Clinical Nurse Specialist Leadership in Redefining How … … · 1 Rhonda Fleischman MSN, RN-BC, CNS, CCRN-CMC Karen Marzlin DNP, RN, CCNS, CCRN-CMC, CHFN Cynthia Webner DNP, RN,

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Rhonda Fleischman MSN, RN-BC, CNS, CCRN-CMC

Karen Marzlin DNP, RN, CCNS, CCRN-CMC, CHFN

Cynthia Webner DNP, RN, CCNS, CCRN-CMC, CHFN

Clinical Nurse Specialist Leadership in Redefining How We Assess

Competency in Nursing

A75M430 NTI 2014 Denver

1 2014

“Professional nursing practice can only advance as much as individual nurses are aware that a knowledge gap

exists in their practice, feel empowered to access further learning, and integrate evidence based competencies into

their professional practice to provide safe, effective, efficient, patient centered, equitable care.”

www.tigersummit.com 2 2014

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=XsAkl0ZEMJwNjM&tbnid=KF_drbo--qW0aM:&ved=0CAUQjRw&url=http://torchbearer.utk.edu/2010/08/college-of-nursing-to-offer-doctor-of-nursing-practice-program/&ei=sJx6U6b5DNGNyATVuYKQBw&bvm=bv.67229260,d.aWw&psig=AFQjCNErz7W6kJX65cFrlO37LVlwTxqybQ&ust=1400630810280117

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• A new competency paradigm introduced in 2011.

• The new design has been enhanced each subsequent year (2012, 2013, and 2014).

• The effectiveness of the new paradigm was measured in 2011 by evaluating

the impact of the new program in the area of bedside cardiac monitoring. – Cardiac monitoring was selected because it is a key area for clinical competence in the

CCU.

– Objective data was used in the initial evaluation.

• Outcome assessment has been expanded to include quality and quantitative evaluation. Additional areas of practice have been added to the evaluation component.

• Project has been developed and implemented by 3 cardiac advanced practice nurses.

– One unit based CNS (role includes clinical practice and education)

– Two CNSs who provide clinical care with a cardiology practice (also serve as co-chairs of the Heart Center Staff Education Committee)

• Project has been done with support of the CCU Unit Director 3 2014

Why a paradigm shift in competency assessment?

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Historical Approach to Competency Assessment

• Skills checklist

– Task based assessment

– Does not account for science behind practice, OR

– Critical thinking or decision making

• Majority of literature on competency assessment in nursing focuses on pre-licensure nursing education and transition into entry level practice – Focus on didactic education

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Competency in Nursing: Lack of Clarity

• There is often an unclear definition of competency within the nursing profession.

– Primary reasons for lack of consensus regarding competency in nursing practice include the following:

• a) multifaceted nature of competency assessment,

• b) variations in specialty practice within the profession,

• c) the evolution of nursing practice from the novice to expert level.

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Continuing Education Alone Does Not Guarantee

Competency

• There is inconsistent evidence that continuing education alone results in a change in a nurse’s clinical performance and subsequent improvement in patient outcomes (IOM, 2003).

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COMPONENTS OF NEW COMPETENCY PARADIGM

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Competency Components: New Paradigm

• Multifaceted in order to reflect the actual transfer of knowledge into practice.

• Critical thinking as key aspect

– Purposeful

– Reflective

– Active

– Evidence based

– Spirit of inquiry

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• KNOWLEDGE is foundation for critical thinking and clinical decision making

• Competency should integrate knowledge, skill, application of evidence in practice, and critical thinking.

• Theoretical Framework: – Benner’s Novice to Expert Theory – The Synergy Model

10 2014

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• Nurses must be engaged in the competency assessment process in order to assume accountability for their clinical practice.

• Increased nurse engagement results in increased nurse satisfaction and retention. – Improved retention of critical care nurses results in a

financial cost savings to the organization. – Actively engaged nurses contribute to improved patient

satisfaction and improved overall quality outcomes.

(Force, 2005, Armstrong & Laschinger, 2006)

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Support for New Components

• Current literature regarding competency assessment focuses on utilizing alternative methods to assess nursing competency including the following: – Evaluation of continuing education activities

– Real time clinical performance assessment

– Review of unit specific quality improvement data

– Peer review

– Self reflection of nursing practice

– Utilization of professional portfolios

(National Education Framework Cancer Nursing, 2008)

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13 2014

The Culture

• Magnet Hospital (2006)

-re-designated in 2010

• 10 year history of a Novice to Expert Staff Education Program for Heart Center – Clinicians as instructors

– 5 Level program

– 102 hours of annual education

– Emphasis on certification preparation

– Linking knowledge to practice expectations for each class within curriculum

14 2014

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Cardiovascular

Patient

Critical

Thinking

Holistic Care

Evidence

Based Practice

Heart Center Core

Cardiovascular Curriculum

Program Model

Novice to

Expert

Synergy

Model

Goals:

Knowledge Acquisition

Practice Change

Certified Staff

Improved Outcomes

Physiological

Basis

of

Understanding

Certification

Readiness

Linking Knowledge

to Practice

Thread through all disciplines

and all settings in the

continuum of care.

