Running head: CONSULTATION PROJECT
Consultation Project
Lauren Walker
Georgetown University
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CONSULTATION PROJECT
The health care system in the United States is continually evolving through the
advances in diagnosis, treatment and health management. Hospital systems and patient
care units work hard to meet unit specific goals including patient safety, enhancing nurse
skills and knowledge, as well as scoring below national benchmark goals. Due to the
evolving shortages of nurses, nursing faculty, aging population, profound increases in
chronic illnesses, and the increased usage of unlicensed support personnel, the hospital
system and patient care units often seek advice and guidance from clinical experts to
meet these goals and standards. According to Zuzelo (2010), consultation is the process
of working with individuals or group to help them resolve actual or potential problems
related to the health status of clients or to health care delivery. Consultation is also a
patient, staff, or system-focused interaction between professionals in which the
consultant is recognized as having specialized expertise and assists the consultee with
problem solving (AACN, 2010).
The Clinical Nurse Specialist (CNS) is an optimal resource that facilities will turn
to for the consultation process. Williams, (2008) describes the CNS Consultant as an
outside expert who can make recommendations and suggestions for improvement. Once
brought into the hospital and needs addressed, the CNS Consultant can help identify key
indicators, look for trends and most importantly, benchmark how organizations are
performing (Zuzelo, 2010). The CNS has clinical expertise, critical thinking and analytic
skills, leadership, management abilities, communication, and program development
experience. Therefore, as stated by Zuzelo (2010) CNS consultation is a reliable and
dependable resource to help address recent technology expansion, outsourcing for
specialized services, evidence-based practice movements, emphasis on health promotion,
explosion of chronic disease, nursing shortage, patient safety concerns, and mounting
ethical dilemmas for healthcare clinicians.
Williams (2008) states that CNS Consultation can also help improve patient
outcomes in a variety of settings through implementing research findings in daily
practice, evaluate the outcomes of interventions before making them systemwide, educate
nurses and others in the area of focus through courses, in-services, and seminars, develop
guidelines for patient care, counsel nurses about patient care issues, and offer specific
care advice about selected conduct outcome and cost-efficiency research. The CNS will
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CONSULTATION PROJECT
provide consultation to staff nurses, medical staff and interdisciplinary colleagues, initiate
consultation to obtain resources as necessary to facilitate progress toward achieving
identified outcomes (AACN, 2010). CNS Consultation allows organizations to move
these necessary services out of acute care, reducing expenses, but preserving the level
and expertise of services (Zuzelo, 2010).
The Consultation process is initiated by a facility or system that externally
contacts the CNS to provide selected fee-based nursing services, initiating the five-phase
process of consultation. The first phase is the initial contact of the facility to the CNS.
After the contact, the two parties meet to define and explore the problem, clarifying the
purpose and identify expectations (Kesten, 2012). An initial contract for services
including role responsibilities and duty of work of the consultant, is then developed by
the CNS, presented to the facility, and signed by both parties (Kesten, 2012).
After the initial contract has been developed and signed, the CNS has gained entry
into the facility to initiate the problem identification, data collection and assessment
process of the clinical concern. For accurate assessment and data collection in this phase,
the Consultant will use their skills and interventions to interview key roles, observe unit
flow and tendencies, validate data, and determine the transparency of unit activities
(Zuzelo, 2010). Gaining entry and problem identification is based on high quality
comprehensive assessment of the client system to fully and completely identify the cause
of the problem and factors potentially helping or hindering the resolution of the problem
(Zuzelo, 2010). Assessment is critical during the problem identification phase and will
occur throughout the entire consultation process. By combining and evaluating standards
of care and benchmarking for the facility, the CNS partakes in this powerful process by
which consultants can determine if patients are receiving the best and most cost effective
care.
Once the CNS has had the opportunity to fully evaluate the data, it is at this point
where they give feedback to the facility and make the decision to act. The CNS will
communicate consultation findings to appropriate parties consistent with professional and
institutional standards (AACN, 2010). When the Consultant identifies the appropriate
parties, they will report their data collection and findings, clarify goals, and make a
recommendation for the next action steps or intervention (Zuzelo, 2010). Once findings
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have been discussed, goals may be revisited and reclarified if necessary. The Consultant
then develops an action plan and the implementation of recommendations will be
performed.
In the implementation phase, it is necessary for the Consultant to identify the
responsible party to help carry out the implementation. Positive relationships with
responsible party will help a positive transition as the intervention is implemented
(Kesten, 2012). Recommendations for improvement or change may be well received by
the facility if the Consultant makes improvements immediately and has no preconceived
biases. To help foster this, the CNS has to develop trusting work relationships quickly,
has to meet mutually agreeable goals within contracted time frame, has to learn how the
system works, and recognize that they cannot necessarily control follow through and
follow-up to recommendations (Zuzelo, 2010). After implementation, the last phase of
CNS Consultation is the termination of the engagement. This last step enables the
Consultant to revisit decisions, evaluate the impact of the interventions, and terminate the
relationship of the decisions. Since the CNS Consultant is an external contracted expert,
long term impact and results from their intervention are not always determined and fully
evaluated.
During a clinical experience, a CNS Graduate Student was contacted by the
CCNS to evaluate and update the current credentialing criteria for moderate sedation
through the redevelopment of the Moderate Sedation Packet for Licensed Healthcare
Providers. The Graduate Student met with the CCNS to discuss the purpose, goals of the
project and clarify the expectation of the system and CCNS. After this discussion, the
Graduate Student, now the Consultant, developed a contract between themselves as the
Consultant and the CCNS. The contract described the role and responsibilities of each
participant, expectations of the project, and time frame in which the consultation would
be completed. The Graduate Student then followed and participated in the phases of
CNS Consultation Theory for the completion of the consultation.
