Journal of Nursing Management, 2016, 24, 39–49
The role of clinical nurse specialists in the implementation and sustainability of a practice change RHONDA L. BABINE and SARAH HALLEN
MS, APRN, ACNS-BC 3
1
, CINDY HONESS
MSN, APRN, ACNS-BC
1
, HEIDI R. WIERMAN
MD
2
MD
1
Clinical Nurse Specialist, Center for Clinical and Professional Development, Maine Medical Center, Portland, Maine, 2Director, Division of Geriatrics, Maine Medical Center, Portland, Maine and 3Maine Medical Partners, Geriatrics, Maine Medical Center, Portland, Maine, USA
Correspondence Rhonda L. Babine Center for Clinical and Professional Development Maine Medical Center 22 Bramhall Street Portland Maine 04102 USA E-mail: [email protected]
BABINE R.L., HONESS C., WIERMAN H.R. & HALLEN S.
(2016) Journal of Nursing Management 24, 39–49 The role of clinical nurse specialists in the implementation and sustainability of a practice change Aim This project’s purpose was to promote and sustain a practice change focusing on delirium utilising the clinical nurse specialist (CNS) in a leadership role. Background Delirium is an altered state of consciousness accompanied by an acute change in cognition that tends to have a fluctuating course. Delirium is strongly associated with negative outcomes and is often unrecognised. Method A policy was implemented stating that the RNs will screen patients for delirium with the confusion assessment method (CAM). Interdisciplinary delirium education was offered prior to the practice change and repeated at 3, 6 and 12 months after implementation. The documentation, completion and CAM accuracy screening were determined by the CNS. Results The CAM documentation and completion audit goal was met and sustained by week 21, and screenings were accurate 83% of the time. Conclusions The CNS has an opportunity to take a leadership role when instituting an innovative practice change. Successful implementation of a new practice requires that patient care units are divided into cohorts with systematic roll-out of the initiative. Implications for nursing management In addition to leadership, CNS availability on the patient care units is imperative to staff acceptance and sustainability of a practice change. Keywords: continuing, delirium, education, leadership, nursing, staff development
Accepted for publication: 9 August 2014
Introduction The clinical nurse specialist (CNS) is one of the four established advanced practice nursing roles in the United States. The term ‘advanced practice nurse’ has been used since the 1980s to delineate certified registered nurse anaesthetists, certified nurse-midwives, clinical nurse specialists and nurse practitioners DOI: 10.1111/jonm.12269 ª 2014 John Wiley & Sons Ltd
throughout most of the United States (Hamric et al. 2009). The CNS practises within a model that comprises three spheres of influence: patient care, nursing education and systems leadership. There are seven core competencies and behaviours that support the CNS practice: direct care, consultation, systems leadership, collaboration, coaching, research and ethical decision-making (National Association of Clinical 39
R. L. Babine et al.
Nurse Specialists 2006–2008, Mayo et al. 2010). Systems leadership can be described as the competency to manage change and empower others to influence clinical practice (National Association of Clinical Nurse Specialists 2006–2008). In 2010, Mayo et al. (2010) found that although the CNS can be associated with all of the seven core competencies, consultation, leadership, patient education, clinical practice and staff development are the primary activities of the successful performance in the role. The CNS’s broad perspective of an organisation and expert skills in systems management, nursing education and patient care is key to implementing a sustainable practice change in a health care system. The CNS can assess the organisation to determine how a practice change will improve a patient’s quality of care and safety. The CNS’s understanding of systems allows for the creative development and implementation of innovations. In addition, the CNS has an impact on the delivery of care by all providers by having robust knowledge of evidence-based practice and being able to work collaboratively within teams (McClelland et al. 2013). The purpose of this article is to describe the leadership role of the CNS in the implementation and sustainability in the adoption of a practice change related to delirium screening on three adult inpatient medical units in an acute care hospital.
Background As early as 1987, Lipowski described delirium as a transient organic mental syndrome of acute onset, characterised by global impairment of cognitive functions, a reduced level of consciousness, inattention, increased or decreased psychomotor activity and a disordered sleep–wake cycle (Lipowski 1987). Delirium is a very common, but unrecognised, problem in an adult inpatient population. Empirical studies show that delirium is strongly associated with negative outcomes, including: an increase in death and complications while in hospital, prolonged hospital stays and nursing home placement (Schuurmans et al. 2001, O’Mahoney et al. 2011). Delirium has also been linked to patient falls while in the hospital (Lakatos et al. 2009, Lee et al. 2013). In a retrospective chart review of 252 patients who fell while in the hospital, Lakatos et al. (2009) found that 96% of the patients had symptoms of delirium at the time of the fall, and 75% of the time the delirium was not diagnosed. It has been hypothesised that on general medicine wards, one-third of patients over 70 years old will experience delirium while in the hospital (Leslie et al. 40
2008). Of the patients undergoing elective non-cardiac surgery, 15% will develop delirium post-operatively (Marcantonio 2013). For patients who undergo high risk surgery (i.e. hip fracture, CABG, aortic aneurysm repair), the probability of developing delirium increases to 50% (Schuurmans et al. 2003, Marcantonio 2013, Chaudhry et al. 2013, Guenther et al. 2013). Of the patients with delirium, half develop delirium before admission and half develop delirium during the hospitalisation (Marcantonio 2013). It is possible to identify delirium in clinical settings and one of the most widely used screening tools is the Confusion Assessment Method (CAM). Developed by Dr Sharon Inouye in 1990, the CAM is sensitive, specific and reliable in detecting the symptoms of delirium (Inouye et al. 1990).