Integration with

orientation, unit specific education,

skill development, and role advancement

Connection To:

Practice,

Research & Quality,

Patient Education,

Precepting Committees

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Distribution of Core Curriculum 23 Instructors

0 1 2 3 4

Hospital APN AdminCVC APNCVSI APNCCU Staff

CCU Assistant ManagerCCU CNS

CVSI StaffCVSI PCS

CVSI EducatorCV Surgery ClinicInvasive Lab Staff

Cardiology Service PCSCardiology Serv Staff

HF CoordinatorMI Coordinaor

ICU Educator2013 Instructor Turnover 2/24 = 8.3% 2013 New Instructors: 1

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2014 Class Schedule

Beginner Practitioner Classes Presented During Time Frame Dates / Times

Part 1 Cardiac Dynamics and Assessment

Heart Failure

Noninvasive Cardiac Testing

Thursday, March 13th

Thursday, October 30th

11:00am – 3:00pm

Part 2 Intro to 12 Lead ECG

ECG Injury and Ischemia

Axis/BBB

Wednesday, March 19th

Wednesday, November 5th

11:00am – 3:00pm

Part 3 Acute Coronary Syndrome

Interventional Cardiology

Open Heart Surgery

Diabetes Management

Thursday, April 10th

Thursday, November 13th

11:00am – 3:00pm

Part 4 CV Pharmacology

Introduction to Device Therapy

Introduction to Pacemaker Rhythm Interpretation and

TTVP Trouble Shooting

Wednesday, April 16th

Wednesday, November 19st

11:00am – 3:00pm

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2014 Class Schedule

Advanced Beginner Practitioner

Classes Presented During Time Frame Dates / Times

Part 1 Evidence Based Nursing Practice

Heart Sounds and Physical Assessment

The Continuum of Sepsis

Fluid/Electrolytes/Renal

Tuesday, April 1st

Wednesday, September 10th

11:00am – 3:00pm

Part 2 Arrhythmia Interpretation

ECG Fundamentals/Axis Degree

BBB and Hemiblocks

Ventricular Ectopy

Tuesday, April 15th

Tuesday, September 16th

11:00am – 3:00pm

Part 3 Hemodynamics in Altered Physiology

Inflammatory Disease

Valve Disease

Cardiomyopathy

Wednesday, April 23d

Wednesday, September

24th

11:00am – 3:00pm

Part 4 Pulmonary Physiology and Acid Base

Concepts of Ventilatory and Oxygenation Support

Cardiac Risk Factors

Cardiac Rehabilitation

Tuesday, April 29th

Tuesday, September 30th

11:00am – 3:00pm

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2014 Class Schedule Skilled Practitioner


Part 1 Pulmonary Physiology and Oxygen Delivery

Pulmonary Pathophysiology

Neurovascular Disease (Ischemic Stroke)

Peripheral Arterial Disease

Tuesday, May 6th

Thursday, October 2nd

11:00am – 3:00pm

Part 2 Narrow Complex Tachycardias

Wide Complex Tachycardias

Injury and Ischemia

Myocardial Mimics and Normal Variants

Tuesday, May 13th

Tuesday, October 7th

11:00am – 3:00pm

Part 3 Pacemakers

ICDs and Cardiac Resynchronization Therapy

NonPharmacological Treatment for Arrhythmias

Antiarrhythmic Pharmacology

Tuesday, May 27th

Thursday, October 16th

11:00am – 3:00pm

Part 4 Advanced Hemodynamics and Assessment

Pharmacology and Hemodynamics

Hematology and Coagulation

Evidence Based Cardiac and Critical Care Practice

Wednesday, June 4th

Wednesday, October 22nd

11:00am – 3:00pm

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2014 Class Schedule Proficient Practitioner (Certification Preparation Course)


Part 1 Issues in Oxygenation Pulmonary Physiology Oxygenation and Ventilatory Support Pulmonary Pathophysiology

Wednesday Feb 12th 8:00am-12:00 Noon Wednesday April 9th 8:00am-12:00 Noon

Part 2 Issues in Advanced Arrhythmias

Bradys and Blocks Atrial fibrillation and flutter Ectopy vs. Aberrancy Pharmacologic / Nonpharmacologic Treatment for Arrhythmias

Wednesday Feb 12th 1:00pm-5:00pm Wednesday April 2nd 1:00pm-5:00pm

Part 3 Patient Management Issues in the continuum of CAD

Advanced ECG: Injury and Ischemia Complications of Myocardial Infarction Evidence Based Guidelines for Patient Management Revascularization Secondary Prevention Strategies

Wednesday Feb 26th 8:00am-12:00 Noon Thursday April 24th 7:30am-11:30am

Part 4 Integrated Advanced Cardiovascular Pathophysiology

Valvular Heart Disease Cardiomyopathies Inflammatory CV Diseases Heart Failure

Wednesday Feb 26th 1:00pm-5:00pm Thursday April 24th 12:30pm-4:30pm

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2014 Class Schedule

Proficient Practitioner (Certification Preparation Course) Classes Presented During Time Frame Dates / Times

