Implementation Project for the Role of the Clinical Nurse Leader in Palliative Care - Coursework Example

? Implementation Project for the Role of the Clinical Nurse Leader in Palliative Care Executive Summary The evolution of the new nursing position ‘Clinical Nurse Leader’ with leadership as a basis over the period of time is actually grounded on education and experience. The White Paper on The Role of the Clinical Nurse Leader of the American Association of Colleges of Nursing (2007) states “The American Association of Colleges of Nursing (AACN), representing baccalaureate and graduate schools of nursing, in collaboration with other health care organizations and disciplines, proposes a new Clinical Nurse Leader (CNL) role to address the ardent call for change being heard in today’s health care system”. In the history of mankind, medical treatment for diseases has undergone radical changes during the recent years and now it encompasses the issues associated with technological advancements, socioeconomic dimensions, palliative care for the terminally ill, management of chronic illness and promotion of health and prevention of diseases. Palliative care is an area in the profession where the nursing professionals play an important role compared to the other medical professionals, and it calls for involvement and dedication on the part of the nurses. The role of the nurses is not limited to providing medical care but extends to psychosocial care taking into consideration the entire gamut of the issues involved in the well being of the patients. The amelioration of the hardships faced by the patients which is predominantly the focal issue of the profession is very complex as it is also related to the psychological conditions, the level knowledge, the social background and the economic conditions of the patients. It is also important to note that the understanding and support of the family members and friends plays a crucial role in the care given to the patients. Apart from streamlining the day-to-day operations, the most important role of the clinical nurse leader lies in instilling confidence in the minds of the patients in managing their own affairs with less and less dependence on the institutions and the family members or friends through empowering them. This will resolve uncertainties in the relationship, improves the quality of care and satisfaction of the patients. This will also in the long run translate into reduction in length of stay in the hospitals, less dependence on human resources of the hospital, understanding of the practical implications of the treatment for readjusting their mind-set in facing the problems with clarity. This will make the patients to approach the service providers as and when the need arises rather than putting continuous pressure on them. This paper seeks to study the role of the Clinical Nurse Leader in relation to the staff nurses and the nurse extenders in increasing the direct care activities and efficiency in time management with the aim of improvement in patient outcomes in a hospital setup with Palliative Care Division having four wards; one for children, two general wards and one for ICU staffed with medical professionals, nurses and social workers. Mostly, the patients admitted are terminally ill who need palliative and psychosocial care. The diagnoses vary from cancers of various sorts to chronic pancreatitis. The services in respect of chemotherapy, radiotherapy and physiotherapy are provided by the specialists drawn from the other division(s) attached to the hospital based on the requisitions from Palliative Care, apart from the medical professionals attached to the palliative care. The critical areas of study relate to staffing plan, recruitment plan, training, and performance evaluation. It is an accepted principle that delegation of authority is possible, but not delegation of responsibilities. The position of Clinical Nurse Leader calls for greater responsibilities which include the responsibility for the performance of the whole team. Therefore, specific patient or staff outcomes need to be measurable for effective control and management. Though it is difficult to establish the yardsticks precisely for the purpose of measurement in the case of palliative care, nevertheless the performance should be amenable to measurement in a scientific manager based on the data accumulated over the period of time. It is pertinent to note here that the administrative functions of the Clinical Nurse Leader outweigh the professional responsibilities of the nurses in general. However, it is also important to note that the professional competence of the clinical nurse leader forms the foundation stone for the successful implementation. The accumulated wisdom, experience in dealing with critical cases, knowledge, tact and diplomacy of the clinical nurse leader command respect and support from the team. The honesty, trustworthiness and willingness on the part of the leader to share the problems and burdens of the team enhance the level of performance in the long run. The cohesiveness and flexibility within the group leads to better coordination and cooperation with the other medical professionals as well as the social workers. In fact it is rightly felt by the nursing community that the position of the clinical nurse leader actually fills up the lacunae in the nursing hierarchy for better administration and control. The issues relating to the nursing community could be articulated in a better way, if there is a position within the hospital with proper authority and responsibility to deal with such issues. . Introduction and background The Clinical Nurse Leader heads the Palliative care division of the hospital which consists of two general wards, one children ward and an Intensive Care Unit. The hospital is located in the area where the people are mostly middle class. Palliative care is defined by The National Institute for Clinical Excellence (2011) as “Palliative care is the active holistic care of patients with advanced progressive illness. Management of pain and other symptoms and provision of psychological, social and spiritual support is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with other treatments”. The Implementation Project for the Role of the Clinical Nurse Leader in Palliative Care is a major leap forward in providing supportive care in addition to treatment. The role of nurses in palliative care is very important considering nature of the treatment and the lacunae in the hierarchy of the traditional set up is filled up by the Clinical Nurse Leaders. This is a senior position carries authority with greater responsibilities at par with the senior medical professionals in the hospital. Palliative care There are so many complexities involved in palliative care for the patients and they are not restricted only to medical treatment. Nursing and psychosocial care plays an important role in the treatment of the patients. Pain associated with the diseases, emotional distress and shock to the patients and their families, frustration due to life style changes caused by stay in the hospital and the physical strain need to be managed efficiently with minimum friction. Intolerant attitude