The Attending Nurse: A New Role for the Advanced Clinician Katherine Niemela, BS, RN, Elizabeth C. Poster, PhD, RN, and Diane Moreau, MN, RN
The Attending Nurse Model as a unique role for the
advanced practitioner was implemented and evaluated in an acute care psychiatric setting with an
Katherine Niemela, B S , RN, is the Attending Nurse, Elizabeth C. Poster, PhD, RN,is Director, Nursing Research and Education, and Diane Moreau, M N , RN, was Clinical Nurse Manager and is currently Director, Quality Management, UCLA's Neuropsychiatric Institute and Hospital, Los Angeles, CA.
adolescent patient population. Program evaluation results demonstrated that the Attending Nurse role increased general satisfaction and role clarify while decreasing role tension. In addition, the role increased communication with patients' family members. Comparisons are made between the tuadi-
tional primary nurse and the Attending Nurse roles.
T h e development of a cost-effective, clinically productive, and professionally attractive role for the advanced clinician is being evaluated across the country (Loveridge, Cummings, & OMalley, 1988; Maurin, 1990).While the role of the clinical nurse specialist has become controversial and has been discontinued in many institutions, other advanced practice roles have been implemented. These include the roles of the nurse case manager and, more recently, the Attending Nurse (Stuart, Laraia, & Ballenger, 1991; Stuart, Reynolds, & Spencer, 1991).The authors' purpose is to describe the role of the Attending Nurse as it was instituted in a pilot program at UCLA's Neuropsychiatric Hospital on an adolescent inpatient unit. The impact of this role on patient care as well as on nursing staff will be addressed.
The Setting
Accepted for publication November 21,1991.
JCPNVol. 5, No. 3, July-September,1992
The adolescent inpatient unit (A-West)chosen for the pilot program is a locked psychiatric ward with a usual census of 12 male and female patients. These patients have dual diagnoses involving a varied degree of developmental disabilities in conjunction with a psychiatric diagnosis. The majority of the patients are admitted to the unit for reevaluation of problems previously identified, but not successfully diagnosed or treated, by other child or mental health care services. The average length of stay for these adolescents is six weeks, during which time the multidisciplinary team focuses on evaluation, diagnosis, and treatment of the complex and often unusual presenting problems. The nursing staff designs and implements individualized behavioral programs to 5
The Attending Nurse: A New Role for the Advanced Clinician
promote adaptive functioning, primarily related to social deficits or self-care practices. Patient care at the Neuropsychatic Hospital is provided through a primary nursing delivery system that utilizes the Johnson Behavioral System Model as its conceptual framework. Primary nurses are regstered nurses accountable for the planning, coordinating, and delivery of patient care from admission to discharge. Psychiatic technicians, licensed vocational nurses, and mental health practitioners in the role of associates assist the primary nurse in carrying out delegated components of nursing care. While ultimate accountabihty and responsibility for nursing care of the individual patient rests with the RN, all members of the nursing staff are responsible and accountable for the safety and well-being of every patient and for the provision of a therapeutic physical and psychologcal environment.
The selection of a clinical nurse to assume
this new role was based upon criteria related to clinical experience, level of education, clinical Performance, and ability to collaborate with colleagues and the multidisciplinary team.
At the time the Attending Model was proposed by nursing leadershp, the nursing staff on A-West was facing shortages similar to those experienced in other hospital settings. Over the previous year several clinical nurses had left the ward or changed to part-time status, leaving several full-time clinical positions unfilled. The unit had only one full-time c h c a l registered nurse and six other registered nurses who were w o r h g on a part6
time or per diem schedule. The part-time staff shared the primary nursing and relief shift-coordinating (team leading) responsibilities. The resulting fragmentation of patient care was frustrating to the nursing staff, the multidisciplinary teams, and the patients as well.
Attending Nurse Role An eight-week pilot program of the Attending Nurse role was implemented in coordination with the nurse executive team, unit nursing staff, and the multidiscip h a r y team of A-West (Moreau, Poster, & Niemela, in press). The selection of a clinical nurse to assume this new role was based upon criteria related to c h c a l experience, level of education, clirucal performance, and ability to collaborate with colleagues and the multidisciplinary team. The Attending Nurse was assigned six patients, and had responsibility for the delivery of comprehensive nursing care 24 hours a day from admission through discharge. The role was developed to provide direct care, delegate and monitor the nursing care delivered by asscdate staff, and assess for specific patient outcomes. All nursing practice used the Johnson Behavioral System Model as a theoretical framework. The Attending Nurse was not assigned administrative tasks, so that she could meet unit needs such as relief-shift coordinating or formal staff supervision/orientation to insure that the role maintained its patientcare focus (seeTable 1). As a result of the implementation of the Attending Nurse role, the structure for care delivery changed from a partnership model of the primary and associate nurse to a triangular team model whereby the Attending Nurse was paired with an associate nurse on the day and evening shift. On this unit the night-shift nursing staff does not participate in the primary or associate roles, since their patient contact is quite limited. Day and evening associate staff members were assigned to the client on a shift-to-shift basis, and were responsible for providing direct patient care as delegated by the Attending Nurse and as prescribed by the nursing care plan. JCF”Vol.5, No. 3,July-September,1992
