Clinical Nurse SpecialistA Copyright B Feature Articledocuments for the nurses’ provision of patient care. Clin-ical nurse specialists (CNSs) provide leadership by serv-ing as council

Clinical Nurse Specialists Shaping Policiesand Procedures Via an Evidence-BasedClinical Practice Council

Elaine Becker, PhD, RN n Vivien Dee, DNSc, RN n Anna Gawlinski, DNSc, RN, FAAN nTheresa Kirkpatrick, MSN, RN n Mary Lawanson-Nichols, MSN, RN n Betty Lee, MN, RN nChristina Marino, MSN, RN n Norma McNair, RN n Mary A. Melwak, PhD, RN nIsabell Purdy, PhD, RN n Shohreh S. Samimi, MSN, RN n Grace Sund, MSN, RN nJennifer Zanotti, MSN, RN

In the practice of nursing, organizations with progressiveevidence-based practice programs implement structures andprocesses whereby nurses are engaged in the review of existingresearch and in the development of clinical practice documentsto better align nursing practices with the best available scientificknowledge. At our academic hospital system, clinical nursespecialists (CNSs) took the lead to help transform a traditionalnursing policy and procedure committee into a hospital-wide,staff-represented Clinical Practice Council (CPC) that ensuresevidence-based nursing practices are reflected in theorganization’s nursing practice documents for the provisionof patient care. Clinical nurse specialists function as mentorsand cochairs who are dedicated to ensuring that nursingpractice is supported by the latest evidence and committedto guiding staff nurses to continually move their practiceforward. The success of the CPC is due to the leadership and

commitment of the CNSs. This article describes the structure,process, and outcomes of an effective CPC where CNSssuccessfully engage frontline clinicians in promoting nursingcare that is evidence based. Clinical nurse specialist leadershipis increasingly made visible as CNSs effectively involve staffnurses in practice reforms to improve patient outcomes.KEY WORDS:clinical nurse specialist, clinical practice council

Progressive organizations with commitment to a cul-ture of evidence-based practice (EBP) must im-plement structures and processes whereby nurses

engage in the review of existing research to better alignnursing practices with the best available scientific knowl-edge.1Y8 To enhance staff nurses’ influence over nursingpractice, our academic hospital system took the lead totransform our traditional nursing policy and procedurecommittee into a hospital-wide, staff nurseYrepresentedClinical Practice Council (CPC). The CPC ensures thatEBPs are reflected in the organization’s nursing practicedocuments for the nurses’ provision of patient care. Clin-ical nurse specialists (CNSs) provide leadership by serv-ing as council cochairs and mentoring staff nurses in theintegrated effort to evaluate evidence and revise nursingpractice documents.

This article describes the structure, process, and out-comes of an effective CPC where CNSs successfully engagefrontline clinicians in promoting nursing care that is evi-dence based. Clinical nurse specialist leadership and effec-tiveness are increasingly made visible as CNSs involve staffnurses in practice reforms that provide evidence-based carethat is safe and effective to improve patients’ outcomes.

Author Affiliations: Director of Research and Evidence-Based Practice(Dr Gawlinski), Clinical Educator and Coordinator of Clinical PracticeCouncil (Dr Becker), Clinical Educator and Administrative Nurse II(Ms Kirkpatrick), Principal Trainer (Ms Marino), Clinical Nurse Specialist(Ms McNair), Quality Specialist in Pediatrics (Dr Melwak), and Unit Di-rector (Ms Samimi), Ronald Reagan University of California Los Angeles(UCLA) Medical Center; Clinical Nurse Specialists, Santa Monica UCLAMedical Center & Orthopaedic Hospital (Mss Lawanson-Nichols, Lee,and Sund); Professor and Director of PhD Nursing Program, AzusaPacific University School of Nursing (Dr Dee); Adjunct Professor, UCLASchool of Nursing (Dr Gawlinski); and Assistant Professor and Director,Neonatal High Risk Infant Follow-up Clinic and Neonatal Clinical Re-search Database Center (Dr Purdy), and Magnet Program Directorand Clinical Nurse Specialist (Ms Zanotti), UCLA Health System.The authors report no conflicts of interest.Correspondence: Anna Gawlinski, DNSc, RN, FAAN, Ronald ReaganUCLA Medical Center, Rm B790, 575 Westwood Plaza, Los Angeles,CA 90095 ([email protected]).DOI: 10.1097/NUR.0b013e3182467292

74 www.cns-journal.com March/April 2012

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PURPOSE OF THE COUNCILHistorically, hospital nursing policy and procedure com-mittees have focused mainly on the process of policyreview, with limited reliance on research and evidence-based literature to guide changes in practice documentsand with minimal involvement of staff nurses.9,10 In aneffort to address the variability in clinical practice andto integrate research within our department of nursing,the CPC was established to accomplish the followinggoals:n Foster exemplary patient care through the develop-

ment, review, and dissemination of clinical nursing pol-icies, procedures, and institutional guidelines of care.