Part 5 Advanced Device Therapy

Renal

Endocrine

Tuesday Mar 4th 7:30am-11:30am

Wednesday May 7th

7:30am-11:30am

Part 6 GI/Liver/Pancreatitis

Hematology and Immunology

Multisystem (Sepsis/SIRS/MODS-Toxic Exposures)

Tuesday Mar 4th 12:30pm-4:30pm

Wednesday May 7th

12:30pm-4:30pm

Part 7 Pharmacology and Optimizing Myocardial Performance

Shock States

IABP

Tuesday Mar 18th

7:30am-11:30am

Wednesday May 14th

7:30am-11:30am

Part 8 Diseases of the Aorta

Trauma

Neurological Conditions

Tuesday Mar 18th 12:30pm-4:30pm

Wednesday May 14th

12:30pm-4:30pm 21 2014

2014 Beyond the Core Topics

Dates Focus Area Topic

Thursday, Feb 13, 2014

Thursday, July 10, 2014 Clinical Reasoning / Critical Thinking

Improving Your Accuracy and Comfort with ECG / Arrhythmia Interpretation

Monday, Feb 24, 2014

Monday, Aug 18, 2014 Clinical Reasoning / Critical Thinking

Cardiorenal Syndrome: Understanding How the Kidneys and Heart Interact

Monday, Mar 17, 2014

Wednesday, Sept 17,

2014

Clinical Reasoning / Critical Thinking

You DO Make a Difference in Patient Outcomes: Understanding Your Contribution to Outcomes

Tuesday, Apr 8, 2014

Wednesday, Oct 29,

2014

Clinical Reasoning / Critical Thinking

Nursing Implications for Anticoagulant and Antiplatelet Therapy

Thursday, May 15, 2014

Thursday, Nov 20, 2014 Clinical Reasoning / Critical Thinking

Hemodynamic Case Studies: Noninvasive and Invasive

Tuesday, Jun 3, 2014

Thursday, Dec 18, 2014 Clinical Reasoning / Critical Thinking

Critical Analysis and Reporting of Abnormal Assessment Findings 22 2014

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2014 Level 5 Symposium Topics Focus Area Topic Content

Impacting Patient Outcomes DATE: TBA

Secondary Prevention in Cardiovascular Disease

1. Implementing New Guidelines for Cholesterol and Diet

2. Implementing New Guidelines for HTN 3. Implementing New Guideline Recommendations

for Obesity / Over Weight and Tobaccoism

Engagement Monday June 17, 2013

Professional Development: Step Forward

1. Charting Your Career Path: What are the Options? 2. Beyond BSN: The Consensus Model for APN

Practice 3. Communicating with Power

Impacting Patient Outcomes Thursday, Sept 18, 2014

Impacting Cardiac Failure

1. Essential Medical Management: Are we doing the right things?

2. Essential Nursing Practice: Making a Difference with Each Encounter

3. Essential Considerations: Circulatory Support Devices in the Treatment of Heart Failure

Engagement Monday, Dec 15, 2014

Clinical Leadership: Step Forward

1. Creating Safe Passages 2. Caring Practice 3. Competent Practice: What, Where and Why

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The Culture of CCU

• CCU organized under a product line Heart Center Model

• CCU provides care to cardiac medical ICU, progressive care and step down patients, and patients preparing for discharge.

• Defining characteristics: - Three-time Beacon Unit (hoping for #4 soon!) - Strong Unit Based Shared Governance - PULSE study - A rich unit based orientation structure and process (est. 2000)

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25 2014

26 2014

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The Culture of CCU

• Orientation components: - Clinical Orientation Pathway for Step down and ICU levels of care

– Daily Score Card for core clinical skill development – Tools are based on the new RN graduate perspective but individualized for

nurses with experience – Established application process for preceptors with Committee Peer Review – Hospital Preceptor Workshop with required refresher every 2 years – Unit-Based Preceptor Quarterly Meetings consisting of current preceptee

orientation needs, clinical skill builder and role development focus

• Orientation outcomes: – > 90% one-year post orientation retention since 2008 – Preceptee satisfaction with orientation > 9.0 (1-10 scale) since 2011

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SPECIFICS OF THE NEW PARADIGM

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Competency Changes as Introduced to Staff

• Required organizational competency will continue.

• General nursing and critical care competencies as well as competencies related to advanced skills (i.e. IABP) will continue to be important.

• Unit specific competency is the area of paradigm shift. The goal is to take cardiac nursing practice to the next level by focusing each year on key areas of cardiac nursing practice.

29 2014


• Competency will be evaluated continuously throughout the year as opposed to at a single point in time during the year. – A variety of competency activities and assessment will be

completed throughout the year.

– The competency process will be more interactive. Each professional nurse will assume responsibility for the documentation of his or her competency in each clinical area.

– Competency assessment will be more closely linked with real time clinical practice.

• An annual competency meeting will occur as an opportunity to review documentation of ongoing competency via the professional portfolio and to set future clinical goals.

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• Each professional nurse will asked to begin a professional portfolio.

– The professional portfolio will be discussed during the annual competency meeting and during the annual evaluation.