Table 1. Attending Nurse JobDescription Summary Statement
The Attending Nurse is responsiblefor the delivery of comprehensiveJohnson Model-based nursing care to a selected caseload of patients and families, 24 hours a day, 7 days a week; provides selected interventions;and delegates and monitors all nursing care delivery to selected caseload. The Attending Nurse also provides leadership, consultation, and guidancv to all members of the nursing staff, collaborates with colleagues on the multidkciphary team, and participates in planning and implementing Quality Assurance and Nursing Research Studies. The Attending Nurse: 1. Performs an in-depth comprehensiveand systematicassessmenton selected caseload of patients. 2. Formulates nursing diagnoses based on assessmentdata and mput from a vanety of sources. 3. Develops a concise plan for complex patient care problems that is relevant, measurable,behavioral,and attainable. 3.1 Identifies short- and long-term goals based on prionhes of care. 3.2 Establishes predicted outcomes and a time frame for obtaining results. 3.3 Develops individualized and structured teaching plans for patients and families wth complex and specializedproblems. 3.4 Participatesin comprehensivedischarge planning. 4. Initiates pabent care plan at tune of admission. 5. Utilizes identifiablepsychotherapeuticprinciples and treatment modalities based on level of clinical privilegesand appropriatenessto patient's plan of care. 5.1 Provides dlred care to groups of pahents or families/si@cant others (e.g., group psychotherapy,therapeutic groups, parent training, family therapy). 5.2 Delegates and monitors all nursing care delivered to patients and famhes in caseload. 5.3 Develops standardized nursing care plans for specific patient populations/problems. 5.4 Applies results of research studies to patient care and nursing practice. 6. Parhcipates in formulating the multidlsciplInarytreatment plan. 6.1 Provides specializedknowledge and skill to assist trainees/staff with management of difficult patients and family/ sigruficant other problems. 7. C r i t i q and ~ ~ ~reviews on continuousbasis the assessment data to determine is data base is adequate, and documents services provided. 8. Maintainsa systematicprocess for evaluating patient/family progress and utilizes selected clinical measurement tools to evaluate change in patient's behavior,as indicated. 8.1 Utilizes selected clinical measurement tools to evaluate change in patient's behavior. 8.2 Initiates quality assurance studies in collaboration with the Quality AssuranceCommittee. 8 3 Utilizes results of quality assurance and research studies to set patient care standardsand make modificationsas needed. 8.4 Collaborates with clinical investigatorsinvolved in the study of nursing phenomena or phenomena related to the delivery of nursing care. 9. Maintains standards required by licensing agencies and hospital and university policies.
10. Provldes clarification on patient care issues, nursing diagnostic formulations,and chical recommendahonsof care to
nursmg staff.
JCPNVol. 5, No. 3, July-September,1992
7
The Attending Nurse: A New Role for the Advanced Clinician
Table 2. Role Comparison Classification
Attending Nurse Clinical Nurse Ill Clinical Nurse IV
Primary Nurse Clinical Nurse I1 Clinical Nurse 111 Per diem RN
Licensure
RN in State of California
RN in state of California
Education
CN 111: Bachelor’s required; master’s preferred CN IV: Master’s required; doctorate preferred 4 years experience in psychiatric nursing At time of hire, or to be obtained within one year Bachelor’s degree: nursing process therapeutic groups parent training (as applicable) Master‘s and doctorate degrees: nursing process adult individual (psychotherapy) child/adolescent therapeutic group group psychotherapy (as applicable) Appointed by Clinical Nurse Manager
CN 11: Bachelor’s required CN 111: Bachelor’s required 6 months minimum Recommended Nursing process Therapeutic groups
Experience Certification Clinical Privileges
Selection Salary Scheduling
Per classihcation Self-scheduling, flexible hours not determined by shift or day. Coverage prearranged by self.
Performance Evaluations A N 111 24 hours, 7 davs/week, admission to Patient Care Responsibilities discharge; caseload 3-6 patients
Reporting Lines
AN III
The Attending Nurse role was conceptuahzed as different from the primary and associate nurse roles in a number of areas. These included classification, educational background, experience, certdication, clinical privileges, process of appointment, job description, scheduling, performance evaluations, patient care responsibilities and reporting mechanism (seeTable 2). The Attending Nurse’s role was made operational in a way that was clearly different from the primary nurse’s role. An average day for a primary nurse on the ward 8
Appointed by Clinical Nurse Manager Per classification 8 hr shifts, 4-5 days/week. Coverage arranged by Clinical Nurse Manager. AN I, CN I11 AN 111 24 hours, 7 days/week, admission to discharge, as delegated by Attending Nurse. Caseload 1-3patients AN1
Associate Nurse Clinical Nurse I Clinical Nurse I1 Per diem RN LIT RN in state of California LPT in state of California No academic requirements specihed No minimum Optional Nursing process Therapeutic groups (optional)
Appointed by Clinical Nurse Manager Per classification 8 or 12 hr shifts. Coverage arranged by Clinical Nurse Manager.
AN I, CN 111, AN 111 Assigned patients for duration of shift (8 or 12 hr). Caseload 2-3 patients.