n Ensure that practice documents are aligned with thelatest research and evidence.

n Provide a forum that stimulates innovative thinkingamong frontline clinicians regarding integrating evi-dence into current practices.

n Provide a mechanism for dissemination and feedbackregarding new practices among frontline clinicians.The CPC facilitates recognition of the staff nurses’

clinical expertise and influence to guide clinical practice.Moreover, through their involvement with the CPC, staffnurses encourage a culture of inquiry that facilitates in-novation. Members of the CPC give thoughtful consi-deration to practices that are efficient and effective inimproving patients’ outcomes. The CPC encourages ac-countability, ownership, and the promotion of clinicalpolicies, procedures, institutional guidelines of care, andcompetencies throughout the hospital system.

STRUCTURE OF THE COUNCILStaff nurses with strong clinical knowledge and leader-ship skills from each unit in the hospital represent theunique needs of their specific unit and help ensure con-sistent nursing practices in their unit and throughout thehospital. The monthly 4-hour council meetings provideopportunities for advanced learning regarding researchand EBP, and the meetings entail actual group and coun-cil work in the following areas: (1) retrieval, critique, andsynthesis of evidence-based literature; (2) interpretationand evaluation of current evidence; (3) review and revi-sion of policies and other practice documents; (4) per-formance as a member of a nursing team within councilstructures; (5) dissemination of EBP changes; and (6) clin-ical role modeling and leadership skills.

Because of the existence of many specialty areas, theCPC has 3 major subgroups (ie, critical careVemergency;intermediate careVmedical surgical; and pediatrics, neo-nate, and perinatal). Each subgroup, which varies in sizefrom 10 to 15 nurses, is cochaired by 1 or 2 CNSs who areknowledgeable in EBP and able to mentor staff in devel-oping EBP documents. A doctorally prepared director ofresearch and EBP serves as the chair of the CPC and as a

mentor for research and EBP. Since initiation of the CPCseveral years ago, additional EBP mentors have been as-signed to each of the 3 subgroups. Figure 1 graphicallydisplays the organizational structure of the CPC.

SELECTION OF STAFF NURSE REPRESENTATIVESEach CPC unit representative is selected by the unit lead-ers (unit director [manager], CNS, or educator) in accor-dance with specified criteria. To create a council that ishighly effective and successful in achieving its goal, thefollowing selection criteria are used when appointingunit representatives:n minimum of 2 years of nursing experiencen minimum of 1-year tenure in the current clinical arean ideally employed full-time or at least 50% timen expressed interest in growing in clinical leadership

by influencing the unit’s clinical nursing practicen expressed interest in learning about the goals and

activities of the council related to development ofpractice documents

n able to commit to being unit representative for atleast 2 years

n interest in partnering with other unit representativesto discuss practices in light of latest evidence

n is considered an informal leader among peers

FIGURE 1. Clinical practice council organizational chart.

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n meets or exceeds expected clinical performancebased on the job description/performance evaluation

n commits to sharing and disseminating new practicerecommendations with unit colleagues.Each CPC representative signs an agreement that de-

lineates the expected adherence to council protocol. Thisprotocol includes regular meeting attendance (a maximumof 2 missed meetings annually), active participation in allphases of document development, and dissemination andreinforcement of practice changes and the supportingevidence to their respective unit nurse colleagues. Theagreement is cosigned by the unit leadership and sub-mitted to the director of research and EBP.

ROLE AND PREPARATION OF STAFFNURSE REPRESENTATIVESTo ensure success of CPC representatives, an initial for-mal orientation and ongoing educational sessions areprovided at each monthly meeting. The formal orien-tation consists of 2 parts. The first part is a verbal dis-cussion by the CNS cochair about the purpose, structure,processes, and expectations of the CPC members of theirsubgroup. The second part of the orientation involves thereview and completion of a self-study module consistingof an overview about EBP and the relationship to the pur-pose and goals of the CPC. A posttest of this self-studymodule is completed by all new CPC representatives.

Recurring education programs are also provided forCPC nurse representatives. These monthly didactic ses-sions cover a range of EBP topics and are given duringthe first 30 to 45 minutes of each meeting. Topics includethe following: what is EBP, determining the levels of evi-dence, searching and retrieving the evidence, critiquingand synthesizing the evidence, and determining if the evi-dence supports a practice change. In addition, operation-alizing the CPC’s role as a clinical leader and disseminatorof practice changes is discussed. Immediately after theeducational session, the entire council has an opportunityfor discussion, questions, and feedback.

