The synergy model and the role of clinical nurse specialists in a multihospital system.

The role of clinical nurse specialists was formalized in the 1950s; the goal was to prepare inpatient, bedside nurses who would serve acutely ill patients via consultation and direct care. Clinical nurse specialists were to be expert clinicians, consultants, educators, and researchers. In the early stages of practice development, the focus was the specific needs of the assigned unit or floor. Organizational restructuring led to the elimination of many positions for clinical nurse specialists, with a shift of some of the nurses' responsibilities to others (ie, managers) or the abandonment of some of the traditional roles. Recently, a reversal occurred in this trend, evidenced by a steady growth in the demand for these advanced practice nurses by organizations seeking to improve patients' outcomes while remaining fiscally responsible. This demand led to changes in role expectations and expanded the responsibilities of clinical nurse specialists to a system-wide or organization-wide level. Contemporary practice of clinical nurse specialists is not well reflected in traditional role definitions or commonly accepted practice models. The Synergy Model, developed by the AACN Certification Corporation, was introduced as a way of linking certified practice to patients' outcomes. The model describes 8 nurse characteristics and 3 spheres of influence. This article describes how a group of clinical nurse specialists applied the model to successfully change from a unit-based to a multisystem practice.     

The clinical nurse leader: promoting patient-centered outcomes

In 2004, a 551-bed nonprofit hospital launched a pilot of the unit-based clinical nurse leader (CNL) role to support staff nurses and their patients. Thus far, the role has demonstrated great promise in promoting individual patient-centered outcomes, although the pilot has identified potential adaptations to enhance aggregate outcomes. These include decreasing the patient-to-CNL ratio, increasing CNL availability to 7 days a week, and reconsidering whether to fill CNL positions with nurses who were prepared as nurse practitioners.     

Pioneering a new role: the beginning, current practice and future of the Clinical Nurse Leader

Aim  To discuss the development of a new nursing role in response to the health care crisis in the United States.
Background  The nursing shortage and fragmentation of care has contributed to the need for nurses who are prepared to laterally integrate care, bring evidence-based practice to the bedside and provide continuity of care to patients and families.
Evaluation  The CNLs review the literature, share their experiences, and discuss outcomes related to improved quality of care.
Key issues  Having clinical nurses with a global perspective acting as facilitators and integrators of care is essential to maintaining a high standard of care. Organizational and management support is critical. The more CNLs that can be embedded in an institution, the more successful the role can be.
Conclusions  The varied utilization of the CNLs in this practice setting has proven its value in a short period of time and facilitated better communication and collaboration among patients and their health care team.
Implications for nursing management  The flexibility and broad scope of this role allows for its use in any practice setting to realize gains in quality outcomes, cost savings, improved patient flow, increased safety, nurse satisfaction and increasing organizational capacity.     

Proposal to Bring Nursing Into the Information Age

Purpose: To address issues related to documentation of nursing care and propose a model that illustrates how nursing practice data, collected through the use of standardized languages, are useful to staff nurses, nurse administrators, researchers, and policy makers.
Significance: Obtaining information about nursing practice is critical in times of health care change and reform.
Conclusions: There are three main challenges: the level of detail to document, the inclusion of nursing language in critical paths, and the need for articulation among different nursing classifications.
Implications: With recent advances in nursing classifications, the documentation systems in nursing can now be improved and much of the previous waste and redundancy eliminated.     

From expert to tasks,expert nursing practice redefined?

Aim. The aim of this paper was to explore the concept of expertise in nursing from the perspective of how it relates to current driving forces in health care in which it discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. Background. Expert nursing practice can be argued to be central to high quality, holistic, individualized patient care. However, changes in government policy which have led to the inception of comprehensive guidelines or protocols of care are in danger of relegating the ‘expert nurse’ to being an icon of the past. Indeed, it could be argued that expert nurses are an expensive commodity within the nursing workforce. Consequently, with this change to the use of clinical guidelines, it calls into question how expert nursing practice will develop within this framework of care. Method. The article critically reviews the evidence related to the role of the Expert Nurse in an attempt to identify the key concepts and ideas, and how the inception of care protocols has implications for their role. Conclusion. Nursing expertise which focuses on the provision of individualized, holistic care and is based largely on intuitive decision making cannot, should not be reduced to being articulated in positivist terms. However, the dominant power and decision‐making focus in health care means that nurses must be confident in articulating the value of a concept which may be outside the scope of knowledge of those with whom they are debating. Relevance to clinical practice. The principles of abduction or fuzzy logic may be useful in assisting nurses to explain in terms which others can comprehend, the value of nursing expertise.     