CN 11, CN 111, AN1
involved care as assigned by the shift-cmrdinator,including that nurse’s primary cases and possibly coverage of another staff member‘s cases. Additional assignments in the shift could focus on administrative needs of the unit such as relief shift-coordinating, milieu needs such as hourly coverage of 1:l status patients (who may or may not be part of the primary cases of that nurse), and supervising or escorting groups of patients to activities. The Attending Nurse planned each work day (which was not regulated by shift hours) based upon priority JCPNVoL 5, No. 3, July-September, 1992
patient care needs that were determined independently. A daily schedule for this nurse included both direct and indirect patient care activities. Early in the shift the Attending Nurse listened to a taped shift report and met briefly and informally with the shift coordinator to discuss her schedule of the day and off-unit commitments, as well as to review the patients’ individual needs. All patients were assessed each work day by the Attending Nurse. While these assessments occurred primarily Monday through Friday, occasionally a weekend assessment was conducted when a patient had been recently admitted or when a family could only be available at that time. Some patients required daily contact while others had individual sessions scheduled periodically throughout the week. Direct patient care was provided by the Attending Nurse for situations in which new programs or interventions were initiated, in which the client was perceived to be in crisis, and in which specific teaching sessions or scheduled meetings were required. Communication between the Attending Nurse and members of both the nursing staff and the multidisciplinary team was an integral aspect of the role. Communication with each patient‘s primary therapist was conducted on a day-to-day basis. Within each shift the Attending Nurse consulted informally with the associate members of the nursing team on their shared cases. These sessions were used to solve problem, review progress, and communicatechanges in the nursing care plan. An average of 2 hours a week was scheduled by the Attending Nurse to receive individual supervision on the ward from the Clinical Nurse Manager and off the ward from the Director of Nursing Practice. These two supervision times were used to focus on clinical issues, professional practice, and implementation of the Attending Nurse role. This combinationof supervisionwas designed to focus on specrficunit-based clinician and role issues to assist in the continued development and actual implementation of the new role from a systems perspective. Documentation responsibilities included weekly evaluations of each patient’s progress utilizing the Johnson Model. Nursing diagnoses based on this model designated the focus of the patient care plans, which were JCPNVol. 5, No. 3, July-September,1992
revised as a part of the weekly evaluations and as new programs were developed. Daily documentation included additions to the shift narratives for each client in order to provide the additional information discovered through assessments or direct care activities. All scheduled admission assessments were conducted by the Attending Nurse for her patients, since this nurse had increased flexibility resulting from self-scheduling. Emergency admissions that would become the Attending Nurse’s patients were assessed by her if she was on duty or available to come in to the hospital. Otherwise, the RN on duty would do an initial short assessment with follow-up by the Attending Nurse within 48 hours. The Attending Nurse provided compre hensive assessments, formulated nursing diagnoses, and developed a comprehensive plan of care for the targeted patient problems. Continuous evaluation of the nursing care plan was conducted throughout the patients’ hospitalization with revisions made as needed.
All scheduled admission assessments were conducted by the Attending Nurse for her patients, since this nurse had increased flexibility resulting from self-scheduling.
Evaluation The Attending Nurse completed a Staff Satisfaction Questionnaire (Ryan, Poster, Auger, Davis, & Ringdahl, 1988) before and after the pilot program, as well a s weekly Perceived Stress Surveys (Cohen, Kamarck, & Mermelstein, 1983). In addition, the Attending Nurse kept a weekly anecdotal notation of clinical events. During the initial planning phase a number of advan9
The Attending Nurse: A New Role for the Advanced Clinician
tages and disadvantages were identified by the clinical nursing task force related to the attending role. These issues also became an important part of the formative evaluation of the pilot program, and were considered in the final decision as to whether the role would become permanent. These factors were evaluated as related to the retention of the Attending Nurse and eventual recruitment of other clinical nurses who met the selection criteria. The results of the program evaluation demonstrated overall success of the role and acceptance by members of the A-West nursing staff and multidisciplinary team (Moreau et al., in press). Anticipated advantages for staff. The anticipated advantages were demonstrated as expected throughout the progression of the pilot program. 1. Flexibility of time. The flexible hours were found to be a distinct advantage to the Attending Nurse, affecting various aspects of her practice. The ability to provide comprehensive nursing care based upon patient priorities rather than shift hours was the most strilung benefit. 2. lmprmied cornin1112 icat ion. Communication improved between nursing and other multidisciplinary staff. The more complex clients and care plans were assigned to this nurse and she felt increased satisfaction with her c h c a l practice. 3. Less fragmentation of cure. Less fragmentation of care existed, since a decreased number of cases were carried by part-time nurses.
4.Increased motivation. The Attending Nurse reported an increase in motivation to continue working at the Neuropsychiatric Hospital. The effecton nxmitment of nurses is ~~III being evaluated as potential positionson other unitsare being reviewed. Overcoming disadvantages. The anticipated disadvantages of the role were also evaluated during the pilot program. 1. Scheduliiig and staffing, Since the Attending Nurse was not counted in the shift staffing composition, 10
with the exception of those shifts in which she would function as the admitting nurse for new clients in her case load, she provided a weekly schedule designating specific hours that she expected to be on the ward. As a result scheduling and planning by the shift administrative nurses were not adversely affected during the pilot program. 2. Clinical supervision. Clinical supervision was not required from the administrative nurses (shift coordinators), as it was clearly provided by the Clinical Nurse Manager and the Director of Nursing Practice. 3. Territoriality. Territoriality of the nurses was not affected, as staff nurses who requested to continue their primary nurse roles were assigned primary cases. Since a nurse from the unit was selected to pilot the Attending Nurse role, the possible negative responses resulting from promoting a ”new hire” were not an issue. Based on the staff‘s comments, it appeared there was more consistency in nursing care than previously described on the unit, while “staff splitting” remained approximately the same due to the type of patients served. 4. Learning needs of staff. This role did not formally address learning needs of the nursing staff; yet informal teaching occurred on an ongoing basis as a result of the increased contact between the Attending Nurse and associate nurses, as well as patients and family members.