Conceptual framework Brooten & Youngblut (2006) have described a three component model, the ‘nurse dose’, as a way nurses achieve practice change and improve patient outcomes and decrease health care costs. The three essential components of this model include: dose (i.e. the number of nurses or the amount of care by nurses), nurse (i.e. education, expertise and experience) and host/host response (i.e. organisational or patient receptiveness) (Brooten & Youngblut 2006). When this model is applied to the role of the clinical nurse specialist in the implementation and sustainability of the described delirium screening intervention, the three components are: ‘dose’ referring to an amount of CNS resource availability, ‘nurse’ referring to continuous re-education to develop staff experience and expertise, and ‘desired host response’ referring to improved delirium screening, care of the delirious patient and the promotion of respectful team communication about delirium.
Methods Context The setting for the project was a large tertiary care hospital. Although the intervention was hospital wide, three adult inpatient units served as the population in which the effectiveness of the intervention was assessed. One of these medical units, the medical pulmonary unit, included a six bed assisted ventilation unit and a three bed intermediate care unit totaling 33 patient beds. The other two units were: a 26 bed medical gerontology unit and a 19 bed medical telemetry ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 39–49
The role of the CNS in a practice change
unit. Nursing and nursing assistant staffing is based on an average daily census, 12 hour shifts and patient acuity (Appendix S1). In our institution prior uncoordinated attempts at implementing delirium identification and management strategies had been unsuccessful, but did help to inform the current project. Previous attempts included: a physician led education targeting physicians, residents and staff on an Acute Care for Elders Unit, and a nurse practitioner led delirium education initiative on the surgical units. The Acute Care for Elders Unit is a geriatric specific model of care that aims to prevent institutionalisation of older patients that require hospitalisation (Kresevic et al. 1998). Although there was a temporary improvement in the awareness of delirium and its care on these units after education, this was not sustained and delirium screening was not integrated into routine care. Periodic review of medical records confirmed this by demonstrating a lack of documentation of delirium screening or diagnosis of delirium in patients with disorientation or changes in cognition. Another project on a different medical unit was successful in implementing delirium screening using the Confusion Assessment Method (CAM) (Inouye et al. 1990) for a short period of time (Babine et al. 2013). However, that project required daily contact and reminders to staff to complete the CAM, and when this ended, so did use of the tool. Based on these previous experiences, it became clear that in order to impact care and management in this area, there needed to be a sustainable institution-wide, interdisciplinary approach. Additionally, delirium screening needed to be incorporated into the usual care of the nurses and that they needed to be able to communicate their findings to providers who would understand the information and respond appropriately. The support for such a comprehensive project was eventually gathered when an interdisciplinary group within our institution replicated the Lakatos study (Lakatos et al. 2009) and found a similar relationship between falls and delirium. Since fall reduction was a priority within our institution at that time, it was the promise of reducing falls by identifying and treating delirium that ultimately granted the support from multiple disciplines required for the successful initiative described.
Practice change and interventions Prior to implementation of the practice change, interdisciplinary bi-weekly meetings were held to ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 39–49
determine the steps of the project and an implementation plan. Disciplines present at meetings included: nursing directors, staff nurses, physicians, nurse practitioners, clinical nurse specialists, staff development specialists, computer programming nurses and the director of nursing research. The steps of the implementation plan included: identification of barriers; development of an institutional policy supporting the proposed practice change which included nurses completing delirium screening on patients; development and presentation of interdisciplinary delirium education, including instruction on how to complete the delirium screening; initiation of the practice change and evaluation of the success of the practice change. Institutional Review Board (IRB) approval (exemption) was obtained prior to project implementation and evaluation. Policy An institutional policy was developed by a clinical nurse specialist in collaboration with physicians, staff development specialists, staff nurses and pharmacy representatives. The policy states that the confusion assessment method (CAM) is performed by the bedside nurse on all adult medical/surgical patients upon admission, transfer, daily and with any changes in cognition. The policy was introduced to staff nurses at the Nursing Practice Council (a self-governed group of nurses with representatives throughout the facility). This body deliberates on and approves policies affecting nursing practice. The policy was also approved by the Institutional Policy Committee. Nursing administrators were notified monthly via e-mail of new or updated policies. Compliance with the policy was audited by the CNS by documentation review in the electronic medical record. Delirium screening tool The CAM delirium screening tool (short version) assesses four clinical features of delirium: acute onset and fluctuating course of symptoms (feature one), inattention (feature two), disorganised thinking (feature three) and altered level of consciousness (feature four). A positive screening for delirium requires the presence of features one and two and either three or four. To determine if cognitive changes are acute, there needs to be evidence of a new change in mental status from baseline. The feature of fluctuation is described as an abnormal behaviour that tends to come and go. Inattention is present when a person has difficulty focusing or has difficulty keeping track of what is being said. Testing attention can be done by 41
The role of the CNS in a practice change
Table 1 Forms of education including goal/objective(s) and method of evaluation Form of education
Time
Title
Goal/Objective(s)
Live Class
4 weeks before ‘go-live’ (October 2011)
Your Role in Delirium Detection and Treatment: An Interdisciplinary Approach
(1) Define and understand delirium and its significance in patient care (2) Learn how to administer and interpret the Confusion Assessment Method (CAM) (3) Define your role on an interdisciplinary team in caring for patients with delirium (4) Learn how to communicate effectively about delirium using SBAR
Pre/post test (Tables 3 and 4)
Elearn: Presentation from Live Class with Audio Added
2 weeks before ‘go-live’ (October 2011)
Same as ‘Live Class’
3, 6 and 12 month post tests (Tables 3 and 4)
Express Inservice
2 weeks before ‘go-live’ (October 2011)
Your Role in Delirium Detection and Treatment: An Interdisciplinary Approach Your Role in Delirium Detection and Treatment: An Interdisciplinary Approach
(1) Define and identify risk factors associated with delirium (2) Learn how to administer and interpret the Confusion Assessment Method (CAM) (3) Learn how to communicate effectively about delirium using SBAR
3, 6 and 12 month post tests (Tables 3 and 4)
Brochure
3 months after ‘go-live’ (February 2012)
Detection, communication and documentation of delirium
6 and 12 month post tests (Tables 3 and 4)
Poster
6 months after ‘go-live’ (May 2012)
Your Role in Delirium Detection and Treatment: An Interdisciplinary Approach Your Role in Delirium Detection and Treatment: An Interdisciplinary Approach