towards care services, absence of family support and financial problems of the patients aggravate the position further. A comprehensive pain assessment and pain management is implemented along with psychosocial care. The anxiety and the emotional strain caused by acute pain due to the diseases need effective care and counseling. Apart from the administrative functions, the CNL provides guidance, advice and training to the nurses and gives counseling to the nurses in clinical and psychological care. The CNL needs to be aware of the latest developments in the field for giving proper training to the nurses. For instance, orientation and distress screening (ODS) model is used for newly diagnosed cancer patients at St. Vincent’s Hospital. The model identifies the unmet needs of the patients for the purpose of Orientation. Psychosocial screening is performed for distress and to identify problems. A psychosocial profile of each patient is collated and disseminated. (Lethborg, C. & Brown, R., 2009) Updating knowledge by continuous learning is very important for the CNL to guide and train the nurses in the performance of their duties and in improving their efficiency. Evidence-based practice focuses on methods of critically appraising and applying available data and research to understand and take informed clinical decision-making better. It is not only related to nursing, but include systems, models, methods and research. Implementation Role of the Clinical Nurse Leader The CNL needs to develop positive attitude and confidence among the nurses in counseling to the patients and their families, and should be in a position to come to their rescue when needed. Empowering the patients to confidently handle their affairs is important in palliative care. When the patient is confident about dealing with the situations himself the following advantages accrue. 1. The pain associated with the anxieties gets reduced. 2. The patients’ level of dependence on family members and nurses comes down. 3. This reduces the duration of stay in the hospital. This could be achieved by imparting knowledge of the disease and their conditions to the patients for coping up with the diseases. The patients need training to carry on the routine chores on their own with confidence. This will make them move to their houses to lead normal life. If the readmission process is made simpler, the patients would prefer to take medication from their houses and get them readmitted if it is necessary. Communication Communication within the hospital setup is multidimensional which includes formal and informal. With the creation of a position CNL, the efficiency in the communication process is improved vastly. Since the administrative aspects, systems and reporting is formalized in the process, overlapping is avoided. The data related to palliative care is accumulated, sorted, analyzed for firming up the strategies in the long run. Improvements in communication facilitate sharing of information. Understanding the perceptions and problems of the patients forms the basis for reorienting the procedures or methods for improvement in quality of care. The knowledge and experience gained in this process would be useful in modifying the strategies which is a continuous process in the improvement of quality. Personnel policy Review of remuneration in the field in line with the hardships associated with the job in the case of nurses is essential as it will enhance the level of devotion and sincerity. In the case of CNL, it is a managerial position which needs knowledge in various facets of the profession, experience and leadership qualities. Therefore, the position in the hierarchy, salaries and perquisites need to be commensurate with the authority and responsibilities. “The nursing home field is plagued with labor shortages, along with difficulties in worker retention, supervision and training opportunities. Common causes of high staff turnover include the difficulty of the work, relatively meager pay and benefits, a lack of respect for staff roles, frustration with the quality of care, and demanding paperwork and regulatory requirements. The professional stress in this area for the professionals is very high”. (Center to Advanced Palliative Care, p.3.7) Therefore, changes in the structure with the induction of CNL would yield good results if it is accompanied with review of remuneration for the nurses as well. Also, the position of CNL encourages youngsters to aspire for the post through sincerity and efficiency. Revision of the role of the staff nurse to increase direct patient care activities The role of staff nurse under the CNL undergoes significant changes. The CLN is in a position to implement standards and organize seminars and meetings on pain management for continuous learning by the staff. The reporting, data management, interaction with the specialists and social workers are to the maximum level handled by the CNL, and the staff nurses are relieved from such responsibilities. The nurses can concentrate more on improving the quality of service, counseling to the patients and their family members and patient outcome measures. Standards: In the pain measurement process, assessment of pain takes into account intensity of the pain, duration, location and other contextual and situational factors. The CCHSA included pain assessment and management in its 2005 Standards. “Specific actions are suggested to meet the standard as it relates to assessment, management, monitoring, documentation and organizational responsibility. The criterion is evidence-based and includes the organization’s accountability to train and update health care professionals, patients and families on pain management options and strategies.” (Nova Scotia Chronic Pain Working Group, 2006). . Chronic pain management in education: Training in pain management involves participation of the professionals from various disciplines which include medicine, pharmacy, radiotherapy, surgery and nursing. “Pain education for health professionals at all levels has been repeatedly identified as an important step to changing ineffective pain management practices.” (Nova Scotia Chronic Pain Working Group, 2006). The CLN is in a position to organize training on a continuous basis for updating the knowledge of the nurses for quality care. Revision of the role of the nurse extender The productivity is not consistent in the case of nurse extenders. However, for the purpose of control of cost and quality of care, the hospitals need to pay attention to the role of nurse extenders. The Implementation Project for the Role of the CLN envisages learning and training for improvement in their productivity. They will free the nurses from the administrative or non-nursing roles which will improve their efficiency and quality of care. Decrease in wastage of time Time management is very important in the hospital set up. For instance, the patients in the general ward are mostly aged and terminally ill. The poor eye sight associated with the age, impairment of hearing, weakness in the body and disorientation due to pain, lack of sleep or other psychological factors make the patients prone to accidents resulting into injuries. Periodical checkup with regard to