Attending Nurse outcomes. It was anticipated that the Attending Nurse would experience increased satisfaction with her work as it related to professional autonomy, improved communication with staff, consistent involvement with families, and increased effectiveness in c h c a l practice. The Staff Satisfaction Survey results of the Attending Nurse showed a 28-point decrease in role conflict, a 13-point increase in role clarity, an 11-point increase in general satisfaction, and a %point increase in satisfaction with peers. Surprisingly, there was a decrease in satisfaction with promotional opportunities JCF”VoL 5, No. 3, July-September,1992
(12 points) and little change in the areas of role tension, satisfaction with work, and satisfaction with pay. Possible explanations for these results included the uncertainty that the role would be continued and personal stress reported from attempting to define and develop a new nursing role. Perceived stress of the Attending Nurse was expected to be elevated initially and to decrease toward the end of the pilot program. The Perceived Stress Survey results showed intermittent increases in stress level, which were related to weekly events. These increases were noted in the anecdotal records, and included high demand situations such as multiple admissions or discharges. Stress scores fluctuated from 13 at Week 1, to a high of 24 during the second week, then down to 9 at the close of the eighth week. It should be noted that the highest possible stress score would be 54 and the lowest zero. Clearly, even during the weeks when there were many potentially stressful events, the Attending Nurse reported a moderate score, which indicated her ability to manage the stressors. Responses to the open-ended survey described the clinical experience most clearly with regard to several anticipated areas of impact. These included flexibility of time; professional autonomy; communication with staff, family members, and the multidisciplinary team; and perceived effectivenessas an Attending Nurse, especially since the most complex patients were under her care. The self-schedulingcomponent of the Attending Nurse role was critical to its success and was directly related to the increase in perceived professional autonomy. A flexible schedule allowed the nurse to prioritize and plan her working hours around the needs of the patients instead of the needs of the unit. In addition, the Attending Nurse was able to continue her education and maintain the fulltime role as a direct result of the scheduling component. Communication with nursing staff, family members, and the multidisciplinary team became more effective in a number of ways. Since the Attending Nurse chose to work portions of both day and evening shifts, she increased her contact with unit staff on both shifts. This daily contact with the associate nursing team members on both shifts was essential for communicating treatment interventions and incorporating others’ observaJ O NVol. 5, No. 3, July-September,1992
tions into the patient data base. The Attending Nurse had increased availability to meet with f a d e s regarding specific care issues and to provide feedback, as well as discharge teaching. With increased flexibility, the Attending Nurse was able to discuss her cases in multidisciplinary team meetings as well as with individual physicians and other team members.
The self-scheduling component of the Attending Nurse role was critical to its success and was directly related to the increase in perceived professional autonomy.
All these factors increased the Attending Nurse’s percep tion of her effdiveness in assessing p h g modmating and providing patient care, compared to her previous role as a primary nurse. Despite the decrease in actual hours spent in direct patient care she felt that the expanded nursing care she provided in indirect activitiesresulted in a hospital stay that was effective and productive for her clients. Conclusion The Attending Nurse role, as piloted at UCLA’s Neuropsychiatric Hospital, was found to be a successful model of advanced practice and one that meets the needs of the patients, the Attending Nurse, and the unit staff. Yet, those considering either replication or modified implementation of a similar advanced role need to consider a number of structure and process factors in order to ensure its success. The clinician providing care as an Attending Nurse must have demonstrated an expert level of performance not only with the patient population but also with the unit team. Implementation of the Attending Nurse role requires that the unit have a 11
The Attending Nurse: A New Role for the Advanced Clinician
significant number of slulled and knowledgeable associate staff to provide the delegated care to the clients and to follow the prescribed nursing plan of care. Furthermore, the staff must recognize the benefits of the position in order to enact the changes necessary to develop this new nursing role. In addition to staffing needs and unit support, nursing administration must be supportive of the role. It is critical that unit nursing leaderslup make a commitment to developing the advanced role as a strategy to promote quality of patient care. As a result of these program evaluation findings, the Attending Nurse role has been adopted as a permanent position on tlus adolescent unit. Future plans include the introduction of a second Attending Nurse on the unit. This addition would allow for an evaluation of the Attending Nurse Model not only as an advanced nursing position for an individual clirucian, but as a new system for the delivery of psychiatric nursing care.
Acknowledgment. The authors wish to acknowledge the contributions of Dr. Vivien Dee and Dr. Brooke Randell in the development of tlus role and the support of the A-West nursing staff throughout the implementation process. References Cohen, S., Kamarck, T , & Mermelstein, R. (1983).A global measure of perceived stress./nitnull of Heolth 1 7 n d Socinl Behnvior, 2 4 , 3 8 5 3 9 6 . Loveridge, C., Curnmings, S., & OMalley, J. (1988). Developing case management in a primary nursing system. IoiiriiaJ of Nursing Administration, 28(10), 36-39. Maurin, J. (1990). Case management: Caring for psychiatric clients. ]oumal of Psychosoclrrl Nursing and Maital Henlth Sen~ices,28(7),7-12. Moreau, D., Poster, E., & Niemela, K. (in press). Implementation and evaluation of an attending nurse model in an inpatient psychiatric setting. Nursing Manngtnnrnt. Ryan, J., Poster, E., Auger, J., Davis, B., & kngdahl, P. (1989).A comparahve study of primary and team nursing models in the psychatric setting. Archives of Psyihiofric Nursing, 2(1), 5 1 3 .
12
Stuart, G., Laraia, M., & Ballanger, J. (1991)A collaborative model for nursing practice. Manuscript submitted for publication. Stuart, G., Reynolds, R., & Spencer, M. (1991).Marketing nursing in an academic psychiatric setting. In R. Alward & C. Camunas (Eds.), 77i~ Nurse's Guide to Mnrkting (pp. 347-357). Albany, Ny: Delmar. Reprints of ths article are available from UMI Article Clearinghouse: 800/521-0600. From Alaska & Michigan: call collect 313/761-4700. From Canada: 800/343-5299.