– Required content of the professional portfolio include:

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Requirements for Professional Portfolio Content

• Required activities form from annual focus areas

– Exemplars – Journal article summaries

• Self Assessment of Adherence to Linking Knowledge to Practice Expectations

• Progress toward established clinical goals • Continuing education activities (required)

– Professional nursing practice – General clinical – Critical care – Cardiac specific (Core Curriculum and Beyond the Core)

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Self Assessment of Linking Knowledge to Practice Expectations

• In conjunction with your annual competency and your evaluation this year you are being asked to complete a self-assessment of the attached clinical expectations. The purpose of this exercise is to increase your awareness of the clinical expectations as well as to assess your current clinical practice. Please be as honest as you can. The goal of this exercise not punitive, but, to develop an understanding of current practice patterns in CCU. This will help us continue to develop future programs on the hopes of enhancing clinical practice and ultimately outcomes. This tool will become part of your professional portfolio and progress reviewed annually. Remember to look at the years of experience attached with each level to understand where your level of practice should be. Please evaluate your clinical practice for each item utilizing the following scale:

• 1 = Never performs in daily practice • 2 = Rarely performs in daily practice • 3 = Occasionally performs in daily practice • 4 = Often performs in daily practice • 5 = Consistently performs in daily practice

For each class in the novice to expert curriculum there are expected practice expectations. These are distinctly separate from objectives.

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Level 1: Beginning Practitioner (0-1 year of clinical experience) Level 1 is designed for new Heart Center employees. The Beginning Practitioner period lasts approximately one year as the Beginning Practitioner becomes acclimated to his or her environment, learns policies and procedures, and develops a baseline understanding of the cardiac patient.

Level 2: Advanced Beginner (1-2 years of clinical experience) The Advanced Beginner continues to develop more confidence in his or her clinical skills. The Advanced Beginner has coped with enough real situations to recognize the recurring components of the situation, but continues to require assistance from a mentor or more experienced nurse to guide actions. The Advanced Beginner level lasts for approximately 1to 2 years.

Level 3: Skilled Practitioner (2-3 years of clinical experience) The Skilled Practitioner in 2 or 3 years of practice has developed a comfort level with his or her routine bedside practice. The Skilled Practitioner expands his or her depth of knowledge and critical thinking skills. For the Skilled Practitioner, plans are established based on conscious, abstract, analytic contemplation of the problem. This deliberate planning helps achieve efficiency and organization. The Skilled Practitioner lacks the speed and flexibility of the proficient nurse but does have a feeling of mastery and the ability to cope with and manage the many contingencies of clinical nursing.

Level 4: Proficient Practitioner (3- 5 years of clinical experience or anyone with more years of experience but not certified) The Proficient Practitioner has mastered a high level of proficiency in the care of the cardiac patient demonstrating both efficiency and flexibility, while utilizing critical thinking skills to drive practice. Decision making becomes less labored due to understanding of the nuances of a situation. The proficient nurse can recognize when the expected normal picture does not materialize. The Proficient Practitioner provides guidance and direction for other staff.

Level 5: Expert Practitioner (Certified Staff) Once the Proficient Practitioner has achieved the goal of specialty certification he or she is considered an Expert Practitioner in the Heart Center. The expert nurse, has an intuitive grasp of each situation and zeroes in on the accurate region of the problem without wasteful consideration of a large range of unfruitful, alternative diagnoses and solutions. The expert operates from a deep understanding of the total situation. The Expert Practitioner’s performance becomes fluid, flexible and highly proficient. When faced with an unfamiliar situation the expert relies on analytical thinking to determine the appropriate clinical response.

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Pulmonary Self-Assessment of

Practice

Clinical Practice Expectation

Level 1 Level 2

Part 4 √ Performs basic blood gas interpretation (assessment for ventilation versus diffusion abnormality, acidosis or alkalosis as metabolic or respiratory origin, compensation). 4

√ Reviews respiratory therapy documentation at the beginning of each shift when caring for patient on ventilator to determine mode of ventilator, settings, and adjunctive therapy. 4

√ Requests family to bring in home CPAP or BiPAP therapy to continue treatment during hospitalization. When not possible ask case manager to obtain setting from patient’s home medical company.

4

√ Reports any tachypnea in a patient on mechanical ventilation. 5 √ Assures 100% compliance with oral care. 5 √ Assures adequate sedation and pain control in all patients who are intubated. 4 √ Performs daily awakening trial. 3 √ Identifies a patient who meets weaning criteria. 5 **

Level 3 Part 1 √ Assesses and documents PaO2 / FIO2 ratios on all patients with ABGs/ ventilator therapy. 5

√ Differentiates respiratory failure as either ventilatory or oxygenation failure. 4

Level 4 Part 1 √ Assesses (from respiratory documentation) peak inspiratory and plateau pressures at the

beginning of each shift for mechanically intubated patients.. 3

√ Trend PaO2/FIO2 ratio on all patients on mechanical ventilation. 5 √ Verify prolonged expiratory time on mechanically ventilated patients with COPD. 3 √ Rule out tension pneumothorax on any mechanically intubuted patient who develops

hypotension. 3*

√ Assure adequate volume status prior to adding positive pressure ventilation and / or increasing PEEP