(1) Define and identify risk factors associated with delirium (2) Learn how to administer and interpret the Confusion Assessment Method (CAM) (3) Learn how to communicate effectively about delirium using SBAR
12 month post tests (Tables 3 and 4)
Live Class
12 months after ‘go-live’ (November 2012)
Your Role in Delirium Detection and Treatment: An Interdisciplinary Approach
(1) Define and understand delirium and its significance in patient care (2) Learn how to administer and inter pret the Confusion Assessment Method (CAM) (3) Define your role on an interdisciplinary team in caring for patients with delirium (4) Learn how to communicate effectively about delirium using SBAR
Pre/post test (Tables 3 and 4)
monitoring and reporting outcomes of the education as evidenced by completion of the CAM in the electronic medical record led to sustainability of the change in practice. Over time as the practice change became established as usual care, the CNS was not required to be present as frequently, but remained as a resource available to staff on an as-needed basis. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 39–49
Evaluation method
Methods of evaluation Data collection The effectiveness of the initial interdisciplinary delirium live education class was assessed by pre- and post-testing on three inpatient medical units. Knowledge acquisition was measured with multiple choice questions about delirium, delirium screening with the 43
R. L. Babine et al.
Conclusions Clinical nurse specialist availability on the patient care units to offer support during implementation of changes is vital to staff acceptance of a new practice. Sustainability of any change in practice is promoted and supported by an active process of facilitation and follow-through. To ensure a permanent practice change, continued education is a crucial and often overlooked activity in the planning and implementation stages. By revisiting the content systematically with additional doses of education in different formats (e.g. e-learns, express in-service, during huddles), the staff are given the opportunity to ask further questions thereby increasing knowledge retention of material and re-enforcing learning. When instituting a practice change in a large tertiary care hospital, it is beneficial to divide patient care units into cohorts and systematically implement the initiative throughout the institution. Focusing on one cohort at a time ensures appropriate knowledge acquisition to the staff and sustainability of the practice change prior to implementation on the next group of patient care units. Education, across all disciplines at the same time promotes and supports role clarity within the interdisciplinary team, and in the evaluation and management of delirium.
Implications for nursing management This project has solidified the relationship between CNS and nursing leadership at the institution. With its emphasis on an interdisciplinary collaboration, an understanding of the complexity of the CNS role has evolved during this practice change. A partnership has also emerged and grown deeper where nursing units have started utilising the CNS for support and recommendations in the care of high risk patient populations. Interdisciplinary education, both in attendees and presenters has provided important support in teambuilding. Once the practice change was implemented, it also provided accountability to all staff by understanding each other’s roles and responsibilities.
Acknowledgements Although this manuscript highlights delirium education and the implementation of a practice change, our efforts could not have been successful without the contribution of the entire team. Authors of this paper would like to acknowledge: Peg Bradstreet, MS,
48
PMHCNS-BC, Sharon Foerster, LCSW, Valerie Fuller, DNP, ACNP, FNP, GNP, Kristiina Hyrkas, RN, MNSc, LicNSe, PhD, and Patricia Todorich, MS, PMHCNS-BC.
Source of funding No funding support was received in the preparation of this article.
Ethical approval Ethical approval was obtained from the Institutional Review Board at Maine Medical Center.
References Agency for Healthcare Research and Quality (2013) TeamStepps. Available at: http://teamstepps.ahrq.gov/about2cl_3.htm, accessed 4 June 2013. Babine R., Farrington S. & Wierman H. (2013) HELP prevent falls: applying HELP principles to reduce falls in an inpatient setting. Nursing 43 (5), 18–21. Benedict I., Robinson K. & Holder C. (2006) Clinical nurse specialist practice within the acute care of elders interdisciplinary team model. Clinical Nurse Specialist 20 (5), 248– 251. Brooten D.A. & Youngblut J. (2006) Nurse dose as a concept. Journal of Nursing Scholarship 38 (1), 94–99. Chaudhry H., Devereaux P. & Bhandari M. (2013) Cognitive dysfunction in hip fracture patients. Orthopedic Clinics of North America 44, 153–162. Guenther U., Theuerkauf N., Frommann I. et al. (2013) Predisposing and precipitating factors of delirium after cardiac surgery: a prospective observational cohort study. Annals of Surgery 257 (6), 1160–1167. Hamric A.B., Spross J.A. & Hanson C.M. (eds) (2009) Advanced Practice Nursing: An Integrative Approach, 4th edn. Sanders Elsevier, St Louis, MI. Hanley C. (2004) Delirium in the acute care setting. MedSurg Nursing 13 (4), 217–225. Inouye S.K., Van Dyck C.H., Alessi C.A., Balkin S., Siegal A.P. & Horwitz R.I. (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine 113 (12), 941–948. Inouye S.K., Bogardus S.T., Baker D.I., Leo-Summers L. & Cooney L.M. (2000) The hospital elder life program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Journal of American Geriatrics Society 48 (12), 1697–1706. Kresevic D.M., Counsell S.R., Covinsky K. et al. (1998) A patient centered model of acute care for elders. Geriatric Nursing 33 (3), 515–527. Lakatos B.E., Capasso V., Mitchell M.T., et al. (2009) Falls in the general hospital: association with delirium, advanced age, and specific surgical procedures. Psychosomatics 50 (3), 218– 226. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 39–49
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CAM and team responsibilities regarding delirium. The respondents’ comfort with delirium knowledge and team communication regarding delirium was measured by a Likert type scale (1, novice to 5, expert). The comfort questions on the post-test were retrospective and asked individuals how they felt prior to the session and how they felt after the session. Demographic information collected from each attendee included clinical role and the number of years in practice within that role. Respondents were identified and tracked using self-initiated codes that consisted of the first three letters of the name of the street where a respondent lives and the last three digit of their home phone number. These unique identifiers were used to protect respondent’s anonymity and to ascertain whether any of the attendees were captured in future samples. Since the ultimate purpose of the intervention was to improve team knowledge and communication regarding delirium, longitudinal evaluation was not performed at the individual level, but rather the team level (‘host/host response’ level). The intervention design included the provision of multiple different forms of education to supplement and complement the initial interdisciplinary classes with the intent of encouraging self-guided and peer–peer education. It was hypothesised that this multimodal approach would enable all staff to have a similar performance to those who experienced the initial interdisciplinary class. To evaluate if this was the case, post-tests identical to the one given at the end of the first education session were administered to a convenience sample of direct patient care staff at 3, 6 and 12 months. Average results for each team sample were compared with the team averages on the pre-test sample baseline. Demographic information including clinical role was collected for each sample. All samples had a similar distribution of roles when compared with the initial education attendee group (Table 2). Test results from each sample were collected, additional sessions of education were offered for general reinforcement of educational content.