9th Annual Conference on
Current Issues in Mental Health Nursing Clinical Issues Relating t o Violence Across the Life Span October 22 - 23,1992 Atlanta, GA. For More Information Contact: Sharon Grover R.N., M.N., Staff Development Coordinator P.O. Box 26119 Grady Memorial Hospital 80 Butler Street Atlanta, GA. 30035 (404) 616-4751
JCPNVoL 5, No. 3, July-September,1992
The Attending Nurse Model as a unique role for the
advanced practitioner was implemented and evaluated in an acute care psychiatric setting with an
Katherine Niemela, B S , RN, is the Attending Nurse, Elizabeth C. Poster, PhD, RN,is Director, Nursing Research and Education, and Diane Moreau, M N , RN, was Clinical Nurse Manager and is currently Director, Quality Management, UCLA's Neuropsychiatric Institute and Hospital, Los Angeles, CA.
adolescent patient population. Program evaluation results demonstrated that the Attending Nurse role increased general satisfaction and role clarify while decreasing role tension. In addition, the role increased communication with patients' family members. Comparisons are made between the tuadi-
tional primary nurse and the Attending Nurse roles.
T h e development of a cost-effective, clinically productive, and professionally attractive role for the advanced clinician is being evaluated across the country (Loveridge, Cummings, & OMalley, 1988; Maurin, 1990).While the role of the clinical nurse specialist has become controversial and has been discontinued in many institutions, other advanced practice roles have been implemented. These include the roles of the nurse case manager and, more recently, the Attending Nurse (Stuart, Laraia, & Ballenger, 1991; Stuart, Reynolds, & Spencer, 1991).The authors' purpose is to describe the role of the Attending Nurse as it was instituted in a pilot program at UCLA's Neuropsychiatric Hospital on an adolescent inpatient unit. The impact of this role on patient care as well as on nursing staff will be addressed.
The Setting
Accepted for publication November 21,1991.
JCPNVol. 5, No. 3, July-September,1992
The adolescent inpatient unit (A-West)chosen for the pilot program is a locked psychiatric ward with a usual census of 12 male and female patients. These patients have dual diagnoses involving a varied degree of developmental disabilities in conjunction with a psychiatric diagnosis. The majority of the patients are admitted to the unit for reevaluation of problems previously identified, but not successfully diagnosed or treated, by other child or mental health care services. The average length of stay for these adolescents is six weeks, during which time the multidisciplinary team focuses on evaluation, diagnosis, and treatment of the complex and often unusual presenting problems. The nursing staff designs and implements individualized behavioral programs to 5
The Attending Nurse: A New Role for the Advanced Clinician
promote adaptive functioning, primarily related to social deficits or self-care practices. Patient care at the Neuropsychatic Hospital is provided through a primary nursing delivery system that utilizes the Johnson Behavioral System Model as its conceptual framework. Primary nurses are regstered nurses accountable for the planning, coordinating, and delivery of patient care from admission to discharge. Psychiatic technicians, licensed vocational nurses, and mental health practitioners in the role of associates assist the primary nurse in carrying out delegated components of nursing care. While ultimate accountabihty and responsibility for nursing care of the individual patient rests with the RN, all members of the nursing staff are responsible and accountable for the safety and well-being of every patient and for the provision of a therapeutic physical and psychologcal environment.
The selection of a clinical nurse to assume
this new role was based upon criteria related to clinical experience, level of education, clinical Performance, and ability to collaborate with colleagues and the multidisciplinary team.
At the time the Attending Model was proposed by nursing leadershp, the nursing staff on A-West was facing shortages similar to those experienced in other hospital settings. Over the previous year several clinical nurses had left the ward or changed to part-time status, leaving several full-time clinical positions unfilled. The unit had only one full-time c h c a l registered nurse and six other registered nurses who were w o r h g on a part6
time or per diem schedule. The part-time staff shared the primary nursing and relief shift-coordinating (team leading) responsibilities. The resulting fragmentation of patient care was frustrating to the nursing staff, the multidisciplinary teams, and the patients as well.
Attending Nurse Role An eight-week pilot program of the Attending Nurse role was implemented in coordination with the nurse executive team, unit nursing staff, and the multidiscip h a r y team of A-West (Moreau, Poster, & Niemela, in press). The selection of a clinical nurse to assume this new role was based upon criteria related to c h c a l experience, level of education, clirucal performance, and ability to collaborate with colleagues and the multidisciplinary team. The Attending Nurse was assigned six patients, and had responsibility for the delivery of comprehensive nursing care 24 hours a day from admission through discharge. The role was developed to provide direct care, delegate and monitor the nursing care delivered by asscdate staff, and assess for specific patient outcomes. All nursing practice used the Johnson Behavioral System Model as a theoretical framework. The Attending Nurse was not assigned administrative tasks, so that she could meet unit needs such as relief-shift coordinating or formal staff supervision/orientation to insure that the role maintained its patientcare focus (seeTable 1). As a result of the implementation of the Attending Nurse role, the structure for care delivery changed from a partnership model of the primary and associate nurse to a triangular team model whereby the Attending Nurse was paired with an associate nurse on the day and evening shift. On this unit the night-shift nursing staff does not participate in the primary or associate roles, since their patient contact is quite limited. Day and evening associate staff members were assigned to the client on a shift-to-shift basis, and were responsible for providing direct patient care as delegated by the Attending Nurse and as prescribed by the nursing care plan. JCF”Vol.5, No. 3,July-September,1992