3*

* Items I plan to focus on this next year (2013) ** Items for which I have documentation of linking knowledge to practice (2012)

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Suggestions for Professional Portfolio Content

• Certifications

– CCRN – CMC – CHFN

• Community involvement / Volunteer activities • Formal academic coursework / degree earned

– BSN – MSN

• Awards / Achievements (Personal and Professional)

• Practice narratives / peer review statements / specific examples of clinical contributions

• Positive feedback from patient satisfaction surveys / call backs

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Suggestions for Professional Portfolio Content

• Attendance and involvement in:

– Unit based shared decision making

– Heart Center committees

– Organizational shared decision making

– Professional organizations

• Certificates

– ACLS

– Fundamentals of Critical Care Support

Sample portfolios are here for your review.

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Using the Portfolio to Move from “Annual” Assessment to Continuous Assessment

Competency in nursing practice is performed 24/7 on a continuous and real time basis.

Competency assessment is moving to a real time evaluation of daily clinical practice to assure the highest level of excellence in nursing practice.

Encouraged to capture evidence of competency on a concurrent basis and include in portfolio.

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Competency Focus Areas To Date

2011 Cardiac Monitoring

Cardiac Rehabilitation

Patient Education for Acute Coronary Syndrome

and Heart Failure

2012 Cardiac Monitoring

Heart Failure

Assessment

2013 Core Clinical Business:

Cardiac Monitoring

Building on Patient Education: Teach Back

New Focus Areas Based on Identified Gaps :

Pulmonary

Hemodynamics

Antiarrhythmic Pharmacology

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For each focus area: Nurses are required to bring evidence of

competency in their portfolio. There are some required activities and there are some activities where nurses are

given a choice.

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Your Choice Activity: Choose One of the Activities below to fulfill cardiac monitoring competency.

Obtain or maintain certification as a CCRN and / or CMC, or CHFN

Submit a peer review written statement for your portfolio demonstrating how you have shown clinical leadership in the area of cardiac monitoring

Submit a self written reflective practice statement for your portfolio on how you have positively impacted clinical practice in the area of cardiac monitoring

Read an evidence based cardiac monitoring journal article and bring to your individual competency meeting.

Attend a Heart Center Clinical Practice Committee Meeting.

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Pilot Results

Cardiac Monitoring

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Pre

Intervention

Data

Post

Intervention

Data

Percent

Improvement

p-Value

Number of Alarm Banks

Reviewed

93 125

# / % patients with Clinically

Significant Arrhythmias

14/93 = 15.05% 26 / 125 = 20.8% N/A 0.28

#/% of Clinically Significant

Arrhythmias Posted to Chart

9/23 = 39.13% 21/27 = 77.78% 38.5% *0.005

#/% Clinically Significant

Arrhythmias Documented in ICU

Flow

8/23 = 34.78% 15/27 = 55.6% 20.82% 0.14

# /% of Clinically Significant

Arrhythmias With Provider

Notification

5/16 = 31.25%

9/22 = 40.9%

9.65% 0.54

2014

Number of Nurses Assessed 27 31

Number of Charts Reviewed 91 106 N/A

Accuracy of V Lead Placement 44/84 = 52.38% 81/102 = 79.4% 27.1%

(p=.08)

Accuracy of Limb Lead

Placement

43/84 = 51.19% 73/102 = 71.6% 20.41%

Appropriate Documentation

of QRS Width

74/86 = 86.05% 96/103 = 93.2% 7.15%

Appropriate Documentation

of BBB

2/13 = 15.38% 19/28 = 67.9% 52.5%

(p=.07)

Accuracy of QTc

Documentation

57/80 = 71.25% 74/79 = 93.7% 22.45%

V lead ST Segment Alarms at

1 mm above and 1 mm below

baseline

33/68 = 48.53% 47/67 = 70.1% 21.57%

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1. The new competency assessment program recognizes my knowledge and skill related to cardiac monitoring. 4.5

2. The new competency assessment program identifies opportunities for improvement of my practice related to cardiac monitoring.

5.0

3. The new competency assessment program reflects important issues in clinical practice. 4.5

4. I am more likely to engage in ongoing learning activities related to cardiac monitoring as a result of the new competency assessment program.

4.0

5. I am more likely to change my clinical practice as a result of the new competency assessment program. 4.0

6. The new competency assessment program will increase my confidence in my rhythm interpretation skills. 4.0

7. The new competency assessment program will provide me autonomy in evaluating my competency. 4.5 45 2014

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2013 Competency Outcome Assessment

• Accuracy of electrode placement for cardiac monitoring (follow up to initial evaluation) – Assessment of sustainable change

• Synergy Model Competencies and Outcomes Assessment for two key areas: – Cardiac Monitoring (Core Business)

– Teach Back (Unit Based Quality Initiative to Expand on 2011 Patient Education and 2012 HF Focus)

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• Resiliency

• Vulnerability

• Stability

• Complexity

• Predictability

• Resource availability

• Participation in care

• Participation in decision making

• Clinical Judgment

• Advocacy / Moral Agency

• Caring Practices

• Collaboration

• Systems Thinking

• Response to Diversity

• Facilitator of Learning

• Clinical Inquiry (Innovator / Evaluator) 48 2014

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Our Methodology

• AACN Synergy definitions were used as the framework.