Supplementary educational materials provided at these times consisted of the same education content only in different formats (Table 1). These included: at 3 months, a brochure; at 6 months, a poster located in the unit charting area; at 12 months, additional live presentations of original content. Figure 1 demonstrates the timeline of the project and the interventions, including the type and the format of the education implemented and the outcomes monitored. As a measure of team practice change, compliance with the nursing delirium policy as measured by the completion of the CAM in the medical record, was audited weekly by the CNS until a goal of 75% CAM completion on the three medical units was achieved. The goal of 75% was determined by the interdisciplinary group that developed the institutional policy as adherence to it. Once this goal was met for three consecutive weeks, the frequency of the audit was decreased to every other week and continued for one year after the implementation of the practice change. After 1 year, the documentation and completion of the CAM audit was changed to every month. All audit results were disseminated immediately to nursing units by the CNS for real time feedback. To validate that staff were performing the CAM correctly, 12 months into the project CAM accuracy audits were performed where a CAM was independently administered by an expert geriatrician concurrently with the bedside nurse. The results were recorded for later comparison by the CNS. Additionally, the CNS performed a medical record review which included a review of the written documentation by physicians and nurses that might indicate the presence of delirium. Data collected included: the presence of one or more of the following terms in the previous 24 hours: ‘delirium’, ‘CAM’, ‘acute onset’, ‘fluctuation’, ‘inattention’, ‘disorganised thinking’ or ‘altered level of consciousness’. Re-education regarding delirium and the use of the CAM was performed by the CNS if evidence of a discrepancy was identified by either expert evaluation or chart review.
Table 2 Distribution of clinical role by sample Clinical role Test (n) Pre-test (106) Post-test (115) 3 month (86) 6 month (70) 12 month (33)
44
% Nurses (n) 52 48 52 50 55
(55) (55) (44) (35) (18)
% Nursing assistants (n) 3 3 9 13 21
(3) (3) (9) (9) (7)
% Rehabilitation (n) 21 18 13 7 9
(22) (22) (11) (5) (3)
% Providers (n) 15 13 13 16 9
(16) (15) (11) (11) (3)
% Other (n) 9 18 13 14 6
(10) (20) (11) (10) (2)
ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 39–49
The role of the CNS in a practice change
Figure 1 Timeline of CNS interventions and measured outcomes are shown.
Data analysis and software Data analysis was performed utilising the Statistical Package for Social Sciences (SPSS, Chicago, IL, USA) 20.0 for Windows. Descriptive statistics including the Student’s t-test’s were performed comparing the average of the team/sample scores on pre-test to the average team score on the post-test, and the 3, 6 and 12 month sample tests. The CAM screening tool compliance and accuracy audits were documented in excel and trends were compared.
Results Demographic information One hundred and fifteen participants attended the education sessions prior to implementation of the practice change. Among the 115 attendees, there were: 55 staff nurses, 15 providers (physicians and physician assistants), three nursing assistants, 22 rehabilitation specialists (PT, OT, speech therapy) and 20 others, ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 39–49
including volunteers from the Hospital Elder Life Programme, nutrition specialists, social workers, companions, pharmacists, chaplains and care coordinators.
Knowledge acquisition Immediate pre- and post-tests were performed before and after the live delirium education classes. The 3, 6 and 12 month post-tests were given to a convenience sample of staff. The number of staff included in each sample was as follows: pre-test 106; post-test 115; 3 months 86; 6 months 70; and 12 months 33. See Table 2 for staff distribution in each sample. Team knowledge of the required CAM elements for delirium screening improved from 24% correct immediate pretest answers to 79% post-test answers (P < 0.001) with persistent improvement compared with the pretest baseline at 3, 6 and 12 months (Tables 3 and 4). Team respondent confidence administering the CAM increased from 2.68 pre-test to 3.82 post-test (P < 0.001) with persistent 3, 6 and 12 months improvement (Tables 3 and 4).