Table 1. Attending Nurse JobDescription Summary Statement
The Attending Nurse is responsiblefor the delivery of comprehensiveJohnson Model-based nursing care to a selected caseload of patients and families, 24 hours a day, 7 days a week; provides selected interventions;and delegates and monitors all nursing care delivery to selected caseload. The Attending Nurse also provides leadership, consultation, and guidancv to all members of the nursing staff, collaborates with colleagues on the multidkciphary team, and participates in planning and implementing Quality Assurance and Nursing Research Studies. The Attending Nurse: 1. Performs an in-depth comprehensiveand systematicassessmenton selected caseload of patients. 2. Formulates nursing diagnoses based on assessmentdata and mput from a vanety of sources. 3. Develops a concise plan for complex patient care problems that is relevant, measurable,behavioral,and attainable. 3.1 Identifies short- and long-term goals based on prionhes of care. 3.2 Establishes predicted outcomes and a time frame for obtaining results. 3.3 Develops individualized and structured teaching plans for patients and families wth complex and specializedproblems. 3.4 Participatesin comprehensivedischarge planning. 4. Initiates pabent care plan at tune of admission. 5. Utilizes identifiablepsychotherapeuticprinciples and treatment modalities based on level of clinical privilegesand appropriatenessto patient's plan of care. 5.1 Provides dlred care to groups of pahents or families/si@cant others (e.g., group psychotherapy,therapeutic groups, parent training, family therapy). 5.2 Delegates and monitors all nursing care delivered to patients and famhes in caseload. 5.3 Develops standardized nursing care plans for specific patient populations/problems. 5.4 Applies results of research studies to patient care and nursing practice. 6. Parhcipates in formulating the multidlsciplInarytreatment plan. 6.1 Provides specializedknowledge and skill to assist trainees/staff with management of difficult patients and family/ sigruficant other problems. 7. C r i t i q and ~ ~ ~reviews on continuousbasis the assessment data to determine is data base is adequate, and documents services provided. 8. Maintainsa systematicprocess for evaluating patient/family progress and utilizes selected clinical measurement tools to evaluate change in patient's behavior,as indicated. 8.1 Utilizes selected clinical measurement tools to evaluate change in patient's behavior. 8.2 Initiates quality assurance studies in collaboration with the Quality AssuranceCommittee. 8 3 Utilizes results of quality assurance and research studies to set patient care standardsand make modificationsas needed. 8.4 Collaborates with clinical investigatorsinvolved in the study of nursing phenomena or phenomena related to the delivery of nursing care. 9. Maintains standards required by licensing agencies and hospital and university policies.
10. Provldes clarification on patient care issues, nursing diagnostic formulations,and chical recommendahonsof care to
nursmg staff.
JCPNVol. 5, No. 3, July-September,1992
7
The Attending Nurse: A New Role for the Advanced Clinician
Table 2. Role Comparison Classification
Attending Nurse Clinical Nurse Ill Clinical Nurse IV
Primary Nurse Clinical Nurse I1 Clinical Nurse 111 Per diem RN
Licensure
RN in State of California
RN in state of California
Education
CN 111: Bachelor’s required; master’s preferred CN IV: Master’s required; doctorate preferred 4 years experience in psychiatric nursing At time of hire, or to be obtained within one year Bachelor’s degree: nursing process therapeutic groups parent training (as applicable) Master‘s and doctorate degrees: nursing process adult individual (psychotherapy) child/adolescent therapeutic group group psychotherapy (as applicable) Appointed by Clinical Nurse Manager
CN 11: Bachelor’s required CN 111: Bachelor’s required 6 months minimum Recommended Nursing process Therapeutic groups
Experience Certification Clinical Privileges
Selection Salary Scheduling
Per classihcation Self-scheduling, flexible hours not determined by shift or day. Coverage prearranged by self.
Performance Evaluations A N 111 24 hours, 7 davs/week, admission to Patient Care Responsibilities discharge; caseload 3-6 patients
Reporting Lines
AN III
The Attending Nurse role was conceptuahzed as different from the primary and associate nurse roles in a number of areas. These included classification, educational background, experience, certdication, clinical privileges, process of appointment, job description, scheduling, performance evaluations, patient care responsibilities and reporting mechanism (seeTable 2). The Attending Nurse’s role was made operational in a way that was clearly different from the primary nurse’s role. An average day for a primary nurse on the ward 8
Appointed by Clinical Nurse Manager Per classification 8 hr shifts, 4-5 days/week. Coverage arranged by Clinical Nurse Manager. AN I, CN I11 AN 111 24 hours, 7 days/week, admission to discharge, as delegated by Attending Nurse. Caseload 1-3patients AN1
Associate Nurse Clinical Nurse I Clinical Nurse I1 Per diem RN LIT RN in state of California LPT in state of California No academic requirements specihed No minimum Optional Nursing process Therapeutic groups (optional)
Appointed by Clinical Nurse Manager Per classification 8 or 12 hr shifts. Coverage arranged by Clinical Nurse Manager.
AN I, CN 111, AN 111 Assigned patients for duration of shift (8 or 12 hr). Caseload 2-3 patients.