Group cohesion and nurse satisfaction: examination of a team-building approach

OBJECTIVES: The purpose of this study was to determine the impact of a team-building intervention on group cohesion, nurse satisfaction, and turnover rates. BACKGROUND: Creating an environment that supports and retains nurses represents a formidable challenge for nursing leaders. Research related to strategies that positively impact the culture in which nurses practice, thus potentially improving nurse satisfaction and reducing turnover, is critically needed. METHODS: Registered nurses (RNs) employed on inpatient units in a 247-bed, private acute care Magnet teaching hospital participated in this quasi experimental preintervention and postintervention design. The RN-RN interaction subscale from the National Database of Nursing Quality Indicators Adapted Index of Work Satisfaction, the National Database of Nursing Quality Indicators Adapted Index of Job Enjoyment, the Group Cohesion Scale, and a facilitator-developed measure were completed preimplementation and postimplementation of unit-tailored intervention strategies, which took place over a 12-month period. Turnover rates were collected 6 month preintervention and postintervention. RESULTS: Improvement in group cohesion, RN-RN interaction, job enjoyment, and turnover was demonstrated. CONCLUSION: Targeted, unit-based strategies can be an effective means of reducing turnover rates and improving group cohesion and nurse satisfaction.     

Towards a comprehensive theory of nurse/patient empowerment: applying Kanter's empowerment theory to patient care

spence laschinger h.k., gilbert s., smith l.m. & leslie k. (2010) Journal of Nursing Management 18, 4–13
Towards a comprehensive theory of nurse/patient empowerment: applying Kanter's empowerment theory to patient care
Aim  The purpose of this theoretical paper is to propose an integrated model of nurse/patient empowerment that could be used as a guide for creating high-quality nursing practice work environments that ensure positive outcomes for both nurses and their patients.
Background  There are few integrated theoretical approaches to nurse and patient empowerment in the literature, although nurse empowerment is assumed to positively affect patient outcomes.
Evaluation  The constructs described in Kanter's (1993) work empowerment theory are conceptually consistent with the nursing care process and can be logically extended to nurses' interactions with their patients and the outcomes of nursing care.
Key issues  We propose a model of nurse/patient empowerment derived from Kanter's theory that suggests that empowering working conditions increase feelings of psychological empowerment in nurses, resulting in greater use of patient empowerment strategies by nurses, and, ultimately, greater patient empowerment and better health outcomes.
Conclusions  Empirical testing of the model is recommended prior to use of the model in clinical practice.
Implications for Nursing Management  We argue that empowered nurses are more likely to empower their patients, which results in better patient and system outcomes. Strategies for managers to empower nurses and for nurses to empower patients are suggested.     

Steering a course towards advanced nurse practitioner: a critical care perspective

Aim: This article is a report of a study of the experiences of expert critical care nurses in their transition to the role of advanced nurse practitioner within an intensive care unit (ICU) setting. Background: The advanced nurse practitioner role was developed to support the ICU team and to undertake many of the roles traditionally associated with junior medical staff in this specialized area. The impetus for this study therefore was generated from the need to explore the role development experiences of trainee advanced nurse practitioners to inform future developments and practice. Methods: This study used grounded theory methodology to conduct and analyse data from 25 participants. The data were collected between March 2010 and August 2010, using interview format. Data collection and analysis was conducted simultaneously using methods associated with grounded theory, theoretical sampling and the constant comparative method. Results: ‘Staying the course to advanced nursing practice’ emerged as the core category, with four related major categories and substantive codes. In conjunction, the substantive theory explaining the essential processes involved comprised of three inextricably linked processes: situational, development and conceptual meaning. The developed conceptual model captures the unique experiences of expert critical care nurses during their transition to confident and competent advanced nurse practitioners. Conclusion: This study provides an account of the role transition from expert critical care nurse to advanced nurse practitioner, specifically the synthesis of expert nursing practice with traditional medical values. The conceptual model has the potential to be utilized as a framework for others embarking upon similar projects, informing advanced nurse practitioner roles within and out with critical care settings.     

