Clinical Nurse Specialist Leadership
in Redefining How We Assess
Competency in Nursing
A75M430
NTI 2014
Denver
Rhonda Fleischman MSN, RN-BC, CNS, CCRN-CMC
Karen Marzlin DNP, RN, CCNS, CCRN-CMC, CHFN
Cynthia Webner DNP, RN, CCNS, CCRN-CMC, CHFN
2014
1
“Professional nursing practice can only advance as much
as individual nurses are aware that a knowledge gap
exists in their practice, feel empowered to access further
learning, and integrate evidence based competencies into
their professional practice to provide safe, effective,
efficient, patient centered, equitable care.”
www.tigersummit.com
2014
2
•
•
•
A new competency paradigm introduced in 2011.
The new design has been enhanced each subsequent year (2012, 2013, and
2014).
The effectiveness of the new paradigm was measured in 2011 by evaluating
the impact of the new program in the area of bedside cardiac monitoring.
– Cardiac monitoring was selected because it is a key area for clinical competence in the
CCU.
– Objective data was used in the initial evaluation.
•
•
Outcome assessment has been expanded to include quality and quantitative
evaluation. Additional areas of practice have been added to the evaluation
component.
Project has been developed and implemented by 3 cardiac advanced practice
nurses.
– One unit based CNS (role includes clinical practice and education)
– Two CNSs who provide clinical care with a cardiology practice (also serve as co-chairs of
the Heart Center Staff Education Committee)
•
2014
Project has been done with support of the CCU Unit Director
3
Why a paradigm shift in
competency assessment?
2014
4
Historical Approach to
Competency Assessment
• Skills checklist
– Task based assessment
– Does not account for science behind practice, OR
– Critical thinking or decision making
• Majority of literature on competency
assessment in nursing focuses on pre-licensure
nursing education and transition into entry level
practice
– Focus on didactic education
2014
5
Competency in Nursing: Lack of Clarity
• There is often an unclear definition of
competency within the nursing profession.
– Primary reasons for lack of consensus regarding
competency in nursing practice include the
following:
• a) multifaceted nature of competency assessment,
• b) variations in specialty practice within the profession,
• c) the evolution of nursing practice from the novice to
expert level.
2014
6
Continuing Education Alone
Does Not Guarantee
Competency
• There is inconsistent evidence that
continuing education alone results in a
change in a nurse’s clinical performance
and subsequent improvement in patient
outcomes (IOM, 2003).
2014
7
COMPONENTS OF NEW
COMPETENCY PARADIGM
2014
8
Competency Components:
New Paradigm
• Multifaceted in order to reflect the actual
transfer of knowledge into practice.
• Critical thinking as key aspect
– Purposeful
– Reflective
– Active
– Evidence based
– Spirit of inquiry
2014
9
Competency Components:
New Paradigm
• KNOWLEDGE is foundation for critical thinking
and clinical decision making
• Competency should integrate knowledge, skill,
application of evidence in practice, and critical
thinking.
• Theoretical Framework:
– Benner’s Novice to Expert Theory
– The Synergy Model
2014
10
Competency Components:
New Paradigm
• Nurses must be engaged in the competency assessment
process in order to assume accountability for their
clinical practice.
• Increased nurse engagement results in increased nurse
satisfaction and retention.
– Improved retention of critical care nurses results in a
financial cost savings to the organization.
– Actively engaged nurses contribute to improved patient
satisfaction and improved overall quality outcomes.
(Force, 2005, Armstrong & Laschinger, 2006)
2014
11
Support for New Components
• Current literature regarding competency assessment
focuses on utilizing alternative methods to assess
nursing competency including the following:
–
–
–
–
–
–
Evaluation of continuing education activities
Real time clinical performance assessment
Review of unit specific quality improvement data
Peer review
Self reflection of nursing practice
Utilization of professional portfolios
(National Education Framework Cancer Nursing, 2008)
2014
12
2014
13
The Culture
• Magnet Hospital (2006)
-re-designated in 2010
• 10 year history of a Novice to Expert Staff
Education Program for Heart Center
– Clinicians as instructors
– 5 Level program
– 102 hours of annual education
– Emphasis on certification preparation
– Linking knowledge to practice expectations for
each class within curriculum
2014
14
Heart Center Core
Cardiovascular Curriculum
Program Model
Linking Knowledge
to Practice
Critical
Thinking
Holistic Care
Evidence
Based Practice
Physiological
Basis
of
Understanding
Certification
Readiness
Novice to
Expert
Thread through
all disciplines
and all settings
in the
continuum of care.