The interactive educational offerings are provided bydoctorally prepared EBP mentors to facilitate nurses’ useof EBP. The education provides the foundation for theCPC representatives to successfully evaluate scientificliterature and harvest the most valuable findings for nurs-ing practice. The knowledge gained by CPC nurses em-powers them with the complex skills needed to navigatereading nursing research studies and decipher the strengthand levels of research and other levels of evidence to iden-tify relevant findings.

The EBP education series is supplemented by infor-mal yet vital mentoring of CPC representatives duringthe council meeting by both the CNS cochairs and EBPmentors. Knowledge of and familiarity with EBP expand

the clinicians’ confidence to contribute suggestions dur-ing council meetings and to disseminate the practice doc-uments to their unit colleagues.

SELECTION OF CNS COCHAIRSBy virtue of their advanced education, familiarity withgraduate-level research, and experience within a clinicalspecialty, the CNS acting as a cochair is integral to thefunctioning of the CPC. A CNS with practical experiencein developing and implementing nursing practice docu-ments, competencies, and leading change is invaluableto the CPC nurse representatives.11,12

The CNS cochairs are selected on the basis of theirperformance in their clinical area and their commitmentto ensuring that clinical practice is evidence based. Se-lection criteria for CNS cochairs include (1) a minimumof 1 year of CNS experience, (2) commitment to the needfor EBP throughout the nursing department and acrossthe healthcare system, (3) ability to conduct a meetingand facilitate a group effectively, (4) ability to be well or-ganized, and (5) willingness to provide a sustained com-mitment and passion for the council.

The CNS cochairs are appointed by their supervisors,who are nurse executives from 2 of the hospitals withinthe healthcare system.

ORGANIZATIONAL SUPPORTBecause of the unit manager’s accountability for re-sources, administrative support of the staff nurse CPCrepresentative begins with the finances and staffing cov-erage.13 The dedicated and protected time away fromthe bedside is considered ‘‘nonproductive’’ hours and achallenge to meet in the current healthcare environment.Each nurse is allocated 4 hours per month to attend themeetings, and these hours cannot be designated as‘‘overtime.’’ At the UCLA Health System, a separate costcenter funds these hours. The CPC unit representative isa skilled experienced nurse, and thus the involvement ofthe unit managers is of utmost importance to ensure thatadequate staffing coverage is available.

As most CPC representatives have a baccalaureate de-gree or associate degree, exposure to and experiencewith the intricacies of researching professional academicdatabases for relevant literature are often minimal.12,14Y16

A biomedical librarian provides support for teaching CPCrepresentatives the skills of searching for and retrievingevidence and can perform up-to-date searches on re-quests of the CNS cochairs.

In addition, the Nursing Research and Education De-partment provides dedicated rooms of sufficient size forthe large group meeting and smaller areas for the sub-group meetings. Each of the rooms has a minimum of1 computer with online access, an attached printer, and


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a projector with technical support for this equipment pro-vided by personnel in the Nursing Research and Edu-cation Department.

Master’s degreeYprepared CNSs serve as cochairs of theCPC, with mentorship from doctorally prepared clinicians.

The doctorally prepared clinicians serve as EBP men-tors. They provide mentoring to the CNS cochairs and theCPC unit representatives at both CNS cochair meetingsand monthly CPC meetings. The mentors provide supportin areas of research methods, understanding researchreports, and assisting with the integration of research find-ings into practice documents. Their advanced knowledgeof research and EBP is particularly useful when appraisingand synthesizing evidence. The expertise of the EBP men-tors provides a valuable resource for CNS cochairs andCPC representatives and adds to developing practicedocuments that are based on current science versus anec-dotal experience.

ROLE AND PREPARATION OF THE CNS COCHAIRThe role of the CNS cochair is to facilitate the subgroupactivities, integrating representatives from different unitsand across the system to work as a team. The CNS co-chairs ensure that all members have input and an equalvoice and maintain group focus and direction. Subgroupactivities include brainstorming and prioritizing clinicalpractice issues that are appropriate for CPC review; search-ing, reviewing, and synthesizing the latest evidence; andrevising/developing the practice document (policy, proce-dure, or institutional guideline of care) and the associatedclinical practice alerts, posttests, and competencies.

The CNS orients new members to the subgroup andfurther provides coaching and mentoring of staff nursesin the skills necessary for literature review and synthesis,development of practice documents, and disseminationto unit staff. The CNS cochairs maintain the focus ofthe subgroup as they work and move the completeddocuments through the processes of document approvaland posting on the intranet.

Although master’s degree preparation exposes theCNSs to research methods, at the time of the initial for-mation of the CPC, few of the cochairs had any formaltraining in EBP. Structured orientation, regular cochairmeetings, and ongoing support and education of theCNS cochairs were imperative in ensuring that the coun-cil was functioning as envisioned. Ongoing continuingeducation and support for CNS cochairs have been aprocess that required time, diligence, and effort but werevital to our success in transitioning from the traditionalpolicy committee to an active, influential CPC.