other health problems other than palliative care is essential to reduce the vulnerabilities. Movement of trolleys, equipments or visits to bath rooms needs to be carefully monitored and organized. When the patients are educated in simple activities, lot of time of the nurses will be saved. Roadblocks The nurses spend more time with the patients in their day-to-day activities, closely monitoring for meeting the various needs of the patients and paying attention to their psychological needs as well. There are many impediments in the process of achieving excellence in care giving. Center to Advanced Palliative Care (2008, P.3.7) states that “Inadequate staffing levels, the absence of continuous education, and inconsistency are widely acknowledged problems in nursing homes.” Nursing curriculum does not adequately cover the End of life care, though the recent developments in the field suggest relook by institutions and the hospitals in this regard. According to Brookshaw et al. (2009) poor understanding of prognosis, family anger and disagreements about treatment and poor communication between doctors and nurses about prognosis and care are the important barriers to the provision of palliative care services from the point of view of nurses. It is further cited that according to Gott, Ahmedzai & Wood:”Doctors and nurses disagree markedly on the palliative care needs of patients”. But, these agreements are getting sorted out amicably. Inadequacy of data related to pain, inaccurate interpretation of the data and assessment measures and inadequacy in documentation are the major barriers in the assessment of pain. Scotia Chronic Pain Working Group (2006, p.29) states, “One way to overcome these barriers in assessment is to build an “institutional commitment” to pain. “Institutionalizing” pain management practices can be achieved by incorporating basic principles of pain assessment and treatment into patterns of practice including documentation systems, policies and procedures, standards of practice, and orientation, continuing education and quality improvement programs.” The CLN has a greater role to play in this regard. Another important barrier is the attitude of the patients who refuse to accept their vulnerable conditions due to lack of understanding and misperceptions. The issues such as cultural and religious beliefs or the social stigma attached to the diseases make it difficult for the patient and their members to accept the realities. The nurses need to cope up with the lack of maturity and understanding on the part of the children who needs constant monitoring. World health organization states that “Palliative care for children is the active total care of the child's body, mind and spirit, and also involves giving support to the family.”  In the case of children, the treatment plan needs to include their parents and families, since they are in need of filial support. Stress on care givers and professional distress Anxiety, lack of regularity in eating and sleeping habits affects the health of the nurses. They become emotionally attached to the patients and their sufferings on account of pain which causes depression to nurses. The dimensions of life and death in their day to day activities, financial difficulties of the patients, economic disparity among the patients, and lack of family or family support and their helplessness to come to the rescue of the patients in such conditions sometimes make them feel responsible for the predicaments of the patients which leads to frustration. Therefore, sometimes they ‘burn out’ due to stress and complexities in dealing with the patients and their family members. Patient outcomes The improvement in the patient outcomes hinges on shared decision-making, participation in the process improvements, commitment from the health-care professionals and collaborative work practices. Palliative care aims to provide relief from pain and distress, integrate psychological and spiritual needs of care, help families to cope up with the patients’ illness and support in their bereavement. The CNL plays an important role in organizational learning, process improvement and human resource management. Outcome measures: The information collected from the patients through questionnaire before and after an intervention would be helpful to assess the outcomes or quality of care delivered. The details with regard to health care provided by the nurses, the health care system and other factors relating to the care would be useful to evaluate and improve the performance. NHS (2008) has issued ‘Guidance on the routine collection of Patient Reported Outcome Measures (PROMs) which would be useful as a guide. Work analysis of the current nursing staff Taxonomy of the nursing activities with reference to medication, assessment, assistance to patient and other aspects are given in Appendix I. In the case of palliative care, coordination with social workers and psychosocial care assumes additional importance. The CNL’s role in this regard is very important in assessing and organizing, because evidence based care calls for comprehensive analysis and care is patient centered and interdisciplinary. Keeping the patient informed and involved ensures quality of care and satisfaction of the patients. Types of Problems Observed The problems encountered in nursing practice are multifarious. In the case of palliative care, apart from pain, psychological problems and the issues related to external factors are numerous. For instance, the availability of the equipments and the operators could be a problem. The equipments may require cleaning in view of infection control. Functionality could be hampered by power failures, bumping into the walls, tables or beds and other obstructions. Similarly, the following are some of the obstacles for efficiency. 1. Physical hurdles which causes wastage of time. 2. Procedural hurdles such as paper work and authorization and approvals. 3. Lack of understanding and cooperation from the patients/family members. 4. Lack of support services. In securing the equipment related services from the other departments, clear-cut procedures need to be evolved to avoid loss of time, waiting time of the patients, nurses and other persons involved. Performance appraisal Performance evaluation under Appendix VIII discusses comprehensive procedures which include responsibilities from the angle of Team Manager, Clinician, Outcomes Manager, Systems, Risk, Information, Cost, Educator, Leadership, and as a Member of the profession individually and in combination with other responsibilities. Also, it discusses the issues under Quality performance indicators, Peer evaluation, Intervention team evaluations, Client evaluations, Supervisor evaluations and Faculty/learner evaluations. Learning Objectives The primary objective is to improve outcomes in quality, safety and satisfaction of the patients and their family members. The lessons learned in the palliative care could be applied successfully to other implementation projects with more confidence where the role of nursing is comparatively less daunting. The induction CNL opens up avenues for enhancing of quality care, better management practices, cost effective care, Evidence based