2014
Cardiovascular
Patient
Integration with
orientation,
unit specific education,
skill development,
and role advancement
Goals:
Knowledge Acquisition
Practice Change
Certified Staff
Improved Outcomes
Synergy
Model
Connection To:
Practice,
Research & Quality,
Patient Education,
Precepting Committees
15
Distribution of Core Curriculum
23 Instructors
ICU Educator
MI Coordinaor
HF Coordinator
Cardiology Serv Staff
Cardiology Service PCS
Invasive Lab Staff
CV Surgery Clinic
CVSI Educator
CVSI PCS
CVSI Staff
CCU CNS
CCU Assistant Manager
CCU Staff
CVSI APN
CVC APN
Hospital APN Admin
2013
Instructor
Turnover
2/24 = 8.3%
2013 New
Instructors: 1
0
2014
1
2
3
4
16
2014 Class Schedule
Beginner Practitioner
Classes Presented During Time Frame
Cardiac Dynamics and Assessment
Heart Failure
Noninvasive Cardiac Testing
Dates / Times
Thursday, March 13th
Thursday, October 30th
11:00am – 3:00pm
Part 2
Intro to 12 Lead ECG
ECG Injury and Ischemia
Axis/BBB
Wednesday, March 19th
Wednesday, November 5th
11:00am – 3:00pm
Part 3
Acute Coronary Syndrome
Interventional Cardiology
Open Heart Surgery
Diabetes Management
Thursday, April 10th
Thursday, November 13th
11:00am – 3:00pm
Part 4
CV Pharmacology
Introduction to Device Therapy
Introduction to Pacemaker Rhythm Interpretation and
TTVP Trouble Shooting
Wednesday, April 16th
Wednesday, November 19st
11:00am – 3:00pm
Part 1
2014
17
2014 Class Schedule
Advanced Beginner Practitioner
Classes Presented During Time Frame
Evidence Based Nursing Practice
Heart Sounds and Physical Assessment
The Continuum of Sepsis
Fluid/Electrolytes/Renal
Dates / Times
Tuesday, April 1st
Wednesday, September 10th
11:00am – 3:00pm
Part 2
Arrhythmia Interpretation
ECG Fundamentals/Axis Degree
BBB and Hemiblocks
Ventricular Ectopy
Tuesday, April 15th
Tuesday, September 16th
11:00am – 3:00pm
Part 3
Hemodynamics in Altered Physiology
Inflammatory Disease
Valve Disease
Cardiomyopathy
Wednesday, April 23d
Wednesday, September
24th
11:00am – 3:00pm
Part 4
Pulmonary Physiology and Acid Base
Concepts of Ventilatory and Oxygenation Support
Cardiac Risk Factors
Cardiac Rehabilitation
Tuesday, April 29th
Tuesday, September 30th
11:00am – 3:00pm
Part 1
2014
18
2014 Class Schedule
Skilled Practitioner
Classes Presented During Time Frame
Pulmonary Physiology and Oxygen Delivery
Pulmonary Pathophysiology
Neurovascular Disease (Ischemic Stroke)
Peripheral Arterial Disease
Dates / Times
Tuesday, May 6th
Thursday, October 2nd
11:00am – 3:00pm
Part 2
Narrow Complex Tachycardias
Wide Complex Tachycardias
Injury and Ischemia
Myocardial Mimics and Normal Variants
Tuesday, May 13th
Tuesday, October 7th
11:00am – 3:00pm
Part 3
Pacemakers
ICDs and Cardiac Resynchronization Therapy
NonPharmacological Treatment for Arrhythmias
Antiarrhythmic Pharmacology
Tuesday, May 27th
Thursday, October 16th
11:00am – 3:00pm
Part 4
Advanced Hemodynamics and Assessment
Pharmacology and Hemodynamics
Hematology and Coagulation
Evidence Based Cardiac and Critical Care Practice
Wednesday, June 4th
Wednesday, October 22nd
11:00am – 3:00pm
Part 1
2014
19
2014 Class Schedule
Proficient Practitioner (Certification Preparation Course)