Teaching in crisis. Patient and family education in critical care

Although the critical care setting is not always a positive teaching environment, it is possible to achieve the goal of optimal patient and family education. The critical care nurse must understand the unique learning needs of patients and families who are experiencing a life crisis a recognize that there are substantial obstacles to overcome to educate in this setting. In addition, it takes experience and resources to develop the teaching skills of the bedside nurse, so that those teachable moments are easily recognized and suitably used to give patients and family members valuable information in small doses. The advanced practice nurse is an essential nursing resource who can spearhead the development of teaching skills for all members of the health care team. In addition, the advanced practice nurse is a clinical expert who can assess the educational needs of patients and their families and provide more detailed and individualized health information from a different perspective. Achieving good patient and family education outcomes is possible when patient care continuity is a priority and the advanced practice nurse is an active part of the nursing team. Exploring the use of new technologies and resources to meet patient and family education needs is absolutely necessary. As hospitals continue to evolve and react to the financial demands placed on them, nursing leadership and critical care nurses will need to articulate clearly all of the essential components of patient care, including patient and family education. In keeping with the rich nursing tradition of patient and family education, critical care nurses and advanced practice nurses have the opportunity to demonstrate their unique teaching skills and continue to promote health education as a priority of patient care.     

The role of technology in critical care nursing

Title.  The role of technology in critical care nursing.
Aim.  This paper is a report of a study to identify the meaning for critical care nurses of technology related to weaning from mechanical ventilation and to explore how that technology was used in practice.
Background.  The literature concerned with the development of critical care (intensive care and high dependency units) focuses mainly on innovative medical technology. Although this use of technology in critical care is portrayed as new, it actually represents a transfer of technology from operating theatres.
Method.  An ethnographic study was conducted and data were collected on one critical care unit in a large teaching hospital over a 6-month period in 2004. The methods included participant observation, interviews and the collection of field notes.
Findings.  The overall theme 'The nursing–technology relation' was identified. This comprised three sub-themes: definition of technology, technology transferred and technology transformed. Novice nurses took a task-focussed approach to weaning, treating it as a 'medical' technology transferred to them from doctors. Expert nurses used technology differently and saw its potential to become a 'nursing technology'.
Conclusion.  Nurses need to examine how they can adapt and to 'reconfigure' technology so that it can be transformed into a nursing technology. Those technologies that do not fit with nursing may have no place there. Rather than simply extending and expanding their roles through technology transfer, nurses should transform those technologies that preserve the essence of nursing and can contribute to a positive outcome for patients.     

Unit-based research in critical care nursing

This article describes the characteristics of unit-based nursing research, highlighting the experiences of staff nurses on two critical care units. On both units, study findings facilitated changes in practice. The authors evaluate their experience and offer suggestions to critical care nurses interested in unit-based research.     

Evaluation of a nurse consultant's clinical activities and the search for patient outcomes in critical care

Aim. To describe the actual clinical activities undertaken by a critical care nurse consultant in an eight‐bedded adult surgical high dependency unit within a large NHS Teaching Hospitals NHS Trust. Background. In the United Kingdom, the first critical care nurse consultants were approved in 2000 following the Department of Health's (1999) revised career structure for nurses. Expert practice is a core function of the role although the nature of expert practice in the context of critical care is unclear. Expert practice is often deemed to be a feature of advanced practice and although a number of studies have investigated this in context of critical care, there is little insight into the nature of advanced practitioners’ clinical practice and how it might influence patient outcome. Design methods. A diary was used by a critical care nurse consultant to record activity during scheduled clinical sessions. Data were collected for four months: 39 sessions were evaluated. Qualitative data were content analysed and coded into categories. Clinical activities were coded, categorized and analysed using SPSS 11.0 for windows (SPSS Inc., Chicago, IL, USA). Findings. Clinical activities included direct care activities, clinical leadership, education and training. Two main themes emerged from the qualitative data and were categorized as clinical reasoning and clinical instruction. Clinical activities arising from clinical reasoning and clinical instruction were aimed at minimizing risk and the provision of quality care. In doing this, one of the outcomes was the detection and resolution of untoward clinical occurrences. Conclusion. The level of achievement – or end point – of clinical activities was that the patient was established in ‘a state free from risk or harm that optimises rehabilitation’. ‘A state free from risk or harm that optimizes rehabilitation’ might be one outcome reflecting the needs of individual critically ill patients that is sensitive to individual nursing contribution. Relevance to clinical practice. There is increasing pressure on health‐care professionals to identify and measure their individual impact on the outcome of patients. This study adds further insight into the complexities associated with evaluating the influence of individual contribution on patient outcome, especially when it is characterized by complex processes involving clinical judgement and decision‐making.     