45
R. L. Babine et al.
Table 3 Knowledge of CAM elements
Determining CAM accuracy
Knowledge of required CAM elements* Test (n)
% correct (n)
Pre-test (106) Post-test (115) 3 month (86) 6 month (70) 12 month (33)
24 79 58 51 58
(25) (90) (50) (36) (19)
P value
The role of clinical nurse specialists in the implementation and sustainability of a practice change RHONDA L. BABINE and SARAH HALLEN
MS, APRN, ACNS-BC 3
1
, CINDY HONESS
MSN, APRN, ACNS-BC
1
, HEIDI R. WIERMAN
MD
2
MD
1
Clinical Nurse Specialist, Center for Clinical and Professional Development, Maine Medical Center, Portland, Maine, 2Director, Division of Geriatrics, Maine Medical Center, Portland, Maine and 3Maine Medical Partners, Geriatrics, Maine Medical Center, Portland, Maine, USA
Correspondence Rhonda L. Babine Center for Clinical and Professional Development Maine Medical Center 22 Bramhall Street Portland Maine 04102 USA E-mail: [email protected]
BABINE R.L., HONESS C., WIERMAN H.R. & HALLEN S.
(2016) Journal of Nursing Management 24, 39–49 The role of clinical nurse specialists in the implementation and sustainability of a practice change Aim This project’s purpose was to promote and sustain a practice change focusing on delirium utilising the clinical nurse specialist (CNS) in a leadership role. Background Delirium is an altered state of consciousness accompanied by an acute change in cognition that tends to have a fluctuating course. Delirium is strongly associated with negative outcomes and is often unrecognised. Method A policy was implemented stating that the RNs will screen patients for delirium with the confusion assessment method (CAM). Interdisciplinary delirium education was offered prior to the practice change and repeated at 3, 6 and 12 months after implementation. The documentation, completion and CAM accuracy screening were determined by the CNS. Results The CAM documentation and completion audit goal was met and sustained by week 21, and screenings were accurate 83% of the time. Conclusions The CNS has an opportunity to take a leadership role when instituting an innovative practice change. Successful implementation of a new practice requires that patient care units are divided into cohorts with systematic roll-out of the initiative. Implications for nursing management In addition to leadership, CNS availability on the patient care units is imperative to staff acceptance and sustainability of a practice change. Keywords: continuing, delirium, education, leadership, nursing, staff development
Accepted for publication: 9 August 2014
Introduction The clinical nurse specialist (CNS) is one of the four established advanced practice nursing roles in the United States. The term ‘advanced practice nurse’ has been used since the 1980s to delineate certified registered nurse anaesthetists, certified nurse-midwives, clinical nurse specialists and nurse practitioners DOI: 10.1111/jonm.12269 ª 2014 John Wiley & Sons Ltd
throughout most of the United States (Hamric et al. 2009). The CNS practises within a model that comprises three spheres of influence: patient care, nursing education and systems leadership. There are seven core competencies and behaviours that support the CNS practice: direct care, consultation, systems leadership, collaboration, coaching, research and ethical decision-making (National Association of Clinical 39
R. L. Babine et al.
Nurse Specialists 2006–2008, Mayo et al. 2010). Systems leadership can be described as the competency to manage change and empower others to influence clinical practice (National Association of Clinical Nurse Specialists 2006–2008). In 2010, Mayo et al. (2010) found that although the CNS can be associated with all of the seven core competencies, consultation, leadership, patient education, clinical practice and staff development are the primary activities of the successful performance in the role. The CNS’s broad perspective of an organisation and expert skills in systems management, nursing education and patient care is key to implementing a sustainable practice change in a health care system. The CNS can assess the organisation to determine how a practice change will improve a patient’s quality of care and safety. The CNS’s understanding of systems allows for the creative development and implementation of innovations. In addition, the CNS has an impact on the delivery of care by all providers by having robust knowledge of evidence-based practice and being able to work collaboratively within teams (McClelland et al. 2013). The purpose of this article is to describe the leadership role of the CNS in the implementation and sustainability in the adoption of a practice change related to delirium screening on three adult inpatient medical units in an acute care hospital.
Background As early as 1987, Lipowski described delirium as a transient organic mental syndrome of acute onset, characterised by global impairment of cognitive functions, a reduced level of consciousness, inattention, increased or decreased psychomotor activity and a disordered sleep–wake cycle (Lipowski 1987). Delirium is a very common, but unrecognised, problem in an adult inpatient population. Empirical studies show that delirium is strongly associated with negative outcomes, including: an increase in death and complications while in hospital, prolonged hospital stays and nursing home placement (Schuurmans et al. 2001, O’Mahoney et al. 2011). Delirium has also been linked to patient falls while in the hospital (Lakatos et al. 2009, Lee et al. 2013). In a retrospective chart review of 252 patients who fell while in the hospital, Lakatos et al. (2009) found that 96% of the patients had symptoms of delirium at the time of the fall, and 75% of the time the delirium was not diagnosed. It has been hypothesised that on general medicine wards, one-third of patients over 70 years old will experience delirium while in the hospital (Leslie et al. 40
2008). Of the patients undergoing elective non-cardiac surgery, 15% will develop delirium post-operatively (Marcantonio 2013). For patients who undergo high risk surgery (i.e. hip fracture, CABG, aortic aneurysm repair), the probability of developing delirium increases to 50% (Schuurmans et al. 2003, Marcantonio 2013, Chaudhry et al. 2013, Guenther et al. 2013). Of the patients with delirium, half develop delirium before admission and half develop delirium during the hospitalisation (Marcantonio 2013). It is possible to identify delirium in clinical settings and one of the most widely used screening tools is the Confusion Assessment Method (CAM). Developed by Dr Sharon Inouye in 1990, the CAM is sensitive, specific and reliable in detecting the symptoms of delirium (Inouye et al. 1990).
