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

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

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

“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.com2

Opening Thought

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Overview of Project • 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 2014

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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

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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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Contextual Factors Impacting

Development and Implementation

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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 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

Goals: Knowledge Acquisition

Practice Change Certified Staff

Improved Outcomes

Physiological Basis

of Understanding

Certification

Readiness

Linking Knowledge to Practice

Thread throughall 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

Hospital APN AdminCVC APN CVSI APN CCU Staff

CCU Assistant Manager CCU CNS

CVSI Staff CVSI PCS

CVSI Educator CV Surgery Clinic Invasive Lab Staff

Cardiology Service PCS Cardiology Serv Staff

HF Coordinator MI Coordinaor

ICU Educator

0 0.5 1 1.5 2 2.5 3 3.5

2013 Instructor Turnover2/24 = 8.3%

2013 New Instructors: 1

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2014 Class Schedule

Beginner Practitioner Classes Presented During Time Frame Dates / TimesPart 1 Cardiac Dynamics and Assessment

Heart FailureNoninvasive Cardiac Testing

Thursday, March 13th Thursday, October 30th 11:00am – 3:00pm

Part 2 Intro to 12 Lead ECG

ECG Injury and IschemiaAxis/BBB

Wednesday, March 19th

Wednesday, November 5th 11:00am – 3:00pm

Part 3 Acute Coronary Syndrome

Interventional CardiologyOpen Heart SurgeryDiabetes Management

Thursday, April 10th Thursday, November 13th 11:00am – 3:00pm

Part 4 CV Pharmacology

Introduction to Device TherapyIntroduction 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 / TimesPart 1 Evidence Based Nursing Practice

Heart Sounds and Physical AssessmentThe Continuum of SepsisFluid/Electrolytes/Renal

Tuesday, April 1st Wednesday, September 10th 11:00am – 3:00pm

Part 2 Arrhythmia Interpretation

ECG Fundamentals/Axis DegreeBBB and HemiblocksVentricular Ectopy

Tuesday, April 15th Tuesday, September 16th 11:00am – 3:00pm

Part 3 Hemodynamics in Altered Physiology

Inflammatory DiseaseValve DiseaseCardiomyopathy

Wednesday, April 23d Wednesday, September 24th11:00am – 3:00pm

Part 4 Pulmonary Physiology and Acid Base

Concepts of Ventilatory and Oxygenation SupportCardiac Risk FactorsCardiac Rehabilitation

Tuesday, April 29th Tuesday, September 30th 11:00am – 3:00pm

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2014 Class Schedule Skilled Practitioner

Classes Presented During Time Frame Dates / TimesPart 1 Pulmonary Physiology and Oxygen Delivery

Pulmonary PathophysiologyNeurovascular Disease (Ischemic Stroke)Peripheral Arterial Disease

Tuesday, May 6th Thursday, October 2nd 11:00am – 3:00pm

Part 2 Narrow Complex Tachycardias

Wide Complex TachycardiasInjury and IschemiaMyocardial Mimics and Normal Variants

Tuesday, May 13th Tuesday, October 7th 11:00am – 3:00pm

Part 3 Pacemakers

ICDs and Cardiac Resynchronization TherapyNonPharmacological Treatment for ArrhythmiasAntiarrhythmic Pharmacology

Tuesday, May 27th

Thursday, October 16th 11:00am – 3:00pm

Part 4 Advanced Hemodynamics and Assessment

Pharmacology and HemodynamicsHematology and CoagulationEvidence 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)

Classes Presented During Time Frame Dates / Times

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

Wednesday Feb 12th

8:00am-12:00 NoonWednesday 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-5:00pmWednesday 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 NoonThursday 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-5:00pmThursday April 24th

12:30pm-4:30pm

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2014 Class Schedule Proficient Practitioner (Certification Preparation Course)

Classes Presented During Time Frame Dates / TimesPart 5 Advanced Device Therapy

RenalEndocrine

Tuesday Mar 4th

7:30am-11:30amWednesday May 7th

7:30am-11:30am Part 6 GI/Liver/Pancreatitis

Hematology and ImmunologyMultisystem (Sepsis/SIRS/MODS-Toxic Exposures)

Tuesday Mar 4th

12:30pm-4:30pmWednesday May 7th

12:30pm-4:30pm Part 7 Pharmacology and Optimizing Myocardial Performance

Shock StatesIABP

Tuesday Mar 18th

7:30am-11:30amWednesday May 14th

7:30am-11:30am Part 8 Diseases of the Aorta

TraumaNeurological Conditions

Tuesday Mar 18th

12:30pm-4:30pmWednesday May 14th

12:30pm-4:30pm

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2014 Beyond the Core Topics Dates Focus Area Topic

Thursday, Feb 13, 2014Thursday, July 10, 2014

Clinical Reasoning / Critical Thinking

Improving Your Accuracy and Comfort with ECG / Arrhythmia Interpretation

Monday, Feb 24, 2014Monday, Aug 18, 2014


Cardiorenal Syndrome: Understanding How the Kidneys and Heart Interact

Monday, Mar 17, 2014Wednesday, Sept 17,

2014


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

Tuesday, Apr 8, 2014Wednesday, Oct 29,

2014


Nursing Implications for Anticoagulant and Antiplatelet Therapy

Thursday, May 15, 2014Thursday, Nov 20, 2014


Hemodynamic Case Studies: Noninvasive and Invasive

Tuesday, Jun 3, 2014Thursday, Dec 18, 2014


Critical Analysis and Reporting of Abnormal Assessment Findings2014

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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

EngagementMonday 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

EngagementMonday, 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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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.

