self-cannulation teaching resource and to foster a renewed sense of the nurse's role in the teaching process. Interpretation/conclusion The application of self-care-deficit nursing theory to the update and development of patient-teaching documentation and resources for self-cannulation provides the nurse with a theoretical approach to assess, plan, evaluate, and document teaching from a patient-focused perspective. Theory in practice provides a means to support and highlight the role of nurses in the patient-learning process. The utilization of practical activities to introduce theory into teaching provides a means to structure care processes and to enhance nurse's adoption of theory in practice. Implications Orem's theory provides a relevant, useful framework to guide nurses in teaching patients self-care. Research on the exploration of nurse's attitudes related to the benefit of adopting theory when teaching patients to perform hemodialysis self-care is needed.

Clinical practice guideline appraisal using the AGREE instrument: renal screening.

Abstract: The purpose of this article is to explain how an evidence-based practice team of 7 nurses appraised the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Chronic Kidney Disease using the Appraisal of Guidelines, Research and Evaluation in Europe (AGREE) instrument. The quality and rigor of clinical practice guidelines (CPGs) vary. The AGREE instrument is a tool that provides a framework to assess the quality of CPGs and determine applicability to practice. By appraising the CPGs using this tool, nurses established best practice for renal screening before angiography. Nursing practice outcomes from the appraisal process include an increased appreciation of the science behind evidence-based treatment recommendations and greater confidence to recommend changes in practice. The AGREE scores substantiated the need to change renal screening to include an index of renal function before cardiac angiography. The AGREE instrument is an effective tool to assess CPG quality. Future research should expand upon translating CPGs into bedside practice.

Clinical nurse specialist practice in evidence-informed multidisciplinary cardiac care.

Abstract: Care gaps exist in the management of cardiac patients throughout the care continuum. The clinical nurse specialist (CNS) is paramount in the development, implementation, and evaluation of tools to assist care providers in the use of evidence-informed therapies to maximize patient outcomes. The purpose of this article was to describe the CNS practice in terms of these evidence-informed initiatives for defined cardiac populations. Putting evidence into practice is one of the primary responsibilities for the CNS practice. Evidence-informed tools such as clinical pathways have been implemented throughout the healthcare region to reduce care gaps for the acute myocardial infarction and cardiac surgery populations. These tools equip care providers with a standards document, physician order sets, cardiac rehabilitation referral process, care guide, depression screening tool, and patient education material. By incorporating interventions known to reduce avoidable adverse events in the cardiac population into the clinical pathways, patient outcomes have been impacted. Ongoing evaluation of the evidence-informed tools through regular tracking of key indicators has enabled refinement of existing processes and care. It is the CNS practice that ensures not only patient care standards, but also daily routine care are underpinned by scientific evidence. Bridging research with clinical practice remains the stronghold for CNS practice.

Quality and safety education for nurses competencies for the clinical nurse specialist.

Abstract: In 2003, the Institute of Medicine published Health Professions Education: A Bridge to Quality. The focus of the book was to produce highly qualified health care providers through major reform in educational practices. Educational changes were centered around 5 core competencies: patientcentered care, health care delivery through interdisciplinary teams, health care based on evidence-based practice principles, use to quality improvement to evaluate current health care delivery, and application of informatics tomanage knowledge, decision making, and communication so that errors are reduced. Nursing quickly answered the call through initiatives such as Technology Informatics Guiding Education Reform (www.tigersummit.org) and Quality and Safety Education for Nurses (QSEN; www.qsen.org). Both of these focused on undergraduate nursing education and initiated changes through the accrediting bodies in nursing: theNational League for Nursing, whose accrediting body is National League for Nursing Accrediting Commission, and the American Association of Colleges of Nursing, whose accrediting body is Commission on Collegiate Nursing Education. The educational changes initiated have found their way to graduate education and several recent articles mapping the QSEN competencies to graduate education for advanced practice nurses. Mapping the QSEN3 competencies (patient-centered care, informatics, safety, evidence-based practice, teamwork and collaboration, and quality improvement) to the clinical nurse specialist (CNS) competencies allows for the practical application of the several CNS core competencies (collaboration, consultation, research, systems leadership, coaching, ethical decision making, and direct care) in practice. An example for mapping between the CNS and QSEN competencies can be illustrated by analyzing the CNSs’ involvement in the implementation and use of new health care technology. Participation in the design and implementation of an electronic health record (EHR) requires competency in systems leadership (CNS) and informatics (QSEN). The CNS should Bdetermine nursing practice and system (EHR) interventions that promote safety (C.3)[ and Bformulate essential information that must be availableI to support patient care in the practice specialty (6).[ This activity may also involve designing, implementing, and analyzing quality improvement projects for the purpose of understanding the current level of care, outcomes for the care provided, the establishment of best practices through the analysis of obtained quality improvement data, and finally implementation of changes so that the best health care outcomes can be obtained (CNS research competencies and QSEN quality improvement and safety competencies). The CNS can be a leader in designing EHR documentation forms that document nursing’s impact to health care outcomes. Discovery of documentation content comes from a query of the literature in evidence-based or health careYbased literature sources. The next step is for the CNS to work with information technology professionals to query the EHR database. This information can then be analyzed to understand which specific health care practices led to specific client outcomes, thus defining best practices. Finally, the CNS can suggest and implement evidencebased changes to the health care practices within their institution, thereby demonstrating the CNS competency of direct patient care and the QSEN competency of patientcentered care. These changes can be seen in decision-support systems that are a critical component of the electronic health care record. As a result of the competency work, the CNSs are in a unique position to demonstrate within their organizations how competencies are integral to the practice, tasks, and projects they lead. The challenge in today’s health care system is Amy J. Barton, PhD, RN