Conceptual framework Brooten & Youngblut (2006) have described a three component model, the ‘nurse dose’, as a way nurses achieve practice change and improve patient outcomes and decrease health care costs. The three essential components of this model include: dose (i.e. the number of nurses or the amount of care by nurses), nurse (i.e. education, expertise and experience) and host/host response (i.e. organisational or patient receptiveness) (Brooten & Youngblut 2006). When this model is applied to the role of the clinical nurse specialist in the implementation and sustainability of the described delirium screening intervention, the three components are: ‘dose’ referring to an amount of CNS resource availability, ‘nurse’ referring to continuous re-education to develop staff experience and expertise, and ‘desired host response’ referring to improved delirium screening, care of the delirious patient and the promotion of respectful team communication about delirium.
Methods Context The setting for the project was a large tertiary care hospital. Although the intervention was hospital wide, three adult inpatient units served as the population in which the effectiveness of the intervention was assessed. One of these medical units, the medical pulmonary unit, included a six bed assisted ventilation unit and a three bed intermediate care unit totaling 33 patient beds. The other two units were: a 26 bed medical gerontology unit and a 19 bed medical telemetry ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 39–49
The role of the CNS in a practice change
unit. Nursing and nursing assistant staffing is based on an average daily census, 12 hour shifts and patient acuity (Appendix S1). In our institution prior uncoordinated attempts at implementing delirium identification and management strategies had been unsuccessful, but did help to inform the current project. Previous attempts included: a physician led education targeting physicians, residents and staff on an Acute Care for Elders Unit, and a nurse practitioner led delirium education initiative on the surgical units. The Acute Care for Elders Unit is a geriatric specific model of care that aims to prevent institutionalisation of older patients that require hospitalisation (Kresevic et al. 1998). Although there was a temporary improvement in the awareness of delirium and its care on these units after education, this was not sustained and delirium screening was not integrated into routine care. Periodic review of medical records confirmed this by demonstrating a lack of documentation of delirium screening or diagnosis of delirium in patients with disorientation or changes in cognition. Another project on a different medical unit was successful in implementing delirium screening using the Confusion Assessment Method (CAM) (Inouye et al. 1990) for a short period of time (Babine et al. 2013). However, that project required daily contact and reminders to staff to complete the CAM, and when this ended, so did use of the tool. Based on these previous experiences, it became clear that in order to impact care and management in this area, there needed to be a sustainable institution-wide, interdisciplinary approach. Additionally, delirium screening needed to be incorporated into the usual care of the nurses and that they needed to be able to communicate their findings to providers who would understand the information and respond appropriately. The support for such a comprehensive project was eventually gathered when an interdisciplinary group within our institution replicated the Lakatos study (Lakatos et al. 2009) and found a similar relationship between falls and delirium. Since fall reduction was a priority within our institution at that time, it was the promise of reducing falls by identifying and treating delirium that ultimately granted the support from multiple disciplines required for the successful initiative described.
Practice change and interventions Prior to implementation of the practice change, interdisciplinary bi-weekly meetings were held to ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 39–49
determine the steps of the project and an implementation plan. Disciplines present at meetings included: nursing directors, staff nurses, physicians, nurse practitioners, clinical nurse specialists, staff development specialists, computer programming nurses and the director of nursing research. The steps of the implementation plan included: identification of barriers; development of an institutional policy supporting the proposed practice change which included nurses completing delirium screening on patients; development and presentation of interdisciplinary delirium education, including instruction on how to complete the delirium screening; initiation of the practice change and evaluation of the success of the practice change. Institutional Review Board (IRB) approval (exemption) was obtained prior to project implementation and evaluation. Policy An institutional policy was developed by a clinical nurse specialist in collaboration with physicians, staff development specialists, staff nurses and pharmacy representatives. The policy states that the confusion assessment method (CAM) is performed by the bedside nurse on all adult medical/surgical patients upon admission, transfer, daily and with any changes in cognition. The policy was introduced to staff nurses at the Nursing Practice Council (a self-governed group of nurses with representatives throughout the facility). This body deliberates on and approves policies affecting nursing practice. The policy was also approved by the Institutional Policy Committee. Nursing administrators were notified monthly via e-mail of new or updated policies. Compliance with the policy was audited by the CNS by documentation review in the electronic medical record. Delirium screening tool The CAM delirium screening tool (short version) assesses four clinical features of delirium: acute onset and fluctuating course of symptoms (feature one), inattention (feature two), disorganised thinking (feature three) and altered level of consciousness (feature four). A positive screening for delirium requires the presence of features one and two and either three or four. To determine if cognitive changes are acute, there needs to be evidence of a new change in mental status from baseline. The feature of fluctuation is described as an abnormal behaviour that tends to come and go. Inattention is present when a person has difficulty focusing or has difficulty keeping track of what is being said. Testing attention can be done by 41
The role of the CNS in a practice change
Table 1 Forms of education including goal/objective(s) and method of evaluation Form of education
Time
Title
Goal/Objective(s)
Live Class
4 weeks before ‘go-live’ (October 2011)
Your Role in Delirium Detection and Treatment: An Interdisciplinary Approach
(1) Define and understand delirium and its significance in patient care (2) Learn how to administer and interpret the Confusion Assessment Method (CAM) (3) Define your role on an interdisciplinary team in caring for patients with delirium (4) Learn how to communicate effectively about delirium using SBAR
Pre/post test (Tables 3 and 4)
Elearn: Presentation from Live Class with Audio Added
2 weeks before ‘go-live’ (October 2011)
Same as ‘Live Class’
3, 6 and 12 month post tests (Tables 3 and 4)
Express Inservice
2 weeks before ‘go-live’ (October 2011)
Your Role in Delirium Detection and Treatment: An Interdisciplinary Approach Your Role in Delirium Detection and Treatment: An Interdisciplinary Approach
(1) Define and identify risk factors associated with delirium (2) Learn how to administer and interpret the Confusion Assessment Method (CAM) (3) Learn how to communicate effectively about delirium using SBAR
3, 6 and 12 month post tests (Tables 3 and 4)
Brochure
3 months after ‘go-live’ (February 2012)
Detection, communication and documentation of delirium
6 and 12 month post tests (Tables 3 and 4)
Poster
6 months after ‘go-live’ (May 2012)
Your Role in Delirium Detection and Treatment: An Interdisciplinary Approach Your Role in Delirium Detection and Treatment: An Interdisciplinary Approach