practice and continuous learning process. Staffing plan The staffing plan as given in Appendix II represents the existing structure with modification. According to Dunhan-Taylor, J. & Pinczuk, J. Z., (2010, p. 406), once appropriate data have been collected, the nurse manager can begin the calculations to build the cost center budget…If patient classification data are not available, then the nurse manager could actually compute direct nursing care hours worked by employee classification for the past year.” The nursing hours per patient day (NHPPD) is a standard measure that quantifies the nursing time available to each patient by available nursing staff. Position description for the clinical nurse leader Clinical nurse leaders need to possess a master's degree in nursing. Finding candidates with a sound and balanced background proved to be difficult, though the position is improving slowly. Internal candidates with proven track record could be considered for the position. These candidates may need some training in the functional aspects to be efficient. Master’s in nursing with additional qualification of Masters in Public Health with attributes such as personal characteristics and experience could be considered ideal. Position description for the Clinical Nurse Leader as given in Appendix III is very exhaustive with qualifications, responsibilities, scope of practice, professional dimensions, career development, performance, collaboration and scientific enquiry dimensions, customer service and other requirements. The job of the clinical nurse leader involves more managerial aspects and implementation rather than direct care. This role is not purely administrative in healthcare delivery system, but significant part of it. Recruitment plan to select clinical nurse leaders Though the responsibility could be properly categorized as managerial, it is important to note that a sound and balanced background is very essential for the position. Though it is not specialty focused, experience with psychosocial care would be an added advantage. Broad outline is given in Appendix IV, covering goals, activities, timelines, responsibilities and important attributes, and a comparative assessment based on these parameters would be useful in the recruitment process. The Appendix VI ‘Process for interviewing and making the selection’ covers the aspects for the purpose of background analysis of the candidate and the frequently asked questions related to the Clinical Nurse Leader as given by American Association of Colleges of Nursing. Competency Checklist AACN End-of-Program Competencies & Required Clinical Experiences for the Clinical Nurse Leader is given in Appendix VI which delineates the competencies expected of every graduate of a CNL master’s education program. A minimum set of clinical experiences required to attain the end-of–program competencies also is included. This competency check-list covers nursing leadership, care environment management and clinical outcomes management. In the case of palliative care, more emphasis is given in respect of pain management and psychosocial care. Orientation plan Orientation program is the first step in the process of integration of the CNL with the hospital. It is important to note that the management practices and procedures adopted by different hospitals vary greatly. The existing system is the starting point for the CNL to firm up any meaningful rationalization strategies. The Appendix VII covers the major aspects of the orientation process in getting oneself acquainted with the existing systems and practices. Conclusion: Achievement of goals and performance evaluation Strategic planning in the reorganization involves educating the patients, interaction with family members, development of the patients’ rapport with the social workers, reducing professional distress to the staff thorough counseling, making readmission procedure simpler and intervening when necessary in critical cases to support the patients and the nurses. Measurement of success is to be with reference to the satisfaction of the patients. The CNL provides leadership, guidance, support and counseling to ensure continuity and relationship. This would reflect in the achievement of the goals with reference to reduction in the duration of stay, rate of accidents, infections, consumption of pain relievers and improvement in quality of care and satisfaction of the patients. Measurable outcome Data Collection Plan and Tool Responsible Person Satisfaction of the Questionnaire to the patients CNL/Ward nurse Patients Quality of care Questionnaire to the patients CNL/Ward nurse Duration of stay Discharge summary Ward nurse Rate of accidents Accidents register Ward nurse/Nurse Extender Infections Case histories Ward nurse/Nurse Extender Consumption Dispensary/ Palliative care (Pain relievers) Case history The other measures of performance include cost benefit analysis, population benefited, attrition rate of employees and overall improvement in the performance evaluation of the individuals in terms of feedback from the patients, attendance, punctuality, complaints received and compliance issues. The initial resistance to changes is expected to be overcome over the period of time when the benefits accrue on account of reorganization which would elicit active support and all round participation. Bibliography American Association of Colleges of Nursing (2005), Clinical Nurse Leader frequently asked questions, http://www.pdflibrary.info/download/ebook/Clinical%20Nurse%20Leader/aHR0cDovL21jbi5pbGxpbm9pc3N0YXRlLmVkdS9kb3dubG9hZHMvQ2xpbmljYWxOdXJzZUxlYWRlcmZyZXF1ZW50eWFza2VkcXVlc3Rpb25zLnBkZg American Association of Colleges of Nursing (2006), AACN End-of-Program Competencies & Required Clinical Experiences for the Clinical Nurse Leader – May 2006, pp. 1-4, http://www.aacn.nche.edu/CNL/pdf/EndCompsgrid.pdf American Association of Colleges of Nursing (2006), Example of a CNL Job Description for an Acute Care Setting, Functional Statement, Staff Nurse, Nurse III (Clinical Nurse Leader), Primary Care Services, http://www.aacn.nche.edu/CNC/pdf/JobDescriptionStaffNurse.pdf American Association of Colleges of Nursing (2006), Performance Evaluation Tool for the Practice Setting: Cross-setting Expectations for the CNL Graduate (How will you know one when you see one?), pp. 1-5, http://www.aacn.nche.edu/cnl/pdf/tk/Expectations3-06.pdf American Association of Colleges of Nursing (2007), White Paper on The Role of the Clinical Nurse Leader, http://www.aacn.nche.edu/publications/whitepapers/clinicalnurseleader.htm Battisto, D., Wood, M.A.V., Pak, R. & Pilcher, J. J. (2009), Using a Task Analysis to Describe Nursing Work in Acute Care Patient, Environments, The Journal of Nursing Administration, Volume 39, Number 12, pp 537-547, http://www.clemson.edu/catlab/wp-content/uploads/2010/02/battisto-pak-vanderwood-pilcher-2009-task-analysis.pdf Brookshaw, K. et al. (2009) Referral and access barriers to a multi-disciplinary outpatient palliative care service, Yarra Ranges Health, Eastern Health, http://www.supportivecancercarevictoria.org/PDF/SSConf09S5KBrookshaw.pdf Center to Advanced Palliative Care (2008) Improving Palliative Care in Nursing homes, New York, www.capc.org