Orientation of the CNS cochair includes a formal edu-cational session with the director of research and EBPabout the role of the CNS cochair, selection and develop-

ment of documents, the approval process, and docu-ment dissemination strategies. Monthly cochair meetings,approximately 90 minutes in length, with the EBP mentorsand the director provide ongoing mentorship support andeducation to the CNS cochairs. Cochair sessions preparethe CNS for the upcoming CPC meeting and allow theCNSs the opportunity to seek guidance and clarificationof problematic areas of CPC document development andapproval processes.

Within the department of nursing, advanced knowl-edge and skill building for the CNS cochairs and otherleaders are available through the annual Advanced Lead-ership Institute. The Advanced Leadership Institute isan annual 8-hour workshop designed to develop the so-phisticated skills necessary for administrative and clinicalleaders to promote and mentor staff nurses and multidis-ciplinary teams in adopting EBPs. Content addressed inthe Advanced Leadership Institute has included applica-tion of EBP models; retrieving and evaluating evidence;implementing, evaluating, and sustaining practice changes;and implementing system changes to facilitate and pro-mote EBP throughout the health system. Additional con-tent has included establishing the strength and level ofevidence, synthesizing the evidence, and determining ifthe evidence supports a practice change. Several of theCNS cochairs received sponsored education outside theorganization at a weeklong immersion program in EBPto further strengthen their knowledge and skills for lead-ing the CPC.14,16

The CNS cochairs are dedicated to ensuring that nurs-ing practice is supported by the latest evidence andguiding staff nurses to continually move their practiceforward. The success of the CPC is due to the engage-ment of these clinical leaders.

IDENTIFICATION OF PRACTICE DOCUMENTSAPPROPRIATE FOR THE CPCThe selection of appropriate practice documents for de-velopment or revision by the CPC is accomplished througha brainstorming process performed annually at the start ofthe fiscal year. The brainstorming process consists of 3phases. During the first phase, nurses identify clinicallyimportant issues regarding inconsistent or ambiguousbedside practice. In the second phase, CPC nurses searchand identify new or recently generated literature that isapplicable to the selected topic/issue and warrants fur-ther investigation and consideration.

The process for searching the literature occurs by dif-ferent council members and at different time points. Ini-tially, the CNS cochair may do a more extensive literaturesearch to bring potentially relevant articles for the groupto review during the meeting. During meetings, the di-rect care nurses often do additional searching to fill in



any gaps. The librarians also help in the search processduring meetings. The search process is done by seekingappraised sources of evidence first. Research studies, na-tional guidelines, and at times nonresearch literature andexpert opinion are sought and reviewed by this process.Systematic reviews with meta-analysis are the preferredsources for literature searches, followed by the variouslevels of research evidence, then clinical literature, thenexpert opinion.

During the third phase, each subgroup evaluates ex-isting CPC documents that are due for review and con-siders requests from leaders for document development.The Iowa Model of Evidence-Based Practice to PromoteQuality Care17 is used as a framework for the initialbrainstorming process described above and during theongoing work of the council. For example, during thebrainstorming process, the CPC representatives are askedto reflect on problem- and knowledge-focused triggers,which are steps in the initial phase of the Iowa Model.

The brainstorming process used by the CPC is prefer-ential to developing a PICO question (population, inter-vention, comparison, and outcome), in that it allows themembers of the subgroups to think more broadly abouttheir practices. This is important in that each subgroupconsists of different units with different patient popula-tions. Thus, using the format of a PICO question wouldnot be an optimal choice for the structure and processesused by the CPC.

Following the brainstorming process, the CPC nursesuse the criteria listed in Table 1 to evaluate each potentialpractice document and generate a list of practice docu-ments they will address for the year. The criteria helpnurse representatives clarify which practice documentsare appropriate for the CPC to address. For example, prac-tice issues most appropriate for the CPC are those thatare under nurses’ domain, encompass multiple specialtyareas, and do not require extensive multidisciplinary ap-proval. In using this evaluation tool (Table 1), practiceissues and documents are screened to ensure coherencewith the structure and goals of the CPC and departmentalpriorities.

The CPC is respectful of practice areas predominantlyunder the domain of another discipline. When needed,the CPC consults with key stakeholders such as respira-tory therapists, occupational therapists, nutritionists, andphysicians. Thus, other disciplines participate in EBP ac-tivities with the CPC in an as-needed basis depending onthe specifics of the practice documents. Each criterion inTable 1 is scored numerically by using 0 for not present,+1 for present/yes, and +2 for highly present/yes. Thetotal score for the practice issue is calculated, and thosepractice documents scoring the highest are the focus ofCPC subgroup work for the coming year.