CN 11, CN 111, AN1
involved care as assigned by the shift-cmrdinator,including that nurse’s primary cases and possibly coverage of another staff member‘s cases. Additional assignments in the shift could focus on administrative needs of the unit such as relief shift-coordinating, milieu needs such as hourly coverage of 1:l status patients (who may or may not be part of the primary cases of that nurse), and supervising or escorting groups of patients to activities. The Attending Nurse planned each work day (which was not regulated by shift hours) based upon priority JCPNVoL 5, No. 3, July-September, 1992
patient care needs that were determined independently. A daily schedule for this nurse included both direct and indirect patient care activities. Early in the shift the Attending Nurse listened to a taped shift report and met briefly and informally with the shift coordinator to discuss her schedule of the day and off-unit commitments, as well as to review the patients’ individual needs. All patients were assessed each work day by the Attending Nurse. While these assessments occurred primarily Monday through Friday, occasionally a weekend assessment was conducted when a patient had been recently admitted or when a family could only be available at that time. Some patients required daily contact while others had individual sessions scheduled periodically throughout the week. Direct patient care was provided by the Attending Nurse for situations in which new programs or interventions were initiated, in which the client was perceived to be in crisis, and in which specific teaching sessions or scheduled meetings were required. Communication between the Attending Nurse and members of both the nursing staff and the multidisciplinary team was an integral aspect of the role. Communication with each patient‘s primary therapist was conducted on a day-to-day basis. Within each shift the Attending Nurse consulted informally with the associate members of the nursing team on their shared cases. These sessions were used to solve problem, review progress, and communicatechanges in the nursing care plan. An average of 2 hours a week was scheduled by the Attending Nurse to receive individual supervision on the ward from the Clinical Nurse Manager and off the ward from the Director of Nursing Practice. These two supervision times were used to focus on clinical issues, professional practice, and implementation of the Attending Nurse role. This combinationof supervisionwas designed to focus on specrficunit-based clinician and role issues to assist in the continued development and actual implementation of the new role from a systems perspective. Documentation responsibilities included weekly evaluations of each patient’s progress utilizing the Johnson Model. Nursing diagnoses based on this model designated the focus of the patient care plans, which were JCPNVol. 5, No. 3, July-September,1992
revised as a part of the weekly evaluations and as new programs were developed. Daily documentation included additions to the shift narratives for each client in order to provide the additional information discovered through assessments or direct care activities. All scheduled admission assessments were conducted by the Attending Nurse for her patients, since this nurse had increased flexibility resulting from self-scheduling. Emergency admissions that would become the Attending Nurse’s patients were assessed by her if she was on duty or available to come in to the hospital. Otherwise, the RN on duty would do an initial short assessment with follow-up by the Attending Nurse within 48 hours. The Attending Nurse provided compre hensive assessments, formulated nursing diagnoses, and developed a comprehensive plan of care for the targeted patient problems. Continuous evaluation of the nursing care plan was conducted throughout the patients’ hospitalization with revisions made as needed.
All scheduled admission assessments were conducted by the Attending Nurse for her patients, since this nurse had increased flexibility resulting from self-scheduling.
Evaluation The Attending Nurse completed a Staff Satisfaction Questionnaire (Ryan, Poster, Auger, Davis, & Ringdahl, 1988) before and after the pilot program, as well a s weekly Perceived Stress Surveys (Cohen, Kamarck, & Mermelstein, 1983). In addition, the Attending Nurse kept a weekly anecdotal notation of clinical events. During the initial planning phase a number of advan9
The Attending Nurse: A New Role for the Advanced Clinician
tages and disadvantages were identified by the clinical nursing task force related to the attending role. These issues also became an important part of the formative evaluation of the pilot program, and were considered in the final decision as to whether the role would become permanent. These factors were evaluated as related to the retention of the Attending Nurse and eventual recruitment of other clinical nurses who met the selection criteria. The results of the program evaluation demonstrated overall success of the role and acceptance by members of the A-West nursing staff and multidisciplinary team (Moreau et al., in press). Anticipated advantages for staff. The anticipated advantages were demonstrated as expected throughout the progression of the pilot program. 1. Flexibility of time. The flexible hours were found to be a distinct advantage to the Attending Nurse, affecting various aspects of her practice. The ability to provide comprehensive nursing care based upon patient priorities rather than shift hours was the most strilung benefit. 2. lmprmied cornin1112 icat ion. Communication improved between nursing and other multidisciplinary staff. The more complex clients and care plans were assigned to this nurse and she felt increased satisfaction with her c h c a l practice. 3. Less fragmentation of cure. Less fragmentation of care existed, since a decreased number of cases were carried by part-time nurses.
4.Increased motivation. The Attending Nurse reported an increase in motivation to continue working at the Neuropsychiatric Hospital. The effecton nxmitment of nurses is ~~III being evaluated as potential positionson other unitsare being reviewed. Overcoming disadvantages. The anticipated disadvantages of the role were also evaluated during the pilot program. 1. Scheduliiig and staffing, Since the Attending Nurse was not counted in the shift staffing composition, 10
with the exception of those shifts in which she would function as the admitting nurse for new clients in her case load, she provided a weekly schedule designating specific hours that she expected to be on the ward. As a result scheduling and planning by the shift administrative nurses were not adversely affected during the pilot program. 2. Clinical supervision. Clinical supervision was not required from the administrative nurses (shift coordinators), as it was clearly provided by the Clinical Nurse Manager and the Director of Nursing Practice. 3. Territoriality. Territoriality of the nurses was not affected, as staff nurses who requested to continue their primary nurse roles were assigned primary cases. Since a nurse from the unit was selected to pilot the Attending Nurse role, the possible negative responses resulting from promoting a ”new hire” were not an issue. Based on the staff‘s comments, it appeared there was more consistency in nursing care than previously described on the unit, while “staff splitting” remained approximately the same due to the type of patients served. 4. Learning needs of staff. This role did not formally address learning needs of the nursing staff; yet informal teaching occurred on an ongoing basis as a result of the increased contact between the Attending Nurse and associate nurses, as well as patients and family members.