• Three reviewers with two reviewers who were blinded to the nurse identification and characteristics.

• Exemplars were read and evaluated for demonstrated Synergy competencies.

• Synergy competencies were evaluated for novice to expert level (level 1, 3 or 5) per AACN Synergy criteria.

• All three reviewers needed to be in agreement for final assigned competency category.

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CLINICAL JUDGMENT Level 1 Competent

Level 3

Level 5 Expert

Clinical reasoning, which includes clinical decision-making, critical thinking, and a global grasp of the situation, coupled with nursing skills acquired through a process of integrating formal and experiential knowledge

ADVOCACY/MORAL AGENCY Level 1 Competent

Level 3

Level 5 Expert

Working on another's behalf and representing the concerns of the patient, family and community; serving as a moral agent in identifying and helping to resolve ethical and clinical concerns within the clinical setting

CARING PRACTICES Level 1 Competent

Level 3

Level 5 Expert

The constellation of nursing activities that are responsive to the uniqueness of the patient and family and that create a compassionate and therapeutic environment, with the aim of promoting comfort and preventing suffering. These caring behaviors include, but are not limited to, vigilance, engagement, and responsiveness

COLLABORATION Level 1 Competent

Level 3

Level 5 Expert

Working with others, (eg, patients, families and healthcare providers) in a way that promotes and encourages each person's contributions toward achieving optimal and realistic patient goals. Collaboration involves intra-and inter-disciplinary work with all colleagues

SYSTEMS THINKING Level 1 Competent

Level 3

Level 5 Expert

The body of knowledge and tools that allows the nurse to appreciate the care environment from a perspective that recognizes the holistic interrelationship that exists within and across healthcare systems

RESPONSE TO DIVERSITY Level 1 Competent

Level 3

Level 5 Expert

The sensitivity to recognize, appreciate, and incorporate differences into the provision of care. Differences may include, but are not limited to, individuality, cultural differences, spiritual beliefs, gender, race, ethnicity, disability, family configuration, lifestyle, socioeconomic status, age values, ad beliefs surrounding alternative/ complimentary medicine involving patients, families, and members of the healthcare team

CLINICAL INQUIRY Level 1 Competent

Level 3

Level 5 Expert

The ongoing process of questioning and evaluating practice, providing informed practice and innovating through research and experiential learning. The nurse engages in clinical knowledge development to promote the best patient outcomes

FACILITATOR OF LEARNING Level 1 Competent

Level 3

Level 5 Expert

The ability to facilitate patient and family learning

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Clinical Judgment

• Level 1: Collects basic-level data; follows

algorithms, decision trees and protocols with all populations and is uncomfortable deviating from them; matches formal knowledge with clinical events to make decisions; questions the limits of one's ability to make clinical decisions and delegates the decision-making to other clinicians; includes extraneous detail

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Clinical Judgment

• Level 3: Collects and interprets complex patient data; makes clinical judgments based on an immediate grasp of the whole picture for common or routine patient populations; recognizes patterns and trends that may predict the direction of illness; recognizes limits and seeks appropriate help; focuses on key elements of case, while sorting out extraneous details

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Clinical Judgment

• Level 5: Synthesizes and interprets multiple, sometimes conflicting, sources of data; makes judgment based on an immediate grasp of the whole picture, unless working with new patient populations; uses past experiences to anticipate problems; helps patient and family see the "big picture"; recognizes the limits of clinical judgment and seeks multidisciplinary collaboration and consultation with comfort; recognizes and responds to the dynamic situation

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2013: Distribution of Your Choice Activities

Competency Area: Antiarrhythmic Medications

Activity Option CE Offering Journal Article Review

LexiComp Drug Review

Certification Status

Percent Distribution 1.9% 43.5% 38.0% 16.7%

Competency Area: Hemodynamics

Activity Option CE Offering

Journal Article Review

Square Wave Test

Clinical Practice Committee

Certification Status

Percent Distribution 12.6% 67.0% 1.9% 1.0% 17.5%

Competency Area: Pulmonary

Activity Option CE Offering

Journal Article Review

Exemplar Certification Status

Percent Distribution 7.0% 61.0% 14.0% 18.0%

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Accuracy of Lead Placement 2010 – 2013

• 2013 Sustained Practice Sample Size: 493 • Hardwire: 35

• Telemetry: 458

Electrode Percent Correct Placement: Pre Competency Implementation

Percent Correct Placement: Post Competency Implementation 2011

Percent Correct Placement: Sustained Results 2013

Left arm 51% (Limb leads combined) 72% (Limb leads combined) 84%

Right arm 51% (Limb leads combined) 72% (Limb leads combined) 86%

Left leg 51% (Limb leads combined) 72% (Limb leads combined) 86%

V1 52% (V leads combined) 79% (V leads combined) 86%

V3 52% (V leads combined) 79% (V leads combined) 78%

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2013 Exemplar Reviews

Curriculum Level Number of

Registered Nurses Percent Distribution

1 (Beginning Practitioner)