Scoring leads to prioritizing practice documents andgenerates a list of 6 documents for each subgroup. Thefinal list of the chosen practice documents that the CPC

Table 1. Evaluation Criteria for the Development of Potential Practice Document, Departmentof Nursing, Clinical Practice Councila

Criteria for Practice Document SelectionPracticeIssue

PracticeIssue

PracticeIssue

PracticeIssue

An existing practice document needs to be revised, updated, or combined with otherdocuments and meets the criteria below

The practice issue is important to the practice of staff nurses and dailypatient care

The practice issue is narrow in focus, predominantly under nursing domain, and cantherefore be effectively accomplished by the structure and process of the ClinicalPractice Council

Addresses a practice that is a priority for the subgroup specialty area (eg, pediatrics,neonates, intermediate care, medical/surgical, or critical care) and the departmentof nursing

Affects a significant number of patients

Priority for the organization or meets regulatory agency requirements

Existing body of research/evidence-based literature exists

Authorship of the practice document has not been under the domain of a nurse specialist’sresponsibility (examples: pressure ulcer, central venous catheter care, restraints)

Total scoreaScoring system: 0 = not present, +1 = present/yes, +2 = highly present/yes.


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will address for the year is e-mailed to the nursingleaders (Table 2). Unit leaders are notified monthly fol-lowing each CPC meeting of the subgroups’ progressand accomplishments regarding the current practicedocument being handled and representatives’ meetingattendance.

The process just described ensures that the CPC’sprogress on the development of practice documents isreviewed by the leadership. The list of annual practicedocuments provides a template for the agenda for sub-sequent monthly meetings over the upcoming year.

PROCESSES USED DURING COUNCIL MEETINGSThe CPC meets monthly for 4 hours. The meetings en-able active participation of members through the reviewof research and other levels of evidence, sharing ofideas, and consulting internal and external experts or de-partments as needed.

Each meeting begins with all the nurse representa-tives from the 3 subgroups present. New members andguests are introduced and welcomed. Subgroups reporton the progress of their documents and the plannedwork of the day. A brief 30-minute education session re-lated to EBP is presented (Table 3) by an EBP mentor, aCNS cochair, or a librarian. Afterward, the members break

out into their respective subgroups to work on the prac-tice documents planned for the meeting.

Working from the prioritized list of documents for thefiscal year developed through a previous brainstormingsession, the nurses identify the clinical practice questionssurrounding the practice document and the need forfurther evidence to support or change practice. The ques-tions typically stem from noted differences in practiceamong individual practitioners or among different units,determining what best practice is, or noted uncertaintyabout a particular skill or equipment; for example, whenworking on the chest tube document, questions as towhat is the best dressing for securing and preventing airleaks were raised. These questions helped to guide thesearch strategy for updating the practice document onchest tubes.

Research that supports or negates current clinicalpractice is reviewed and discussed. The evidence mayinclude national guidelines, systematic reviews, meta-analyses, research articles, clinical articles, and expertopinion. Expert opinion is included when there is adearth of research or literature support, and as appropri-ate. For example, when research evidence was lackingregarding valid and reliable instruments to assess riskof falls for pediatrics patients and a falls prevention guide-line, the CPC representatives conducted a national inquiryof expert opinions.

The members appraise the evidence for its level,strength, and relevance to their population of patients.The selected evidence is compiled into a synthesis table.After organizing and summarizing the evidence, the mem-bers begin to develop or revise the practice document.

Table 2. Sample Practice DocumentDevelopment by Subgroups of the ClinicalPractice Council

Pediatrics, neonate, and perinatal subgroup

& Glucose monitoring in the newborn

& Developmentally supportive care in the neonate

& Care of the pediatric patient on extracorporeal membraneoxygenation

& Skin-to-skin kangaroo care

& Oxygen therapy for the pediatric patient

Intermediate care: medical surgical subgroup

& Venus thromboembolism prophylaxis

& Chest tube management

& Care of the patient with a tracheostomy

& Cooling measures for treatment of fever

& Bowel management

Critical care: emergency subgroup

& Family visitation guidelines

& Transport of the intubated patient

& Intravenous insulin management

& Neuromuscular blockade

& Continuous cardiac output

Table 3. Sample Educational Sessions forDevelopment of Nurses on the ClinicalPractice Council

& Levels of evidence

& Meta-analysis, systematic reviews

& Experimental study

& Quasi-experimental study

& Descriptive study

& National practice guidelines

& Finding and pulling the evidence together

& Evidence-based practice models

& Rapid critical appraisals/critique

& Guidelines, policies, and procedures

& Writing cognitive objectives

& Writing posttest questions



CPC-RELATED PRACTICE DOCUMENTSSeveral types of practice documents are generated by theCPC: nursing policies and procedures, institutional nurs-ing guidelines of care, clinical practice alerts, posttestsfor evaluating knowledge, and competencies. Each ofthese documents has a purpose and a format that isfollowed by all CPC subgroups. Table 4 lists the defini-tion for each of the practice documents adopted by ourinstitution on the basis of our review of the literature.