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• 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. 2014

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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. 4Level 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 2014

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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. 2014

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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. 2014

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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. 2014

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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

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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

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2013 Outcome Assessment

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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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Synergy Model

Patient Characteristics

• Resiliency • Vulnerability • Stability • Complexity • Predictability • Resource availability • Participation in care • Participation in decision

making

Nurse Competencies

• Clinical Judgment • Advocacy / Moral Agency • Caring Practices • Collaboration • Systems Thinking • Response to Diversity • Facilitator of Learning • Clinical Inquiry (Innovator /

Evaluator) 482014

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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 CompetencyImplementation

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

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Teach Back Exemplars:

Level 2(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

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Teach Back Exemplars: Level 3

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 • Exemplars with no teach back addressed: 2 (5.3%) • Outcomes: 42

Outcomes

Patient learning

35

Family Learning

6

Family comfort / satisfaction

1

2014

60

Teach Back Exemplars: Level 4 – Beyond the Core

Proficient Practitioner



3 31.8%5 6.1%

Response to Diversity 22 1 54.5%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. 2014

61

Teach Back Exemplars: Certified Staff (Expert)



3 21.2%

5 12.1%


3 21.4%

5 7.1%

Systems Thinking 4 1 50%

3 50%

5 -

Caring Practice 3 1 33.3%

3 66.7%

5 -

Advocacy 3 1 100%

3 -

5 -

• 18 Participants• 36 Exemplars • Exemplars with no teach back addressed: 3 (8.3%) • Outcomes: 38

Outcomes

Patient learning

31

Family Learning

5


2

2014

62

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. 2014

63


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 Change in Immediate Treatment

4 = 28.6%


1 = 7.1%

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


Level 2 (Advanced Beginner)

2014

64



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 • Exemplars with

Outcomes = 64.1%Outcomes


23 = 59.0%


4 = 10.3%

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


Level 3 (Skilled Practitioner)

2014

65



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%

Systems Thinking 1 1 100% 3 - 5 -

Facilitator of Learning 1 1 100% 3 - 5 -

• 38 participants• 76 Exemplars • 3 Exemplars

unsatisfactory • Exemplars with

Outcomes = 75%

Outcomes Change in Immediate Treatment

50 = 65.7%


13 = 17.1%



Level 4 (Proficient Practitioner)

2014

66



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 • Exemplars with Outcomes = 69.2%

Outcomes


19 = 48.7%


8 = 20.5%

Increased staff knowledge

1 = 2.6%



Level 5 (Expert Practitioner)

2014

67

Patient Outcomes

2014

68

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

2014

69

Cardiac Monitoring Exemplars with Outcomes

Level 1 Level 2 Level 3 Level 4 Beyond

Core

Certified 0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

% Outcomes

# Exemplars: 32

# Exemplars: 14

# Exemplars: 39

# Exemplars: 76 # Exemplars:

39

2014

70

Exemplars with Change in Immediate Treatment


Core

Certified 0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

% Change Immediate Treatment

% Change Immediate Treatment

2014

71

Exemplars with Change in Overall Plan of Care


Core

Certified 0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

% Change in Overall Plan of Care

% Change in Overall Plan of Care

2014

72

Nurse Competencies

2014

73

Expert in Clinical Judgment


Core Certified

0.00%2.00%4.00%6.00%8.00%

10.00%12.00%

% Expert

2014

74

Expert in Advocacy


Core Certified

0.00%

5.00%

10.00%

15.00%

20.00%

% Expert

2014

75

Expert in Collaboration


Core Certified

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

% Expert

2014

76

Expert in Clinical Inquiry


Core Certified

0.00%5.00%

10.00%15.00%20.00%25.00%30.00%

% Expert

2014

77

Expert in Caring Practice


Core Certified

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

% Expert

2014

78

Cardiac Monitoring Exemplar

• Beyond the Core Level Nurse• Competencies (Level 5)

-Clinical Judgment-Advocacy-Collaboration-Clinical Inquiry

2014

79

Cardiac Monitoring Exemplar

• Beginning Practitioner (Level 1)• Competencies (Level 3)

-Clinical Judgment-Clinical Inquiry

2014

80

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!

2014

81

Conclusion

2014

82

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

2014

83

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

2014

84

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 2014

85

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

2014

86

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. 2014

87

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.

2014

88

THANK YOU!

[email protected]@[email protected]

2014

mailto:[email protected]



Documents

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