The role of the Clinical Nurse Specialist (CNS) has been a part of the healthcare environment in the United States for decades; the first text book published for clinical nurse specialist was in 1973 (Fulton, 2014). This role involves providing expertise and support to nurses caring for patients at the bedside, helping drive practice changes throughout the organization, and ensuring the use of best practices and evidence-based care to achieve the best possible outcomes for the patient (What is a CNS?, 2018). At Inspira Health Network (IHN), the Outcomes Manager (OM) Council members collectively function in the role quite like the CNS. This team consists of Clinical Outcomes Managers (COM) and Education Outcomes Managers (EOM), who are Registered Nurses (RN) in leadership positions and who possess past experiences in various areas of patient care, i.e. critical care, emergency department, progressive care, and acute care environments. As a three-time designated Magnet facility (Vineland, Elmer, and Bridgeton campuses since 2008), and a High Reliability Organization (HRO), IHN is an organization that is extremely committed to safety and quality. This article will describe the role of the OM team that supports various aspects of nursing care including compliance to promote commitment regarding policy and protocols, quality, safety, specialty certification, professional development, Evidence-Based Practice (EBP) and research. This has led to the organizations’ decrease in Healthcare Acquired Infections (HAI’s), increased certifications, and continues to foster the increase in unit-based research projects.
Supporting Excellence in Nursing Practice; Compliance to Commitment
As a clinical resource, the COM supports excellence in nursing practice, from compliance to commitment, by encouraging accountability and mindfulness to achieve optimum quality outcomes. Building a solid foundation is an important component to acquiring longevity in quality care. The COM utilizes an interdisciplinary approach to ensure that the care being given to our patients is safe and quality outcomes are achieved. Excellence in nursing practice is expected of all staff and communicated clearly by the COM; this begins in orientation and is built upon during that process which continues in the department that the staff have chosen for their career path. Clear communication starts and ends with the goal of at or above the National Database for Nursing Quality Institute (NDNQI) benchmark outcomes. This encourages the staff to remain compliant and accountable, with mindfulness to achieve these optimum quality outcomes.
Creating and Promoting the Awareness of Quality in Mentoring
The OM creates the awareness of quality and safety by being a mentor to the bedside nurse, promoting quality and patient safety in the patient care environment. Healthcare in the United States and globally continues to change and grow at a rapid pace, promoting a sharp focus on health promotion and illness prevention. Continuous quality improvement is paramount, and every level of the healthcare organization is involved in obtaining and upholding safety principles and standards related to quality care and the reduction of harm to those they strive to serve. It is the role of the OM to provide the knowledge and skills to teach, change, and assist in the formation of winning strategies for both seasoned and novice nurses to keep current of EBP in healthcare. They must test and analyze these existing systems and work to create a just culture of safety in which all professionals are comfortable practicing while establishing accountability. The OM acts as change agent in this process and provides clear leadership to those delivering clinical care in this consistently, ever-changing landscape we call nursing.
Providing Mentorship in Support of Professional Growth to Specialty Certification
Evidence supports that certification and advanced education is related to patient safety. The COM collaborates with the EOM to assist in providing mentorship through the clinical ladder in support of professional growth leading to obtaining certification in their specialty. The certification process can be intimidating, and most nurses fear it on some level. At IHN, professional growth is an expectation. The COM and EOM reach out to eligible staff nurses and identify the perceived barriers to starting the certification process. When surveyed, nurses relayed that they had test anxiety, were unclear about eligibility requirements and/or what resources to utilize for studying. Nurses were unclear as to how the organization assisted with payment and could not clearly articulate the benefits of certification in relation to the clinical ladder, their professional growth, and supporting the culture of safety at IHN. The OM team took this information and worked together to assist in providing mentorship and support of this professional growth experience. The EOM team updated the didactic orientation agenda for new RNs to include information on certification including prerequisites, application processes and available support. Information was also added showing how certification acquisition and professional growth is built into the IHN Clinical Ladder. Inspira RN’s are encouraged to start their career with the future in mind.