Dunhan-Taylor, J. & Pinczuk (2010), Financial Management for Nurse Managers: Merging the Heart with the Dollar, 2nd Ed., Jones and Bartlett Publishers, Sudbury, MA 01776)  Lethborg, C. & Brown, R. (2009) A targeted orientation and information program for newly diagnosed cancer patients at St. Vincent’s Hospital. St. Vincent’s Hospital, http://www.supportivecancercarevictoria.org/PDF/SSConf09S5CLethborg.pdf NHS (2008), ‘Guidance on the routine collection of Patient Reported Outcome Measures (PROMs), http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_092625.pdf The National Council for Palliative Care (2011), Palliative Care Explained, http://www.ncpc.org.uk/site/professionals/explained Nova Scotia Chronic Pain Working Group, (2006) ACTION PLAN For THE ORGANIZATION AND DELIVERY OF CHRONIC PAIN SERVICES IN NOVA SCOTIA, 19 Jul 2006. http://www.gov.ns.ca/health/reports/pubs/Action_Plan_Chronic_Pain.pdf World Health Organization, (2010) Palliative Care, file:///C:/Documents%20and%20Settings/ADMIN/Desktop/WHO%20%20%20Palliative%20car e.htm Appendix I Taxonomy of Nursing Activities Activity Description Examples Administering Refers to the preparation, Retrieving medications, preparing medications, Medication administration, and administering medications, documenting documentation of administration of medications, monitoring Medications. intravenous pump Patient Any action where Identifying patient, reviewing medical assessment the nurse is performing information, checking vital signs and other evaluation or assessment indicators of physical status, visual of the patient observation, talking with or listening to patient, patient teaching, wound/dressing care Assisting Tasks that require the nurse Helping the patient to the toilet or shower, patient to assist with the helping the patient with a bedpan/urinal or hygiene or general bed bath, general hygiene (eg, washing well-being of the patient hands, brushing teeth), assisting with meals, dressing patient Break Away from the ward Lunch, scheduled break, idle time Cleaning/ Any activity where the nurse Changing bed linens, cleaning off the bedside Organizing/ is cleaning or table, looking for a needed piece of equipment Gathering organizing a patient room or gathering supplies for a certain task Communi- Any action where the nurse Talking with a doctor, talking with another cation is conversing with someone nurse, making a phone call to discuss a patient other than patient Documen- Any action where the Updating in-room board, completing chart on tation nurse is recording patient, using bedside computer information Movement Actions where the nurse Admitting patient, discharging patient, transferring is helping a patient patient to a different unit, transferring patient to move from one location to a different room, transporting patient for another diagnostic procedures, assisting patient in a move (eg, from a bed to a chair) Other Any activity that does not Any task that does not fit into one of the other fall into one of the categories already-described categories Source: Battisto, D., Wood, M.A.V., Pak, R. & Pilcher, J. J. (2009, p. 542)), Using a Task Analysis to Describe Nursing Work in Acute Care Patient, Environments, The Journal of Nursing Administration, Volume 39, Number 12, pp 537-547. Appendix II Staffing Plan Clinical Nurse Leader: General shift Head nurse: 3 (Three shifts – 1 per shift, common for all the wards) Staff nurses Children’s ward: 3 (Three shifts) General wards: 6 (Three shifts in two wards) ICU – 3 (Three shifts) Nurse extenders: 6 (Three shifts – 2 per shift, common for all the wards Ward boys: 9 (Three shifts- 3 per shift, common for all the wards) Service coordinator: 1 (general shift) Services in respect of Chemotherapy, Radiotherapy and Physiotherapy are provided by the medical professionals and specialists drawn from the other division(s) attached to the hospital based on the requisitions from Palliative Care. Appendix III Position description for the Clinical Nurse Leader QUALIFICATIONS: Current, active, full and unrestricted registration as a Registered Nurse (RN) and meets licensure requirements for practice in accordance with VA Handbook 5005/27, Part II, Appendix G6, Nurse Qualification Standards The Clinical Nurse Leader (CNL) has a Master’s Degree in Nursing (MSN) or Post-Graduate Clinical Management Program with didactic and supervised preceptorship by a Board Certified Clinical Nurse Leader. CNL must be certified by the American Association of Colleges of Nursing (AACN). BLS Certification required. SUPERVISORY CONTROLS: The Staff Nurse is directly responsible to the Associate Chief Nursing Service (ACNS) Primary Care Services. RESPONSIBILITIES: The CNL uses the nursing process and evidence-based practice to work collaboratively with the Core Team (Patient, Primary Care Provider, RN Care Manager and Patient Care Technician) and Expanded Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing the patient-driven holistic care plan for life. The CNL, as a member of the expanded team, promotes patient and family health education with a focus on self-management, prevention, and wellness, based on the patient’s goals. The CNL is responsible for the lateral integration of patient care, i.e., assessing patient needs and accessing expertise across healthcare disciplines. As a change agent, promotes an environment that embraces new knowledge, innovations and improvements. Fundamental aspects of the CNL role include: leadership in the care of patients; standardization of care; identification, delegation and oversight of care delivery and outcomes. The CNL refines data systems to identify trends and opportunities for improvement. SCOPE OF PRACTICE: The RN CNL is an advanced generalist who functions at the microsystems level. The CNL directs and can provide comprehensive preventative and wellness care, as well as the spectrum of acute, episodic, chronic and end-of-life care to Veterans. The CNL collaborates for the improvement of patient care outcomes in the Primary Care Medical Home. The CNL executes position responsibilities that demonstrate clinical leadership, experience, and creative approaches to the management of patient care across microsystems. The CNL serves as a mentor and consultant to healthcare staff involved in patient care. The Scope of Practice of the Staff Nurse is defined by the four dimensions outlined in the Nurse Qualification Standards and is specific to the grade as follows: Nurse III: Executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of complex client care. PROFESSIONAL DIMENSIONS: PRACTICE DIMENSION (Practice, Ethics, Resource Utilization) • Provides leadership in implementation and evaluation of guidelines, professional standards and policies that impact patient care in the Primary Care Medical Home. • Develops and promotes systems to improve access and continuity of care. • Uses advanced clinical knowledge and critical thinking skills to mentor staff in planning, implementing and evaluating interventions that improve patient outcomes. • Uses clinical knowledge and skill and a variety of information technologies including clinical databases, to anticipate risk, perform risk assessments and other surveillance strategies to