(1) Define and identify risk factors associated with delirium (2) Learn how to administer and interpret the Confusion Assessment Method (CAM) (3) Learn how to communicate effectively about delirium using SBAR
12 month post tests (Tables 3 and 4)
Live Class
12 months after ‘go-live’ (November 2012)
Your Role in Delirium Detection and Treatment: An Interdisciplinary Approach
(1) Define and understand delirium and its significance in patient care (2) Learn how to administer and inter pret the Confusion Assessment Method (CAM) (3) Define your role on an interdisciplinary team in caring for patients with delirium (4) Learn how to communicate effectively about delirium using SBAR
Pre/post test (Tables 3 and 4)
monitoring and reporting outcomes of the education as evidenced by completion of the CAM in the electronic medical record led to sustainability of the change in practice. Over time as the practice change became established as usual care, the CNS was not required to be present as frequently, but remained as a resource available to staff on an as-needed basis. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 39–49
Evaluation method
Methods of evaluation Data collection The effectiveness of the initial interdisciplinary delirium live education class was assessed by pre- and post-testing on three inpatient medical units. Knowledge acquisition was measured with multiple choice questions about delirium, delirium screening with the 43
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Conclusions Clinical nurse specialist availability on the patient care units to offer support during implementation of changes is vital to staff acceptance of a new practice. Sustainability of any change in practice is promoted and supported by an active process of facilitation and follow-through. To ensure a permanent practice change, continued education is a crucial and often overlooked activity in the planning and implementation stages. By revisiting the content systematically with additional doses of education in different formats (e.g. e-learns, express in-service, during huddles), the staff are given the opportunity to ask further questions thereby increasing knowledge retention of material and re-enforcing learning. When instituting a practice change in a large tertiary care hospital, it is beneficial to divide patient care units into cohorts and systematically implement the initiative throughout the institution. Focusing on one cohort at a time ensures appropriate knowledge acquisition to the staff and sustainability of the practice change prior to implementation on the next group of patient care units. Education, across all disciplines at the same time promotes and supports role clarity within the interdisciplinary team, and in the evaluation and management of delirium.
Implications for nursing management This project has solidified the relationship between CNS and nursing leadership at the institution. With its emphasis on an interdisciplinary collaboration, an understanding of the complexity of the CNS role has evolved during this practice change. A partnership has also emerged and grown deeper where nursing units have started utilising the CNS for support and recommendations in the care of high risk patient populations. Interdisciplinary education, both in attendees and presenters has provided important support in teambuilding. Once the practice change was implemented, it also provided accountability to all staff by understanding each other’s roles and responsibilities.
Acknowledgements Although this manuscript highlights delirium education and the implementation of a practice change, our efforts could not have been successful without the contribution of the entire team. Authors of this paper would like to acknowledge: Peg Bradstreet, MS,
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PMHCNS-BC, Sharon Foerster, LCSW, Valerie Fuller, DNP, ACNP, FNP, GNP, Kristiina Hyrkas, RN, MNSc, LicNSe, PhD, and Patricia Todorich, MS, PMHCNS-BC.
Source of funding No funding support was received in the preparation of this article.
Ethical approval Ethical approval was obtained from the Institutional Review Board at Maine Medical Center.
References Agency for Healthcare Research and Quality (2013) TeamStepps. Available at: http://teamstepps.ahrq.gov/about2cl_3.htm, accessed 4 June 2013. Babine R., Farrington S. & Wierman H. (2013) HELP prevent falls: applying HELP principles to reduce falls in an inpatient setting. Nursing 43 (5), 18–21. Benedict I., Robinson K. & Holder C. (2006) Clinical nurse specialist practice within the acute care of elders interdisciplinary team model. Clinical Nurse Specialist 20 (5), 248– 251. Brooten D.A. & Youngblut J. (2006) Nurse dose as a concept. Journal of Nursing Scholarship 38 (1), 94–99. Chaudhry H., Devereaux P. & Bhandari M. (2013) Cognitive dysfunction in hip fracture patients. Orthopedic Clinics of North America 44, 153–162. Guenther U., Theuerkauf N., Frommann I. et al. (2013) Predisposing and precipitating factors of delirium after cardiac surgery: a prospective observational cohort study. Annals of Surgery 257 (6), 1160–1167. Hamric A.B., Spross J.A. & Hanson C.M. (eds) (2009) Advanced Practice Nursing: An Integrative Approach, 4th edn. Sanders Elsevier, St Louis, MI. Hanley C. (2004) Delirium in the acute care setting. MedSurg Nursing 13 (4), 217–225. Inouye S.K., Van Dyck C.H., Alessi C.A., Balkin S., Siegal A.P. & Horwitz R.I. (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine 113 (12), 941–948. Inouye S.K., Bogardus S.T., Baker D.I., Leo-Summers L. & Cooney L.M. (2000) The hospital elder life program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Journal of American Geriatrics Society 48 (12), 1697–1706. Kresevic D.M., Counsell S.R., Covinsky K. et al. (1998) A patient centered model of acute care for elders. Geriatric Nursing 33 (3), 515–527. Lakatos B.E., Capasso V., Mitchell M.T., et al. (2009) Falls in the general hospital: association with delirium, advanced age, and specific surgical procedures. Psychosomatics 50 (3), 218– 226. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 39–49
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CAM and team responsibilities regarding delirium. The respondents’ comfort with delirium knowledge and team communication regarding delirium was measured by a Likert type scale (1, novice to 5, expert). The comfort questions on the post-test were retrospective and asked individuals how they felt prior to the session and how they felt after the session. Demographic information collected from each attendee included clinical role and the number of years in practice within that role. Respondents were identified and tracked using self-initiated codes that consisted of the first three letters of the name of the street where a respondent lives and the last three digit of their home phone number. These unique identifiers were used to protect respondent’s anonymity and to ascertain whether any of the attendees were captured in future samples. Since the ultimate purpose of the intervention was to improve team knowledge and communication regarding delirium, longitudinal evaluation was not performed at the individual level, but rather the team level (‘host/host response’ level). The intervention design included the provision of multiple different forms of education to supplement and complement the initial interdisciplinary classes with the intent of encouraging self-guided and peer–peer education. It was hypothesised that this multimodal approach would enable all staff to have a similar performance to those who experienced the initial interdisciplinary class. To evaluate if this was the case, post-tests identical to the one given at the end of the first education session were administered to a convenience sample of direct patient care staff at 3, 6 and 12 months. Average results for each team sample were compared with the team averages on the pre-test sample baseline. Demographic information including clinical role was collected for each sample. All samples had a similar distribution of roles when compared with the initial education attendee group (Table 2). Test results from each sample were collected, additional sessions of education were offered for general reinforcement of educational content.