Levels of evidence supporting new practice changesor key existing practices are reflected in revised docu-ments. For example, in a policy or institutional guidelineof care, the acronym RNLE is used to reflect the levelof evidence that is supported by research (R), nationalpractice guideline (N), nonresearch literature (L), andexpert opinion (E). The related citations for evidence-based interventions appear in the reference list at theend of the document in the reference format of theAmerican Psychological Association. Figure 2 providesan example of a practice document that is an institutionalguideline of care to meet the psychosocial needs of pa-tients’ families. The accompanying clinical practice alertis illustrated in Figure 3.

The wide variety of education and experiences of staffnurses regarding research and EBP necessitates thisbroad and simplified approach of the acronym RNLE toorganizing levels of evidence. Nurses involved in theCPC are educated about the more detailed levels of evi-dence found in the literature and used by healthcareorganizations. However, not all nurses within our health-care system have this knowledge and thus find thesimplified approach to classifying levels of evidence tobe user-friendly.

In addition, the simplified approach to classifyinglevels of evidence fits well with the time constraints im-posed by a 4-hour monthly meeting. Discussions regard-ing the level and appraisal of evidence and decisions toaccept evidence are done in the subgroups led by theCNS, who are well versed in the intricacies of researchand EBP.

APPROVAL AND DISSEMINATION PROCESSOnce the practice document has been drafted by thesubgroup, the document is reviewed by the other sub-groups that may be affected by the practice. For ex-ample, the document on psychosocial care of patients’families was authored by the critical careVemergencysubgroup and sent to the intermediate careVmedicalsurgical and the pediatrics, neonate, and perinatal sub-groups for review and feedback. Suggested revisionswith supporting evidence are returned to the authoringsubgroup.

Thereafter, the CNS cochair sends the document tothe leaders in the department of nursing at both institu-

tions within the UCLA Health System for review andfeedback. This fulfills one of the purposes of the CPC:to facilitate consistency of evidence-based nursing prac-tices across the 2 hospitals within the UCLA HealthSystem. Depending on the scope of the practice docu-ment, other persons with a stake in the process maybe asked to review and give feedback. Feedback fromindividuals and committees is sent to the authoringsubgroup. The subgroup reviews and considers theirfeedback and supporting evidence; revisions are madeas needed.

The document proceeds to the department of nursingpolicy committees for approval. Upon approval, the pol-icy or guideline is posted on the UCLA Health Systemintranet. The CPC members are notified of the docu-ment’s approval, posting on the intranet, and readinessfor dissemination to unit staff. To ensure accountabilityamong CPC members, a confirmation of disseminationletter is sent to each representative to confirm dissemina-tion; unit leaders are asked to corroborate the member’sefforts.

The CPC was developed to engage our frontline cli-nicians in a structured effort to evaluate evidence andrevise relevant nursing practice documents. At the timethe CPC was launched, there was no interest in or finan-cial support for purchasing a prepackaged program ofpolices and procedures. Our organization is in the pro-cess of evaluating the use of a prepackaged program ofpolicies and procedures and thus far has found that theseprograms do not necessarily meet all our needs.

DisseminationCollaboratively, all unit CPC representatives engage in dis-seminating and communicating new and revised practicedocuments and changes in practice to their respectiveunits and throughout the hospital. As the CPC representa-tive has reviewed the evidence to develop the nursingdocument, the representative has all of the backgroundinformation for disseminating practice changes and thesupporting rationales. Dissemination of this informationto all direct care providers is critical in translation of theCPC’s work into changes in care at the bedside.

Clinical Practice Council nurse representatives fromeach unit of the hospital are able to use specific dissemi-nation strategies identified in collaboration with theirCNS and unit leaders to meet the needs of their unit. Var-ious strategies or combination of strategies is used at theunit level. For example, one unit may use the staff meet-ing forum to present the new practice document and asknurses to self-evaluate their knowledge via the posttest.Another unit may use daily shift change huddles to high-light the new information and distribute the clinicalpractice alert that highlights the change in practice. Ad-ditional strategies may include using unit communication


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boards that are located in every clinical area to post newCPC-related documents. A structure in conjunction withthe communication boards such as online quizzes or a

sign-off process ensures accountability for the informa-tion. Information may be presented at traditional staffmeetings. Clinical Practice Council representatives may

Table 4. Definitions and Templates of Practice Documents

Document Type Definition Template Subheadings

Policy A policy is a formal practice document that governsacceptable clinical practices and limits surroundingclinical practice. Specific organizational policies usuallyserve as the ‘‘shoulds’’ and ‘‘thou shalts’’ of agencies.18Although policies and procedures are often usedinterchangeably, policies are broader directives and maybe incorporated at the beginning of a practice documentfor procedures. The policy document identifies who isqualified to perform a particular nursing procedure andunder what circumstances these procedures are executed.