In each nurse’s lounge, the OM’s provide various materials including visuals related to specialty certifications for the nurses to review. The COM will further discuss the certification process followed by the EOM navigating the application process, prepayment and securing additional study resources. Together, the OM teams assist with assembling study groups and provide insight on study patterns. Various study materials are readily available such as exam manuals, test guides, compact discs, and sample tests. The nurses are provided a certification review gift card that allows them access to online review courses, as well as the opportunity to take the first exam at no cost. Mentors are provided for each nurse utilizing staff that have already acquired a certification in his/her field. This mentorship provides a supportive and nurturing relationship.
Staff are invited to attend an annual certification fair offered by the Professional Development and OM Councils. Specialty certified nurses participate in the fair and are available to discuss their certification and answer any questions about the process, including available resources. Information is provided on how certification influences their progression on the clinical ladder. If a nurse is initially unsuccessful in passing the certification exam, the COM and EOM will follow up, identify the barriers, and work one on one with the nurse to guide him/her through a second examination. The excitement and pride that newly certified nurses bring to their units has proven to be a great incentive and encouragement for other nurses to apply for their certification as well. In the eighteen months since the initiation of the first fairs, certification rates have increased from 31% to 56% across the network.
Promoting EBP Changes and Organizational Protocols
The OM team collaborates to bring culture change to the clinical nurse with the goal to improve patient outcomes in a continuously changing environment. By assessing, identifying, and providing clinical expertise, the OM acts as a change agent to lead and facilitate new practices, and functioning as a research consultant to both novice and experienced nurses. The team collaborates to bring standardized interventions and organizational protocols to clinical practice based on EBP. This approach helps the clinical nurse take patient care to the next level while ensuring that optimal outcomes are achieved. Recently, a comprehensive oral hygiene program in the Intensive Care Unit (ICU) was added to the ventilator care order set to support evidence-based practice in VAP reduction, which included the use of Chlorhexidine Gluconate (CHG) 0.12% oral rinse for twice a day toothbrushing. Another recent EBP initiated practice was the implementation of chlorhexidine pre-operative wipes, “nose to toes” for in-patients prior to specific procedures. This change originated from a research project conducted in the IHN Surgical Services Department for out-patients requiring joint and colon procedures. The utilization of these wipes had shown a reduction in surgical site infections in the out-patient setting, hence the practice was transitioned into the in-patient setting for those specific surgeries.
Fostering Relationships with The Leadership Team & Clinical Nurses
The OM team has a strong commitment to patient quality and safety and work closely with the leadership team in overseeing policy and procedure (P&P), including new and improved products, and financial stewardship considerations. Through active participation on many councils and committees, the OM team demonstrates their commitment to practice by facilitating quality and safety measures that directly impact policy and protocol, i.e. Medical/Surgical Collaborative, Pressure Ulcer Steering Committee, and Value Analysis/Materials Committee (VA), and Professional Development, Practice, & Quality Councils. The OM’s work with unit leaders to review, update, and create policies based on current organizational needs, best practice guidelines, and new product initiation.
Multidisciplinary collaboration occurs when troubleshooting and determining needed changes in relationship to policy and protocol. The OM’s serve as a liaison to review with unit leadership a plan to educate the staff on any new products or new changes that may occur related to a new or change in P&P. This is completed through multiple methods, i.e. official training sessions, unit to unit in-services, bedside demonstration, and slide show presentations. The OM’s assist with policies that are related to their area of expertise, or actively participates in collaborative groups that review changes and updating policies as needed. A good example of this would be the Medical/Surgical collaborative; this group is a network collaborative that reviews current policies/procedures and attempts to standardize across the network, by either combining existing policies or recommending use of Lippincott Procedural Manual for procedural policy.