16 16.3%

2 (Advanced Beginner) 7 7.1%

3 (Skilled Practitioner) 19 19.4%

4 - Beyond the Core (Proficient Practitioner)

38 38.8%

Certified Staff (Expert Practitioner)

18 18.4%

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Teach Back Exemplars: Level 1

(Beginning Practitioner)

Competency Number Level Percent

Facilitator of Learning 28 1 67.8%

3 28.6%

5 3.6%

Response to Diversity 5 1 100%

3 -

5 -

Systems Thinking 1 1 100%

3 -

5 -

Caring Practice 1 1 100%

3 -

5 -

Clinical Judgment 1 1 100%

3 -

5 -

•16 participants

• 32 Exemplars

• Exemplars with no teach back addressed: 4 (12.5%)

• Outcomes: 31

Outcomes

Patient learning

27

Family Learning

4

57 2014


(Advanced Beginner) Competency Number Level Percent


3 42.9%

5 -

Response to Diversity 9 1 44.4%

3 55.6%

5 -

• 7 Participants

• 14 Exemplars

• Outcomes: 18

Outcomes

Patient learning

14

Family Learning

4

58 2014

30


Skilled Practitioner



3 55.6%

5 -


3 33.3%

5 -

Systems Thinking 3 1 33.3%

3 66.7%

5 -

Collaboration 2 1 100%

3 -

5 -

Advocacy 1 1 100%

3 -

5 -

• 19 Participants

• 38 Exemplars


• Outcomes: 42

Outcomes

Patient learning

35

Family Learning

6

Family comfort / satisfaction

1

59 2014

Teach Back Exemplars: Level 4 – Beyond the Core

Proficient Practitioner



3 31.8%

5 6.1%


3 27.3%

5 18.2%

Systems Thinking 8 1 37.5%

3 37.5%

5 25%


3 -

5 50%

Collaboration 1 1 -

3 100%

5 -

Advocacy 1 1 -

3 100%

5 -

• 38 Participants • 77 Exemplars • 8 Exemplar efforts not satisfactory •No teach back addressed: 4 (5.2%) • Outcomes: 78

Outcomes

Patient learning

62

Family Learning

13


3

Note: One example of uncaring practice. 60 2014

31

Teach Back Exemplars: Certified Staff (Expert)



3 21.2%

5 12.1%


3 21.4%

5 7.1%


3 50%

5 -

Caring Practice 3 1 33.3%

3 66.7%

5 -

Advocacy 3 1 100%

3 -

5 -

• 18 Participants

• 36 Exemplars


• Outcomes: 38

Outcomes

Patient learning

31

Family Learning

5


2

61 2014

Cardiac Monitoring Exemplars:

Level 1 (Beginning Practitioner)


Clinical Judgment 30 1 76%

3 24%

5 -

Advocacy 5 1 100%

3 -

5 -


3 -

5 -

Clinical Inquiry 1 1 50%

3 50%

5 -

• 16 participants

• 32 Exemplars

• Exemplars with Outcomes = 68.8%

Outcomes

Change in Immediate Treatment

19 = 59.4%

Change in Overall Plan of Care

4 = 12.5%

* N for outcomes = number of exemplars. Some exemplars may be > 1 outcome. 62 2014

32


Clinical Judgment 9 1 66.7%

2 33.3%

3 -

Advocacy 5 1 80%

2 20%

3 -


2 -

3 -

Caring Practice 2 1 -

2 100%

3 -

Systems Thinking 1 1 -

2 100%

3 -

• 7 participants • 14 Exemplars • 2 Exemplars unsatisfactory • Exemplars with Outcomes

= 35.7%

Outcomes


4 = 28.6%


1 = 7.1%

* N for outcomes = number of exemplar. Some exemplars may be > 1 outcome. 63


Level 2 (Advanced Beginner)

2014



3 52.9%

5 -

Advocacy 6 1 50%

3 50%

5 -

Collaboration 6 1 66.7%

3 -

5 33.3%

Clinical Inquiry 6 1 50%

3 50%

5 -

• 19 participants

• 39 Exemplars

• 2 Exemplars unsatisfactory


Outcomes


23 = 59.0%


4 = 10.3%

* N for outcomes = number of exemplars Some exemplars may be > 1 outcome. 64


Level 3 (Skilled Practitioner)

2014

33



3 34.3%

5 4.3%

Advocacy 18 1 55.6%

3 27.8%

5 16.7%

Collaboration 19 1 15.8%

3 47.4%

5 36.8%

Caring Practice 2 1 -

3 50%

5 50%

Clinical Inquiry 13 1 53.8%

3 30.8%

5 15.4%


3 -

5 -

Facilitator of Learning 1 1 100%

3 -

5 -

• 38 participants

• 76 Exemplars

• 3 Exemplars unsatisfactory

• Exemplars with Outcomes = 75%

Outcomes


50 = 65.7%


13 = 17.1%

* N for outcomes = number of exemplar. Some exemplars may be > 1 outcome.