& Purpose

& Policy

& Scope

& Procedure

& Forms/related documents

& References

& Author contact

& Publication and revision dates

& Department approval signatures

Guideline A guideline is a set of evidence-based recommendationsfor care of a patient population that is usually issuedby a professional association, leading healthcare center,or government organization.19 Guidelines assist instandardizing the management of disease states andare composed of current evidence-based knowledgeand management strategies.

& The format is variable, depending on theorganization or agency that has publishedthe guideline.

& Levels of evidence supporting specific interventionsare usually reflected in the guideline.

Institutionalguidelines of care

An institutional guideline of care is an agency-specific,evidence-based practice document that directs theassessment, interventions, and education of a specificpopulation of patients within a specific institution.

& Patient goals/outcomes

& Assessment

& Interventions

& Patient/family education

& Forms/related documents

& References

& Author contact

& Publication and revision dates

& Department approval signatures

Nursingprocedures

A nursing procedure describes a series of recommendedactions or steps for completion of a specific task or functionthat a nurse performs while providing care to a patient.

& Delineates the steps of the procedure in asequential manner

Clinical practicealert

A clinical practice alert is a 1- to 2-page documentthat summarizes the new or expected evidence-basedpractices reflected in new or updated institutionalpolicies or guidelines of care. The clinical practice alertsare designed similarly to the practice alerts publishedby the American Association of Critical Care Nurses.

& Document number and title

& Expected practice

& Summary of evidence

& Select references

Posttest A posttest is a 5- to 10-item knowledge survey toevaluate the learner‘s knowledge regarding new orupdated practices and their supporting evidence. Theposttest is designed to cover critical information that isreflected in the institutional policy or guideline of care.

& Purpose

& Objectives

& Multiple-choice questions or case scenarioswith questions

Competency A competency is a set of prerequisite skills andpsychomotor performance for high-risk and low-volumenursing practices that identifies the organization‘s levelof satisfactory technical skill performance of nursingpractices.

& A competency will be developed for select documentsgenerated by the Clinical Practice Council that addresshigh-risk and low-volume nursing practices.



FIGURE 2. Example of a partial practice document and institutional guideline of care.


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also use e-mail as an adjunct to communication; all directcare providers have a hospital system e-mail account andare able to access e-mail during their clinical shift. TheCNS and the unit director or unit educator are availableto support and mentor CPC representatives in the disse-mination process.

One specific dissemination strategy is to use the UnitPractice Council structure. The CPC representative bringsthe nursing policy, procedure, institutional guideline ofcare, and practice alert information to the unit practicerepresentatives to ensure their comprehension of thepractice change and supporting evidence. As part ofthe role as a member of the Unit Practice Council, eachmember would be responsible for further disseminationto their assigned staff nurse colleagues, which would ty-pically consist of 5 or 6 direct care nurses. The UnitPractice Council representative would also be responsi-ble for eliciting questions or feedback and bringing thisback through the shared governance structure. Thisprocess allows the CPC representative to present the in-formation that is likely to be applied during that par-ticular clinical shift and readily connect with a largenumber of direct care providers.

As liaisons between their units and the CPC, CPC re-presentatives provide feedback to the council on thesuccessful dissemination of the new information on theirunits. The CNS cochair facilitates the CPC representa-tive’s reporting the results of their dissemination andany challenges associated with the dissemination at thenext CPC meeting.

IMPACT ON NURSING PRACTICE ANDPATIENTS’ OUTCOMESA culture of inquiry is fostered at all stages of the pro-cesses used during council meetings as nurses areguided in reflecting on their current practices and seek-ing evidence to find new ways to improve patient care.The nursing department integrates select EBPs into thedocumentation system and performance improvementinitiatives. The goal is to remind staff about practices,monitor compliance, and measure the effect on patientcare and outcomes.

The following 2 examples demonstrate how the CPChas successfully engaged frontline clinicians in promotingnursing care that is evidence based and has produced im-proved practices to promote safe, effective care, and bet-ter patient care outcomes.n Example 2. The CPC critical care subgroup reviewed

the existing nursing practice documents related todrainage of cerebrospinal fluid via lumbar drains.New medical research and nursing literature revealedthat it was necessary to revise current nursing prac-tice to ensure safety of patients undergoing a thoraco-

abdominal aortic aneurysm repair. Changes includedtransducing the lumbar drain to the monitor andmaintaining the patient on bed rest and in the inten-sive care unit while the lumbar drain was in place.The CPC facilitated the coordinated development ofa specific physician order set for managing these pa-tients that included the practice of transducing thelumbar drain to the monitor. Nurses were educatedabout the new practice changes regarding monitoringand drainage management in these patients, patientassessment, and when to notify the physician. Al-though no untoward patient events had occurred,the potential for a devastating outcome such as cere-bral herniation leading to neurological deficits wasprevented as a result of staff nurse representatives’evaluation of existing practice compared with the lat-est published evidence.