The OM applies expert knowledge and acts as change agents to ensure quality focused and cost-effective care delivery outcomes The COM’s follow their Nurse Sensitive Indicators (NSI), such as Catheter Associated Urinary Tract Infection (CAUTI) and develop education plans when improvement is indicated. Reviewing patient outcomes is an important part in the COM’s role where direct educational needs of the staff can be addressed. For example, when there was an increase in CAUTI rates in one of the network facilities this led to the development of skill session by the COM’s to check competency for all RN/LPN staff who insert urinary catheters. Multiple sessions were arranged with use of several simulation models allowing optimal access for nursing staff to participate. For “demonstration use only” urinary catheter kits were utilized to allow staff to prove their ability to insert urinary catheter using aseptic technique. During these sessions, findings revealed inconsistencies with aseptic technique which was then remediated in real time with the staff member, as well as maintenance interventions for infection prevention and nursing skill reinforcement. The COM identified barriers that may contribute to the root cause and together proposed a recommendation of using a pre-packaged wipe, and a peri-bottle containing soap and water for perineal cleansing during maintenance of the catheter. By implementing these wipes, compliance increased with perineal cleansing prior to insertion; the usage of the peri-bottle has prevented the utilization of rough wash cloths for cleansing sensitive perineal areas when an indwelling catheter is present.
Reducing Incidences of Healthcare Acquired Infections (HAI’s)
In pursuit of improving quality outcomes, the collaboration of the COM’s results in reducing the incidences of HAI’s by incorporating EBP and IHN research to change the delivery of care by utilizing a team approach. The COM assist in development of clinical process improvement initiatives based off analysis of clinical outcomes data. Furthermore, the COM facilitates the research of products on the market to help assist with reduction in infections. At IHN, OM’s are the chairpersons of the committees including Central Line Associated Bloodstream Infection (CLABSI), Catheter Associated Urinary Tract Infections (CAUTI), and Nosocomial Pressure Injury (NPI). Prevention bundles exist for each HAI and are reinforced by the OM team daily. Changes are implemented based on EBP and new standards learned from the literature or obtained at conferences.
In 2015, the Medical Intensive Care Unit COM led a Comprehensive Unit Specific Project (CUSP) through Johns Hopkins Hospital which resulted in an interdisciplinary collaboration with Pulmonologists to revise the ventilator patient care bundle, creating an RN and Respiratory Therapist driven protocol to expedite weaning timeframes, consequently reducing Ventilator Associated Pneumonia (VAP) incidences. This bundle now includes daily Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT) to reduce ventilator days, prevent VAP and reduce mortality of ventilated patients. The COM performs daily audits on all central lines to promote questioning of the necessity of those devices. This is also discussed in daily interdisciplinary nursing rounds and, if found unnecessary, is promptly replaced with a less risky vascular access such as a Midline or peripheral intravenous catheter line. In 2017, the COM team presented the use of subcutaneous securement device for central lines. Evidence-based research demonstrated the effectiveness of using this device to provide stability and maintaining aseptic technique. The outcome was favorable with reducing the CLABSI incidence from 22 to 0 in two of IHN’s campuses. The same routine is utilized with indwelling catheters to promote reduction in unnecessary usage which has decreased urinary catheter utilization and CAUTI incidences from 39 to 5 across two campuses. Furthermore, in the pursuit to reduce HAI’s, the COM team is currently working with interdisciplinary teams, i.e. Infection Control, on several projects such as revising our Early Mobility P&P, to make it a feasible and realistic plan of care for the ventilated and non-ventilated patient.
In conclusion, the OM functions like the CNS by providing expertise and support to clinical nurses to help drive practice change throughout the organization and ensure the use of evidence-based care in the pursuit of achieving the best patient outcomes. Consistent rounding and communication on the units promotes ongoing collaboration with all level unit leadership keeping the OM’s core focus on quality and patient safety. This harmonious relationship among all nursing levels engages staff in compliance and commitment to EBP. This has led to improvement in quality outcomes and professional development at IHN.
Fulton, J. S. (2014). Evolution of the Clinical Nurse Specialist Role and practice in the United States. In J. S. Fulton, B. L. Lyon, & K. A. Goudreau, Foundations of Clinical Nurse Specialist Practice (2nd ed., pp. 1-15). New York, NY: Springer Publishing.
What is a CNS? (2018). Retrieved from National Institute of Clinical Nurse Specialists: https://nacns.org/about-us/what-is-a-cns/