65


Level 4 (Proficient Practitioner)

2014



3 45.9%

5 10.8%

Advocacy 12 1 50%

3 33.3%

5 16.7%


3 25%

5 50%


3 -

5 50%

Clinical Inquiry 7 1 14.3%

3 57.1%

5 28.6%

• 18 participants

• 39 Exemplars


Outcomes


19 = 48.7%


8 = 20.5%

Increased staff knowledge

1 = 2.6%

* N for outcomes = number of exemplar. Some exemplars may be > 1 outcome.

66


Level 5 (Expert Practitioner)

2014

34

67 2014

Outcome Definitions

Immediate Treatment

• Medication and/or dose changes

• Electrolyte replacement (labwork)

• Consults

• Central line placement

Change of Overall Plan of Care

• Cancellation of tests/procedures

• Change in code status

• Cancellation of discharge

• Emergent procedures (heart cath/PCI/OHS)

• Change in level of care

68 2014

35

Cardiac Monitoring Exemplars with Outcomes

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Level 1 Level 2 Level 3 Level 4Beyond

Core

Certified

% Outcomes

# Exemplars: 32

# Exemplars: 14

# Exemplars: 39

# Exemplars: 76 # Exemplars:

39

69 2014

Exemplars with Change in Immediate Treatment

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%


Core

Certified

% Change Immediate Treatment

% Change ImmediateTreatment

70 2014

36

Exemplars with Change in Overall Plan of Care

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%


Core

Certified

% Change in Overall Plan of Care

% Change in Overall Planof Care

71 2014

72 2014

37

Expert in Clinical Judgment

0.00%

5.00%

10.00%

15.00%

Level 1 Level 2Level 3

Level 4Beyond

Core

Certified

% Expert

73 2014

Expert in Advocacy

0.00%

5.00%

10.00%

15.00%

20.00%


Level 4Beyond

Core

Certified

% Expert

74 2014

38

Expert in Collaboration

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%


Level 4Beyond

Core

Certified

% Expert

75 2014

Expert in Clinical Inquiry

0.00%

10.00%

20.00%

30.00%


Level 4Beyond

Core

Certified

% Expert

76 2014

39

Expert in Caring Practice

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%


Level 4Beyond

Core

Certified

% Expert

77 2014

Cardiac Monitoring Exemplar

• Beyond the Core Level Nurse

• Competencies (Level 5)

-Clinical Judgment

-Advocacy

-Collaboration

-Clinical Inquiry

78 2014

40

Cardiac Monitoring Exemplar

• Beginning Practitioner (Level 1)

• Competencies (Level 3)

-Clinical Judgment

-Clinical Inquiry

79 2014

Teach-Back Exemplar

• Beyond the Core Level Nurse

• Competencies

– Facilitator of learning (level 5)

– Caring practice (level 5)

– Diversity (level 5)

– Advocacy (level 3)

• This next exemplar made us smile!

80 2014

41

Conclusion

81 2014

Initials Insights • A more holistic perspective • Shift in accountability to the individual

registered nurse • Brings to light the scope of knowledge and skill

required for competence at the point of care • Direct observation of specific individual

practice is necessary to identify gaps that may not be identified by more global quality indicators (NDNQI, Core Measures, etc).

• Majority of nurses are willing to embrace structures and processes that raise the bar for clinical practice standards

82 2014

42

2013 Unexpected Discoveries

• Physician resistance to nurse expertise

• Many nurses are novice in writing about competency, not comfortable with self reflection

• Gap in knowledge and skill regarding tobacco cessation counseling

• Honesty regarding self assessment of linking knowledge to practice expectations

83 2014

2013 Insights

• Capturing clinical judgment at the point of care provides recognition for the complexity of clinical decision making.

• Bringing to light previously nonncaptured associations and non measured outcomes – Self reflection statements and clinical examples within

the portfolios capture application of knowledge at the point of care that would otherwise not be acknowledged.

• Telling the story of nursing practice

84 2014

43

2013 Insights

• A nurse may be at a different level of development for different competencies

• Years of experience alone does not equate to expert level of practice

• Portfolio was objective validation of subjective pre-assessment

• After 3 years of mentoring and coaching – ready to step up the level of expectation for satisfactory competency

• Competency assessment is basis for clinical goal development and for inclusion in evaluation process for clinical performance

85 2014

Future Goals

• Clarity regarding level of quality for portfolio components and progress toward goals.

• Balance between evaluator and coach/mentor.

• Move forward with less “content” and more focus on evidence of excellence in practice.

• Balance between recognizing certification and continuing to develop certified nurses.

• Opportunity to recognize specific nursing strengths for future growth and development.

• Correlate competency assessment with advancement in skill training and other opportunities.

86 2014

44

Concluding Thought

This recognition results in either deep professional satisfaction from knowing the full extent that one’s work is worthwhile, or it provides the catalyst for future growth and development.

87 2014

88

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2014

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Documents

Clinical Nurse Specialist Leadership in Redefining How … … · 1 Rhonda Fleischman MSN, RN-BC, CNS, CCRN-CMC Karen Marzlin DNP, RN, CCNS, CCRN-CMC, CHFN Cynthia Webner DNP, RN,