New knowledge, innovations, and improvement in a Magnet® Children's Hospital Cardiac Center

Bedside nurses involved in research and evidence-based practice (EBP) have the ability to change policies, patient care, and outcomes. This article describes the journey of a research committee using the Magnet? component of new knowledge, innovation, and improvements. Using several tools, the unit-based committee developed skills in meeting management, nursing research methods, and EBP. Focusing to improve family and nurse communication about the plan of care, the committee recommended changes in the existing Plan of Care tool, including family input and recommendations for families to view and add to the sheet and participate in daily rounds, which was not the standard practice. Since this intervention was implemented, patient satisfaction has increased, as well as nurse engagement and intent to stay. This project exemplifies how nurse-driven innovations and family partnership led to new knowledge, innovations in learning about research, applying it to practice, and improving practice.     

Expertise among critical care nurses: A grounded theory study

ObjectivesExplore critical care nurses’ personal perceptions of expertise, expert performance and transition from novice to expert performer in clinical practice.DesignFollowing constructivist approach to grounded theory this investigation used qualitative open-ended interviews focused on the social construction of expertise in critical care nursing and the experiences of clinical practice that define that process.SettingA multi-site urban area in the southeastern United States.Participants10 certified critical care nurses, three males and seven females, with 10–30+ years of critical care experience.FindingsExperience and knowledge are the foundation of expertise and expert performance. The higher the acuity the more frequent the experience the greater the nurses’ aptitude and opportunity for learning and professional growth. It was also noted that self-actualisation was a major determinant in the development of expertise in critical care.ConclusionKey findings suggested that clinical experience and personal motivation combined with self-actualisation, the drive to maximise personal potential, determine critical care nurse’s trajectory towards professional excellence. Expert performance evolves over time. Knowledge acquisition and experience have an interdependent reciprocal relationship inferring that you cannot have one without the other. Social expectations and experiences have a direct impact on professional aptitude and development if expertise.     

The importance of knowing the patient in weaning from mechanical ventilation

Aim: The aim of the research was to understand how nurses used technology to wean patients from mechanical ventilation.
Background: The literature concerned with the development of critical care centres on the role of technology with little emphasis on the nursing contribution.
Design: An ethnographic approach was used to understand how nurses used technology to wean patients from mechanical ventilation.
Methods: Data were gathered by participant observation and interviewing over a 6-month period. In total, 250 h of field notes were recorded.
Results: Data were analysed by the content analysis method. Knowing the patient was a central theme identified. Three sub-themes were identified: ways of knowing, continuity of care and the role of the patient in the weaning trajectory.
Conclusion: 'Knowing the patient' was implied during the interviews as essential to the delivery of patient-centred care. There were two main factors that needed to be present in order for nurses to know their patients: continuity of care and expertise. 'Ways of knowing' was reliant on gaining information about the patient. The role of the patient was a passive recipient of treatment.
Implications for practice: Knowing the patient has been defined as a characteristic of expert nursing. To be truly patient-centred nursing needs to address the barriers that prevent nurses from getting to 'know' their patients.     

Testing an instrument measuring Greek nurses' knowledge and attitudes regarding pain

This pretest-post-test study was conducted to test the construct validity, test-retest reliability, and internal consistency of the Nurses' Knowledge and Attitudes Survey Regarding Pain with Greek nurses. Forty-six registered nurses were randomly assigned to an expert or nonexpert group. The expert group viewed 4 translated educational videotapes about pain management. The nonexpert group received no pain education. All of the nurses completed a pretest and a post-test using a Greek translation of the Nurses' Knowledge and Attitudes Survey Regarding Pain, with a time delay of 8 to 12 days between testing. The expert nurses learned significantly more than the nonexpert nurses from pretest to post-test, M = 9.0 and M = 1.5 items, respectively. Expert and nonexpert nurses correctly answered 51.5% and 43.3% of the pretest and 74.6% and 47.2% of the post-test questions, respectively. Test-retest reliability for the 28 nonexpert nurses was r = 0.68, P < .001. Cronbach's alpha for the entire sample was 0.88 (n = 30) at the post-test. These results contribute to the validity and reliability of the Greek version of the Nurses' Knowledge and Attitudes Survey Regarding Pain and provide the basis for phase II of the study, which will use the Nurses' Knowledge and Attitudes Survey Regarding Pain to examine the state of pain management in an anticancer facility in Greece.