customize interventions and promote achievement of health related outcomes and patient safety. • Designs and provides age and population specific health promotion and risk reduction strategies. • Translates evidence-based research into practice to ensure that patients benefit from the latest innovations in nursing science. • Uses knowledge of health organizations, systems, policy leadership and change to develop, implement and coordinate evidence-based standards, policies and procedures. • Participates in system review to critically evaluate and assess resource utilization and safety issues with care teams and updating life plans accordingly. • Serves as a resource and advocate in the protection of patient and family rights. Effects change through advocacy for the profession, interdisciplinary health care team and the patient. • Maintains privacy and confidentiality of all patient information, including electronic, print, and conversations. • Serves as an expert resource to implement and teach skills, including motivational interviewing to promote patient self-management toward patient-driven holistic care plan for life. • Provides patient-driven care in a safe, efficient and cost-effective manner, using evidence based principles. PROFESSIONAL DEVELOPMENT DIMENSION (Education/Career Development, Performance) • Maintains knowledge of current techniques, trends and professional issues in the Primary Care Medical Home. • Serves as a professional leader in the system of healthcare delivery and embraces lifelong learning. • Participates in professional organizations that support advancement of the CNL role and the nursing profession, resulting in high quality, cost-effective health care. • Functions as a change agent to maintain expertise and enhance role performance of self and others. • Considers the economic, legal and political factors that influence healthcare delivery when developing the patient-driven holistic care plan for life. • Serve as a mentor/preceptor for students. Complete mandatory reviews, including motivational interviewing, in order to promote patient self management toward individualized life plan of care. • Educates colleagues and/or students and serves as a preceptor and/or mentor. COLLABORATION DIMENSION (Collegiality, Collaboration) • Demonstrates professional behavior (i.e., respect, civility, ability to accept constructive criticism), effective communication and interpersonal skills. • Actively participates in interdisciplinary groups to coach, educate and serve as a resource to all direct care providers in the care of the complex patient. • Shares expertise within and beyond the facility through leadership and active participation on task forces, committees and professional affiliations. • Maintains a work environment that honors diversity SCIENTIFIC INQUIRY DIMENSION (Quality of Care, Research) • Develops and/or monitors data systems that reflect patient care outcomes affected by changes in the patient-driven holistic care plan for life. • Initiates and participates in quality improvement activities that result in staff accountability and improved outcomes. • Utilizes current research to validate and/or change health care practice at the microsystem level. • Provides leadership in the implementation of performance improvement tools and methodologies to advance the quality of patient care. • Makes sustained contributions to the body of nursing science through teaching and/or publishing activities. • Follows infection control and medical center policies, including reusable patient equipment. • Promotes patient and personnel safety. CUSTOMER SERVICE REQUIREMENTS Meet the needs of customers while supporting VA missions. Consistently communicates and treats customers (Veterans, their representatives, visitors, and all VA staff) in a courteous, tactful, and respectful manner. Provide the customer with consistent information according to established policies and procedures. Handles conflict and problems in dealing with the customer constructively and appropriately. AGE, DEVELOPMENT, AND CULTURAL NEEDS OF PATIENTS REQUIREMENTS Provide care and/or services appropriate to the age of the patients being served, adult and geriatric. Assesses data reflective of the patient’s status and interprets the information needed to identify each patient’s requirements relative to their age-specific, developmental, and cultural needs. COMPUTER SECURITY REQUIREMENTS Protect printed and electronic files containing sensitive data in accordance with the provisions of the Privacy Act of 1974 and other applicable laws, federal regulations, VA statutes and policy, and VHA policy. Protect the data from unauthorized release or from loss, alteration, or unauthorized deletion. Follows applicable regulations and instructions regarding access to computerized files, release of access codes, etc., as set out in the computer access agreement that the employee signs. Follows applicable regulations and instructions regarding access to computerized files, release of access codes, etc., as set out in the computer access agreement that the employee signs. Source: American Association of Colleges of Nursing (2006), Example of a CNL Job Description for an Acute Care Setting. Appendix IV Recruitment plan to select clinical nurse leaders Recruitment plan envisages qualities, experience and temperament on the part of the candidates to meet the following aspects related to the profession. Therefore, the in-house professionals and the external candidates are screened after careful verification, evaluation and appraisal. Goals: To increase direct patient care activities, To reduce wastage of time and To improve patient outcome Activities: Management of palliative care services to the patients, Coordinating with the surgeons, technicians and other medical professionals and psycho social care, Documentation, Data management, Admission and Discharge duties. Timelines: Routine time management, Staff’s leave and permissions, Comprehensive care to the patients, Arrangement of therapy and food supplies, Overseeing cleaning services and House-keeping Responsibilities: The Clinical Nurse Leaders are required to oversee the functions of Ward Nurses, Nurses in ICU and Nurse Extenders. Coordination with the Social Workers, Medical Professionals and visitors to the patients A qualified nurse also needs to have a sound and balanced background with professional experience and dedication to inspire confidence among the team members. Special requirements: Nursing experience in palliative care, experience in coordinating with the social workers, knowledge about legal provisions related to public health is important. Additional qualification in psychology or social sciences will be an added advantage. Capabilities in organizing and experience in participating meetings, training programs, peer reviews, audit, clinical meetings in learning needs of the nurses, fire evacuation training, etc. Proficiency in Code of Rights and Health and Information Privacy Act is desired. Knowledge and experience in budgeting, cost effective clinical practices, standards and quality parameters is very critical in the selection process. Knowledge and experience in health and safety policies, procedures and guidelines of the prospective CNL need to be considered in respect of the employees, patients and the visitors need to be considered.  