Attending Nurse outcomes. It was anticipated that the Attending Nurse would experience increased satisfaction with her work as it related to professional autonomy, improved communication with staff, consistent involvement with families, and increased effectiveness in c h c a l practice. The Staff Satisfaction Survey results of the Attending Nurse showed a 28-point decrease in role conflict, a 13-point increase in role clarity, an 11-point increase in general satisfaction, and a %point increase in satisfaction with peers. Surprisingly, there was a decrease in satisfaction with promotional opportunities JCF”VoL 5, No. 3, July-September,1992
(12 points) and little change in the areas of role tension, satisfaction with work, and satisfaction with pay. Possible explanations for these results included the uncertainty that the role would be continued and personal stress reported from attempting to define and develop a new nursing role. Perceived stress of the Attending Nurse was expected to be elevated initially and to decrease toward the end of the pilot program. The Perceived Stress Survey results showed intermittent increases in stress level, which were related to weekly events. These increases were noted in the anecdotal records, and included high demand situations such as multiple admissions or discharges. Stress scores fluctuated from 13 at Week 1, to a high of 24 during the second week, then down to 9 at the close of the eighth week. It should be noted that the highest possible stress score would be 54 and the lowest zero. Clearly, even during the weeks when there were many potentially stressful events, the Attending Nurse reported a moderate score, which indicated her ability to manage the stressors. Responses to the open-ended survey described the clinical experience most clearly with regard to several anticipated areas of impact. These included flexibility of time; professional autonomy; communication with staff, family members, and the multidisciplinary team; and perceived effectivenessas an Attending Nurse, especially since the most complex patients were under her care. The self-schedulingcomponent of the Attending Nurse role was critical to its success and was directly related to the increase in perceived professional autonomy. A flexible schedule allowed the nurse to prioritize and plan her working hours around the needs of the patients instead of the needs of the unit. In addition, the Attending Nurse was able to continue her education and maintain the fulltime role as a direct result of the scheduling component. Communication with nursing staff, family members, and the multidisciplinary team became more effective in a number of ways. Since the Attending Nurse chose to work portions of both day and evening shifts, she increased her contact with unit staff on both shifts. This daily contact with the associate nursing team members on both shifts was essential for communicating treatment interventions and incorporating others’ observaJ O NVol. 5, No. 3, July-September,1992
tions into the patient data base. The Attending Nurse had increased availability to meet with f a d e s regarding specific care issues and to provide feedback, as well as discharge teaching. With increased flexibility, the Attending Nurse was able to discuss her cases in multidisciplinary team meetings as well as with individual physicians and other team members.
The self-scheduling component of the Attending Nurse role was critical to its success and was directly related to the increase in perceived professional autonomy.
All these factors increased the Attending Nurse’s percep tion of her effdiveness in assessing p h g modmating and providing patient care, compared to her previous role as a primary nurse. Despite the decrease in actual hours spent in direct patient care she felt that the expanded nursing care she provided in indirect activitiesresulted in a hospital stay that was effective and productive for her clients. Conclusion The Attending Nurse role, as piloted at UCLA’s Neuropsychiatric Hospital, was found to be a successful model of advanced practice and one that meets the needs of the patients, the Attending Nurse, and the unit staff. Yet, those considering either replication or modified implementation of a similar advanced role need to consider a number of structure and process factors in order to ensure its success. The clinician providing care as an Attending Nurse must have demonstrated an expert level of performance not only with the patient population but also with the unit team. Implementation of the Attending Nurse role requires that the unit have a 11
The Attending Nurse: A New Role for the Advanced Clinician
significant number of slulled and knowledgeable associate staff to provide the delegated care to the clients and to follow the prescribed nursing plan of care. Furthermore, the staff must recognize the benefits of the position in order to enact the changes necessary to develop this new nursing role. In addition to staffing needs and unit support, nursing administration must be supportive of the role. It is critical that unit nursing leaderslup make a commitment to developing the advanced role as a strategy to promote quality of patient care. As a result of these program evaluation findings, the Attending Nurse role has been adopted as a permanent position on tlus adolescent unit. Future plans include the introduction of a second Attending Nurse on the unit. This addition would allow for an evaluation of the Attending Nurse Model not only as an advanced nursing position for an individual clirucian, but as a new system for the delivery of psychiatric nursing care.
Acknowledgment. The authors wish to acknowledge the contributions of Dr. Vivien Dee and Dr. Brooke Randell in the development of tlus role and the support of the A-West nursing staff throughout the implementation process. References Cohen, S., Kamarck, T , & Mermelstein, R. (1983).A global measure of perceived stress./nitnull of Heolth 1 7 n d Socinl Behnvior, 2 4 , 3 8 5 3 9 6 . Loveridge, C., Curnmings, S., & OMalley, J. (1988). Developing case management in a primary nursing system. IoiiriiaJ of Nursing Administration, 28(10), 36-39. Maurin, J. (1990). Case management: Caring for psychiatric clients. ]oumal of Psychosoclrrl Nursing and Maital Henlth Sen~ices,28(7),7-12. Moreau, D., Poster, E., & Niemela, K. (in press). Implementation and evaluation of an attending nurse model in an inpatient psychiatric setting. Nursing Manngtnnrnt. Ryan, J., Poster, E., Auger, J., Davis, B., & kngdahl, P. (1989).A comparahve study of primary and team nursing models in the psychatric setting. Archives of Psyihiofric Nursing, 2(1), 5 1 3 .
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Stuart, G., Laraia, M., & Ballanger, J. (1991)A collaborative model for nursing practice. Manuscript submitted for publication. Stuart, G., Reynolds, R., & Spencer, M. (1991).Marketing nursing in an academic psychiatric setting. In R. Alward & C. Camunas (Eds.), 77i~ Nurse's Guide to Mnrkting (pp. 347-357). Albany, Ny: Delmar. Reprints of ths article are available from UMI Article Clearinghouse: 800/521-0600. From Alaska & Michigan: call collect 313/761-4700. From Canada: 800/343-5299.
9th Annual Conference on
Current Issues in Mental Health Nursing Clinical Issues Relating t o Violence Across the Life Span October 22 - 23,1992 Atlanta, GA. For More Information Contact: Sharon Grover R.N., M.N., Staff Development Coordinator P.O. Box 26119 Grady Memorial Hospital 80 Butler Street Atlanta, GA. 30035 (404) 616-4751
JCPNVoL 5, No. 3, July-September,1992