n Example 2. The adult intermediate careVmedical/surgical subgroup and the pediatrics, neonate, andperinatal subgroup reviewed existing nursing prac-tice documents related to the placement, assessment,and management of large-bore nasogastric tubes.Translating new research evidence regarding the ac-curate assessment and verification of placement oflarge-bore nasogastric tubes, the CPC members, inmultidisciplinary collaboration, incorporated radiolog-ical confirmation of tube placement in adults and pHtesting, as well as radiological confirmation when nec-essary, in neonates. The evidence cited in the CPCnursing policy resulted in being used by multidisci-plinary leaders to create health system policy to reflectsimilar evidence-based recommendations and a changein practice throughout the entire organization basedon the CPC’s work.In addition to the 2 examples of practice changes

described, each practice document that is revised ordeveloped based on research incrementally contributesto promoting safe, effective care and better patient out-comes. Efforts to instill EBPs significantly improved whenstaff nurses are involved in the process from the be-ginning. Fostering the participation of staff nurses inthe process of clinical inquiry influences other impor-tant outcomes such as nurses’ professional growth anddevelopment.

LESSONS LEARNEDThe development and refinement of a CPC has progressedsystematically for 5 years, and we have experienced ob-stacles, challenges, opportunities, and lessons learned.Strategies that continually strengthened the structure andprocesses of the CPC include the following:n Enhancing communication between CPC unit rep-

resentatives and leadership. Maintaining and using



FIGURE 3. An example of a clinical practice alert. Format adopted from the American Association of Critical Care Nurses.


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communication lines between the CPC representa-tive, unit leaders, and staff are of utmost importanceto ensure awareness of and accountability for prac-tice changes. Continued regular reporting of the CPC’swork in progress and attendance facilitates involve-ment of unit leaders despite competing demands.Dialogue between unit leaders and their CPC repre-sentative between CPC meetings, during documentdevelopment and dissemination, enhances timelyclarification of conflicting practices and preservesthe collegial effort.

n Strengthening the dissemination role of CPC unit re-presentatives. Dissemination is a key function of theCPC unit representative that requires ongoing sup-portive coaching and mentoring from unit leadersand CPC cochairs. A tracking mechanism has beenimplemented that includes confirmation of unit lead-ers that the CPC representatives from their unit haveactively disseminated new practice changes in the unit.Some units have larger numbers of staff to whom in-formation must be imparted. This situation raises thequestion of how many representatives from a unit areneeded. Circumstances such as number of staff, com-plexity of the patient population, and finances influ-ence that decision.

n Ensuring consistency of CPC unit representatives atmeetings. To maintain continuity in developing apractice document from one monthly meeting tothe next meeting, the representative obligation wasincreased from 1 year to 2 years. Extending the com-mitment ensures efficient development of practicedocuments and ensures that time is sufficient forthe representative to experience the cycle of educa-tional sessions, learn the group process, and becomeconfident in the role of disseminator.

n Balancing academic scholarship and the realities ofclinical practice. Thoughtful consideration of thedepth of researching the evidence is necessary tobalance the challenge of rigorous academic scholar-ship and the realities of using the clinicians’ timeefficiently and effectively. Clinical nurse specialistcochairs perform background work between meet-ings to prepare and run an efficient and effectivemeeting. Clinical nurse specialist cochairs have re-fined the process of searching and screening theevidence to enhance effective use of the CPC rep-resentatives’ time during meetings. In the future,whether accessing commercially available practicedocuments that are based on the latest evidence issufficient to guide the care of complex patients re-mains to be seen.

n Enhancing the infrastructure for an effective meet-ing. Environmental challenges that were overcomeincluded locating suitable meeting locations and equip-

ment. Requirements expand with increased member-ship and compete with other organizational initiatives.Limited access to meeting rooms, computers with In-ternet access, lavatories, and refreshments can disruptthe progress of the council meeting.Future directions for strengthening and developing

the CPC include evaluating the following:(1) experience and level of satisfaction of the nurses

involved in the CPC,(2) circumstances and frequency of using CPC-

produced documents for clinical decision mak-ing, and

(3) effectiveness of select practice documents on pa-tient outcomes.

CONCLUSIONImproving staff nurses’ professionalism through increaseduse of leadership behaviors, autonomous practice, and theability to influence patients’ outcomes positively throughthe use of evidence-based principles can be achieved byproviding frontline clinicians with a framework to achievethese outcomes.20 Success of the CPC depends on theCNSs’ leadership and commitment in mentoring staffnurses in the process of developing EBP documents.

The CPC provides a structure and mechanism throughwhich staff nurses can participate and contribute theirclinical expertise, an essential component of EBP, to nurs-ing documents, expand their role as leaders, and use thelatest evidence to achieve the best outcomes for patients.

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