Innovative use of electronic health record reports by clinical nurse specialists.

Abstract: Purpose The purpose of the study was to demonstrate how clinical nurse specialists (CNSs) can use information pulled from the electronic health record (EHR) in innovative ways to improve nursing care of vulnerable older adults. Background As the number of older adults increases, the need will grow for easier access to evidence-based practice nursing interventions for the older population. Clinical nurse specialists are the experts in evaluating research and will also need to find innovative ways to bring the evidence-based practice pertinent to the care of older adults to the bedside nurse. Description of the project/innovation Clinical information from various parts of the EHR is pulled into computer-generated reports that focus on identifying older adult patients with specific high-risk indicators. The specific clinical information pulled into the reports and examples of how the reports are used will be presented. Four reports are described including new hospital admissions of patients older than 65 years, current hospitalized patients with dementia/delirium, current hospitalized patients on cholinesterase inhibitors, and a comprehensive report of all current hospitalized patients older than 65 years focusing on specific geriatric indicators identified in the literature. Outcomes/implications Computerized reports can be used to facilitate the use of nursing practice guidelines and evidence-based clinical tools such as the confusion assessment method and to increase use of nursing plans of care. The reports can also provide real-time key indicators that can be used to facilitate identification of older adult patients in need of CNS and/or geriatric team consultation. More research still needs to be done regarding the impact of the EHR on nursing indicators such as number of falls, delirium, and use of restraints.

Bispectral index monitoring to facilitate early extubation following cardiovascular surgery.

Abstract: Frequently, intensive care nurses assume responsibility for extubating patients after undergoing cardiac surgery. Bispectral index (BIS) monitoring assesses level of mental arousal and awareness when sedated. This study was to determine if the BIS might facilitate earlier extubation of patients following cardiac surgery. A study was conducted comparing 25 stable patients returning to the intensive care unit with a BIS with 25 patients managed without the BIS (N = 50). Data collected included age, sex, surgery, pH, CO2, and temperature on arrival/extubation, total intravenous propofol and pain medication, and BIS scores. Student t tests determined that there were no differences between groups for age, amount of propofol and pain medication received, or time to extubation (P > .05). Regression analysis determined that total propofol, total hydromorphone, and age were significant predictors of time to extubation. In this study, the BIS monitor did not facilitate earlier extubation in the stable patient after cardiac surgery.

Building your personal leadership brand.

Abstract: A s healthcare professionals, we work in a somewhat fickle and cyclical industry. There are periods of personnel shortages, rapid facility expansion, and explosive growth. Our fortunes may shift quickly toward periods of economic downturn, personnel downsizing, and massive expenditure reduction. These rapid industry changes make us all vulnerable and put our positions and livelihood at risk. In a fragile healthcare marketplace, this dynamic raises the question: What can we do to minimize our professional vulnerabilities? One answer to this question is to build your personal leadership brand. The purpose of this article is to introduce the concept of personal leadership branding as a vehicle for enhancing professional value and workplace influence.

Prescription and over-the-counter drug and substance abuse: something available for every age, anytime and anywhere: update for the clinical nurse specialist.

Abstract: I oversee the health of secondary school students in a large Midwestern school district. Increasingly, we are seeing 9th and 10th graders abusing nicotine replacement therapies (NRTs). One student was found with multiple NRT patches, and a 10th grader was found to be consuming the 24-hour dose NRT gum during school hours. Neither student smokes. However, they report they feel ‘‘better able to think’’ onNRT. Both students on assessment had significant elevation in heart rate and blood pressure, as well as nausea and anxiety. Neither student seemed concerned about adverse effects or aware of the risks of using NRT. As a result, we have added NRT to our list of prescription and over-the-counter (OTC) drugs for which we provide student education. We are also seeing a rise in cough syrup abuse. In fact, the list for abuse screening is growing. What is the state of prescription and OTC-drug abuse in the United States at this time?