Supplementary educational materials provided at these times consisted of the same education content only in different formats (Table 1). These included: at 3 months, a brochure; at 6 months, a poster located in the unit charting area; at 12 months, additional live presentations of original content. Figure 1 demonstrates the timeline of the project and the interventions, including the type and the format of the education implemented and the outcomes monitored. As a measure of team practice change, compliance with the nursing delirium policy as measured by the completion of the CAM in the medical record, was audited weekly by the CNS until a goal of 75% CAM completion on the three medical units was achieved. The goal of 75% was determined by the interdisciplinary group that developed the institutional policy as adherence to it. Once this goal was met for three consecutive weeks, the frequency of the audit was decreased to every other week and continued for one year after the implementation of the practice change. After 1 year, the documentation and completion of the CAM audit was changed to every month. All audit results were disseminated immediately to nursing units by the CNS for real time feedback. To validate that staff were performing the CAM correctly, 12 months into the project CAM accuracy audits were performed where a CAM was independently administered by an expert geriatrician concurrently with the bedside nurse. The results were recorded for later comparison by the CNS. Additionally, the CNS performed a medical record review which included a review of the written documentation by physicians and nurses that might indicate the presence of delirium. Data collected included: the presence of one or more of the following terms in the previous 24 hours: ‘delirium’, ‘CAM’, ‘acute onset’, ‘fluctuation’, ‘inattention’, ‘disorganised thinking’ or ‘altered level of consciousness’. Re-education regarding delirium and the use of the CAM was performed by the CNS if evidence of a discrepancy was identified by either expert evaluation or chart review.
Table 2 Distribution of clinical role by sample Clinical role Test (n) Pre-test (106) Post-test (115) 3 month (86) 6 month (70) 12 month (33)
44
% Nurses (n) 52 48 52 50 55
(55) (55) (44) (35) (18)
% Nursing assistants (n) 3 3 9 13 21
(3) (3) (9) (9) (7)
% Rehabilitation (n) 21 18 13 7 9
(22) (22) (11) (5) (3)
% Providers (n) 15 13 13 16 9
(16) (15) (11) (11) (3)
% Other (n) 9 18 13 14 6
(10) (20) (11) (10) (2)
ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 39–49
The role of the CNS in a practice change
Figure 1 Timeline of CNS interventions and measured outcomes are shown.
Data analysis and software Data analysis was performed utilising the Statistical Package for Social Sciences (SPSS, Chicago, IL, USA) 20.0 for Windows. Descriptive statistics including the Student’s t-test’s were performed comparing the average of the team/sample scores on pre-test to the average team score on the post-test, and the 3, 6 and 12 month sample tests. The CAM screening tool compliance and accuracy audits were documented in excel and trends were compared.
Results Demographic information One hundred and fifteen participants attended the education sessions prior to implementation of the practice change. Among the 115 attendees, there were: 55 staff nurses, 15 providers (physicians and physician assistants), three nursing assistants, 22 rehabilitation specialists (PT, OT, speech therapy) and 20 others, ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 39–49
including volunteers from the Hospital Elder Life Programme, nutrition specialists, social workers, companions, pharmacists, chaplains and care coordinators.
Knowledge acquisition Immediate pre- and post-tests were performed before and after the live delirium education classes. The 3, 6 and 12 month post-tests were given to a convenience sample of staff. The number of staff included in each sample was as follows: pre-test 106; post-test 115; 3 months 86; 6 months 70; and 12 months 33. See Table 2 for staff distribution in each sample. Team knowledge of the required CAM elements for delirium screening improved from 24% correct immediate pretest answers to 79% post-test answers (P < 0.001) with persistent improvement compared with the pretest baseline at 3, 6 and 12 months (Tables 3 and 4). Team respondent confidence administering the CAM increased from 2.68 pre-test to 3.82 post-test (P < 0.001) with persistent 3, 6 and 12 months improvement (Tables 3 and 4).
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Table 3 Knowledge of CAM elements
Determining CAM accuracy
Knowledge of required CAM elements* Test (n)
% correct (n)
Pre-test (106) Post-test (115) 3 month (86) 6 month (70) 12 month (33)
24 79 58 51 58
(25) (90) (50) (36) (19)
P value