High standard of clinical skills in palliative care is given more weight in the selection process. However, the following attributes are essential in view of the strategic importance of the position. Important attributes: The CNS’s commitment to professional excellence and quality of care Expertise in communication and reporting Excellent interpersonal skill Flair for learning, teaching and educating the staff Capable to work under stress and emergency situations and provide guidance to the team Appendix V Process for interviewing and making the selection Behavioral interview questions vary from family background to the balanced state of mind. Eliciting information in a normal conversational manner without exerting pressure on the candidate is very important. The interviewing committee needs to consist of persons from the medical and nursing background, especially experienced in the palliative care. Family background Ethnic background Social background Cultural background Attitude Patience Dedication Honesty Balanced state of mind The frequently asked questions related to the Clinical Nurse Leader as given by American Association of Colleges of Nursing, (2005): What is the Clinical Nurse Leader? What does a Clinical Nurse Leader do? Is the Clinical Nurse Leader needed in the health care system? What is the educational preparation of a Clinical Nurse Leader? Can this new nurse role be achieved by making some changes in the current four-yearbaccalaureate curriculum? Will the CNL replace baccalaureate-prepared nurses and is AACN recommending that baccalaureate programs close? How is Clinical Nurse Leader different from a Clinical Nurse Specialist or other advanced practice nurse? What education-practice models have been developed to prepare the CNL for practice? Will the development of education and practice models for the CNL include creating a new legal scope of practice and license? Does this initiative involve an evaluation component? What steps are being taken to move the CNL initiative forward? Is AACN seeking input and collaboration from stakeholder groups? Why is AACN leading the CNL initiative? What is the connection between the CNL and the practice doctorate in nursing? Source: American Association of Colleges of Nursing (2005), Clinical Nurse Leader frequently asked questions. Appendix VI Competency Checklist AACN End-of-Program Competencies & Required Clinical Experiences for the Clinical Nurse Leader – May 2006 (File AACN1 – attached) Source: American Association of Colleges of Nursing (2006) Appendix VII Orientation plan 1. Familiarization with the hospital lay-out, introduction with the medical professionals, Nurses, Nurse Extenders and others. 2. Documentation procedure involved in admission, discharge and record maintenance, updating case histories. 3. Familiarization with the systems, communication channels. 4. Nature of the patients admitted for palliative care, problems associated with and the responsibilities in palliative care. 5. Special instructions with regard to use of medical equipments and other facilities. 6. Instructions with regard to managing visitors to the patients like family members and friends. 7. Educating the patients and their family friends and relatives to manage their affairs with confidence. 8. Training in record works, record keeping and reporting. 9. Steps to be taken while assuming the charge from the reliever and handing over the charge after finishing the shift to the incoming nurse. 10. Readjust the orientation program based on the strengths and weaknesses observed during orientation, to give more inputs and additional guidance wherever necessary. 11. Orientation plan includes special training if necessary in any weak areas, such as computer programs, reporting or psychology to strengthen the knowledge of the newly recruited nurse. 12. Demonstration of the medical equipments and accessories for learning through observation and questioning since the models and makes of the machines as well as the functionalities vary from manufacturer to manufacturer. Appendix VIII Performance Evaluation Performance Evaluation Tool for the Practice Setting: Cross-setting Expectations for the CNL Graduate (How will you know one when you see one?) The following criteria pertain to performance, not role. It is the expectation that the performance of nurses prepared at the advanced generalist master’s level and certified as a Clinical Nurse Leader (CNL) will meet the following criteria, independent of the specific role or title to which they are assigned. These criteria assume that CNLs also meet all of the expectations associated with excellent staff nurses. The criteria also assume that newly graduated CNLs will begin their careers as novice CNLs, not as staff nurses, and that their performance as a CNL will evolve over their first year of employment. Finally, examples of quality performance indicators are outlined at the end of this document. For all indicators, it is expected that each CNL will maintain and assemble documentation of personal and professional growth for periodic performance assessments. It also is suggested that performance assessment includes systematic peer evaluation, intervention team evaluation, client evaluations and, when appropriate, learner/educator evaluations. As Team Manager & Clinician 1. Effective and comprehensive management of client (individual, family, community) care a. Assumes accountability for client welfare b. Identifies client risks based on a comprehensive assessment and evaluation c. Collaborates with the client in designing and executing the total care plan, explaining the plan with reference to the evidence and seeking the client’s suggestions, understanding and endorsement. d. Consults appropriately with other health professionals in designing the plan of care or intervention. e. Communicates the care plan to other members of the intervention team, seeking their recommendations and then delegating appropriately f. Advocates effectively on behalf of the client with the intervention team and with the client’s network As an Outcomes Manager 2. Oversees the management of specific micro-system populations a. Identifies and becomes knowledgeable about microsystem client populations i. Acquires information about the population through local information systems ii. Seeks knowledge through reference literature and current journals, etc. b. Identifies population-level clinical/health problems c. Uses information systems to collect and review outcome measures routinely used to measure outcomes d. Identifies and resolves population-level clinical/health problems e. Engages intervention team in evaluating progress in achievement of desired outcomes As a Team Manager 3. Integrates and mobilizes the clinical/intervention team to assure both excellence and comprehensiveness of care. a. Meets regularly with the clinical/intervention team b. Evaluates their performance based on client outcomes c. Creates and revises the care plan in collaboration with the team and assures that all members are fully informed d. Shares knowledge from reference