To determine the scope of the problem and collect data, the Graduate Student met
with the Department Head of Anesthesiology and CCNS to discuss current credentialing
criteria for Licensed Health Care Providers in their hospital system, current concerns with
the criteria, involved practitioners participating in Moderate Sedation and was given the
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current Moderate Sedation Packet. Through the data collection process, it was
determined that Moderate Sedation procedures is a daily intervention performed at an
inpatient and outpatient setting daily. Many team members participate in these
procedures including Physicians, Nurse Practitioners, Physician Assistants, Registered
Nurses as well as contracted Anesthesiologists who are licensed outside the system. With
the large amount of staff and agency participants in moderate sedation, there are large
inconsistencies of the Moderate Sedation program. The inconsistencies include
documentation and expectations for physicians, nurses and Licensed Healthcare
Providers practice and participating in Moderate Sedation procedures as well as the use
of a very outdated credentialing packet for initial and renewal system credentialing.
The redevelopment of the Moderate Sedation Packet first involved organizing the
current packet into sections and updating each individually. This was important to fully
understand and completely redevelop each section. The Graduate Student included and
evaluated the current Moderate Sedation System Policy, performed a review of geriatric
considerations for undergoing moderate sedation, performed a literature review for
current best practice standards of the Licensed Health Care Provider performing a
moderate sedation procedure, and redeveloped a moderate sedation competency quiz.
Through this process, the CCNS and Department Head of Anesthesiology was
continually updated on recent developments and articles. It was in this stage where the
Graduate Student needed specific clarifications regarding target groups, system
references and policy clarification. Once the packet was redeveloped with updated
standards, a recommendation for inclusion material was submitted by the Consultant to
the CCNS and Department Head of Anesthesiology.
While the CCNS was the direct contact and key informant during the Consultation
Process, the Graduate Student Consultant turned to the Department Head of
Anesthesiology for implementation. This was necessary since he was the direct
supervisor and mentor to all Licensed Health Care Providers being credentialed for
leading Moderate Sedation Procedures. Both the CCNS and Department Head of
Anesthesiology reviewed the recommendations for change through the final packet. The
Department Head of Anesthesiology then accepted the packet. When the packet was
submitted to the CCNS and Department Head of Anesthesiology, and all expectations
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CONSULTATION PROJECT
were met, the Consultation was complete. Unfortunately, the Graduate Student was
unable to review the long-term results from this packet due to limited clinical time and
completion of the consultation.
The implementation of the CNS Consultation project was a positive experience as
the Graduate Student was able to easily follow the steps of the Consultation Process. The
five phases of the Consultation Model are very clear and when the Graduate Student was
consulted to redevelop the Moderate Sedation Packet, the student naturally fell into each
step in the development of the project, seeking guidance and clarification when
appropriate. Since this was the first Consultation experience for the Graduate Student,
there were many unexpected barriers for the project that were not anticipated. The first
Moderate Sedation Policy that was given to the Graduate Student was over ten years old.
Since the Graduate Student Consultant was an external expert, there was difficulty
obtaining internal documents such as policies and current practicing system wide
standards of care. A more recent updated policy, compared to the policy in the packet,
was given to the Graduate Student by the CCNS, and the student converted it to be used
in the packet. However this was still not the most updated policy and the packet policy
had to be redone to include the 2011 policy. The original Moderate Sedation Packet and
updated Moderate Sedation Policy were also given to the student in a PDF form. A form
of this document was unable to be converted into a WORD Document or in a form that
could be easily updated. The Graduate Student started to manually convert to a word
document with the updated recommendations; however, hours were being spent on file
conversion. The Graduate Student then investigated into a PDF to WORD document
convertor file that successfully converted the files into versions that could be edited.
Having an established relationship with the CCNS was a positive strength through
the development of the Consultation Project. The Graduate Student was given
independence to be the expert and independently work towards providing the best
recommendations for change. The CCNS served as a positive guide with resources and
system connections. Now recognizing that it is necessary to continue to work and
collaborate with the entire team to successfully obtain all the needed data, it will be easier
to anticipate and follow up on similar experiences as a new CCNS in the Consultation
process. While the CCNS served as a guide in the process, as a new CCNS, it is also
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important to look to an experienced CCNS as a mentor and peer advisor when
participating in the Consultation Process. Not only is it important to look to an
experienced CCNS as a guide, but to establish collaboration and positive relationships
with the system in which the CCNS is consulting with. This will open communication
and be easier to seek clarification when barriers are reached. It is also important to
update the system regarding the status of the Consultation and abide by contracted dates,
unless major changes are needed. By following the Consultation Model and establishing
a positive relationship with consulting system, it will help transition towards a positive
Consultation experience by the CNS to influence best practice standards and system wide
change.
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CONSULTATION PROJECT
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References
American Association of Critical Care Nurses. (2010). Clinical nurse specialist core
competencies. (Executive Summary).The National CNS Competency Task Force.
http://www.aacn.org/wd/certifications/Docs/corecnscompetencies-execsumm.pdf.
Kesten, K. (2012). In Walker L. (Ed.), Consultation: Bring on the experts. 27 March
2012.
Williams, S. (2008). Clinical nurse specialost program evaluation via national association
of clinical nurse specialists consultation. Clinical Nurse Specialist, 22(5), 247-250.
Zuzelo, P. (Ed.). (2010). The clinical nurse specialist handbook (6th ed.). Philadelphia,
PA: Jones and Bartlett Publishers.