and journal literature to improve care As a Clinician, Outcomes Manager & Systems Analyst/Risk Anticipator As a Clinician, Outcomes Manager & Systems Analyst/Risk Anticipator 4. Assesses the microsystem and deploys its resources appropriately to improve outcomes a. Evaluates the entire microsystem and how it fits with the work of the larger organization (e.g. the high cost and high volume activities). b. Evaluates the capacity of the microsystem resources to accomplish the work of the unit i. Appraises the human resources available to the microsystem to accomplish the work (e.g. nursing staff, pharmacy, dietary, medical consultation, custodial) ii. Assesses formal and informal organization and operations of the microsystem, including deployment of resources. iii. Assesses the material and communication resources available to accomplish the work of the microsystem c. Deploys unit resources effectively in the care of clients and the improvement of population-level clinical outcomes As a Team Manager, Clinician & Information Manager 5. Practices in a cost-effective manner a. Identifies waste in the system and opportunities for cost (material, time, personnel) savings b. Uses technology effectively to reduce cost and enhance clinical outcomes c. Sets priorities to work efficiently while not compromising quality d. Presents and is open to ideas for revenue enhancement that will benefit clients e. Proposals modifications in microsystem using business models including return on investment As an Educator 6. Participates in the clinical education of CNL students, novice CNLs, and other nurses, as an educator, mentor and preceptor As an Outcomes Manager, Educator, and Systems Analyst/Risk Anticipator 7. Translates research and clinical outcome studies into practice a. Is current in literature related to microsystem practice b. Participates in microsystems review and analysis of past trends to project risks to client safety and quality of care outcomes c. Uses evidence to challenge and modify existing policies, protocols and care maps d. Introduces evidence into practice through education of intervention team and relevant professional staff e. Incorporates evidence-based practice changes into information and integrated documentation systems f. Communicates evidence-based practice modifications to other health As an Educator, Team Manager, and Advocate 8. Provides clinical leadership within the microsystem a. Promotes professional development of the team members b. Assures continuing education of the team members c. Educates microsystem staff, e.g. grand rounds, innovative practices, etc. d. Participates in performance evaluation of intervention team members. As an Advocate, Member of the Profession, and Outcomes Manager 9. Assumes leadership in organizational governance and professional activities a. Represents the microsystem on organizational committees b. Is a member, and eventually leader, in relevant professional organizations. c. Disseminates microsystem successes in care management to larger nursing community As a Clinician and Team Manager 10. Knows and applies organizational mission, values and strategic plan a. Practices in accordance with the values of the organization b. Uses strategic plan to guide practice c. Participates in development of mission, value statement and strategic plan As a Team Manager and Advocate 11. Monitors and advocates for social justice in microsystem activities. As a member of the Profession 13. Engages in professional development activities Quality Performance Indicators Peer evaluations (inter and intra-professional co-workers) The CNL: o Consults appropriately with nurse specialists (CNS, NP) and members of other professions (medicine, pharmacy, physical therapy, etc.) o Engages professional peers in plan of care o Keeps consultants informed on client progress o Consultation reflects comprehensive knowledge of client o Provides consultation and assistance to peers Intervention team evaluations The CNL: o Is accessible to team members o Is credible about the client o Is knowledgeable about the particular health or clinical problem(s) o Invites participation from all team members o Communicates care plan clearly with rationale o Educates team members o Meets regularly with team, o Is respectful of the contribution of each team member o Encourages and provides for continuing professional development (team should be more qualified this year than last year) o Assists team to solve problems effectively Client evaluations The CNL: o Provides satisfying, high quality care o Advocates appropriately o Introduces the members of the intervention team and explains the role of each o Is knowledgeable about the problem, consults the literature and answers questions o Engages the client and network in the planning and implementation of the care/health plan o Is accessible to the client and network o Educates the client and network how to manage health/clinical problem Supervisor evaluations The CNL: o Keeps the supervisor informed regarding client progress, plans of care, modifications or unusual events, and team performance issues o Is accountable and available via flexible hours to address client needs o Plans and implements care that is effective, comprehensive, based on evidence, and has clearly defined outcomes o Identifies relevant population-based problems o Identifies patient cohort risks and areas for quality improvement o Demonstrates currency of knowledge about identified client populations (e.g. reads current journals and translates to work) o Uses information systems effectively to solve problems, evaluate self and team performance o Seeks better clinical/health outcomes, elimination of errors, and reduction in costs and operational waste o Reviews protocols and procedures for consistency with latest evidence o Engages in effective intra and inter-professional consultation and collaboration o Develops and coordinates a knowledgeable, proficient and well-organized team o Team functions well during crises and stressful periods o Delegates appropriately o Creates more effective systems reflecting knowledge of the nature and volume of work, the human and material resources available, and sound business practices related to cost and return on investment o Integrates mission, values and organizational strategic plan into personal and team practice o Serves effectively in microsystem governance o Represents the microsystem effectively in the larger organization o Demonstrates a spirit of retention and problem solving and encourages other micro-system personnel to do the same. o Assumes responsibility for educating, mentoring, guiding and evaluating novice CNLs, CNL students and other nurses. o Monitors care plans and operations for social justice and takes appropriate action. Faculty/learner evaluations o Provides rationale for practice o Creates learning opportunities for students to practice CNL objectives o Accessible to student and academic advisor o Meets with academic advisor routinely and as needed Source: American Association of Colleges of Nursing (2006), Performance Evaluation Tool for the Practice Setting: Cross-setting Expectations for the CNL Graduate (How will you know one when you see one?) Read More