Classes Presented During Time Frame
Dates / Times
Part 1
Issues in Oxygenation
Pulmonary Physiology
Oxygenation and Ventilatory Support
Pulmonary Pathophysiology
Wednesday Feb 12th
8:00am-12:00 Noon
Wednesday April 9th
8:00am-12:00 Noon
Part 2
Issues in Advanced Arrhythmias
Bradys and Blocks
Atrial fibrillation and flutter
Ectopy vs. Aberrancy
Pharmacologic / Nonpharmacologic Treatment for
Arrhythmias
Wednesday Feb 12th
1:00pm-5:00pm
Wednesday April 2nd
1:00pm-5:00pm
Part 3
Patient Management Issues in the continuum of CAD
Advanced ECG: Injury and Ischemia
Complications of Myocardial Infarction
Evidence Based Guidelines for Patient Management
Revascularization
Secondary Prevention Strategies
Wednesday Feb 26th
8:00am-12:00 Noon
Thursday April 24th
7:30am-11:30am
Part 4
Integrated Advanced Cardiovascular Pathophysiology
Valvular Heart Disease
Cardiomyopathies
Inflammatory CV Diseases
Heart Failure
Wednesday Feb 26th
1:00pm-5:00pm
Thursday April 24th
12:30pm-4:30pm
2014
20
2014 Class Schedule
Proficient Practitioner (Certification Preparation Course)
Classes Presented During Time Frame
Dates / Times
Part 5
Advanced Device Therapy
Renal
Endocrine
Tuesday Mar 4th
7:30am-11:30am
Wednesday May 7th
7:30am-11:30am
Part 6
GI/Liver/Pancreatitis
Hematology and Immunology
Multisystem (Sepsis/SIRS/MODS-Toxic Exposures)
Tuesday Mar 4th
12:30pm-4:30pm
Wednesday May 7th
12:30pm-4:30pm
Part 7
Pharmacology and Optimizing Myocardial Performance
Shock States
IABP
Tuesday Mar 18th
7:30am-11:30am
Wednesday May 14th
7:30am-11:30am
Part 8
Diseases of the Aorta
Trauma
Neurological Conditions
Tuesday Mar 18th
12:30pm-4:30pm
Wednesday May 14th
12:30pm-4:30pm
2014
21
2014 Beyond the Core Topics
Dates
Focus Area
Topic
Thursday, Feb 13, 2014
Thursday, July 10, 2014
Clinical Reasoning
/ Critical Thinking
Improving Your Accuracy and Comfort with
ECG / Arrhythmia Interpretation
Monday, Feb 24, 2014
Monday, Aug 18, 2014
Clinical Reasoning
/ Critical Thinking
Cardiorenal Syndrome: Understanding How
the Kidneys and Heart Interact
Monday, Mar 17, 2014
Wednesday, Sept 17,
2014
Clinical Reasoning
/ Critical Thinking
You DO Make a Difference in Patient
Outcomes: Understanding Your Contribution
to Outcomes
Tuesday, Apr 8, 2014
Wednesday, Oct 29,
2014
Thursday, May 15, 2014
Thursday, Nov 20, 2014
Clinical Reasoning
/ Critical Thinking
Nursing Implications for Anticoagulant and
Antiplatelet Therapy
Clinical Reasoning
/ Critical Thinking
Hemodynamic Case Studies: Noninvasive and
Invasive
Tuesday, Jun 3, 2014
Thursday,
2014 Dec 18, 2014
Clinical Reasoning
/ Critical Thinking
Critical Analysis and Reporting of Abnormal
22
Assessment Findings
2014 Level 5 Symposium Topics
Focus Area
Impacting Patient
Outcomes
Topic
Content
Secondary Prevention in 1. Implementing New Guidelines for Cholesterol and
Diet
Cardiovascular Disease
2. Implementing New Guidelines for HTN
3. Implementing New Guideline Recommendations
for Obesity / Over Weight and Tobaccoism
DATE: TBA
Monday June 17,
2013
Professional
Development: Step
Forward
1. Charting Your Career Path: What are the Options?
2. Beyond BSN: The Consensus Model for APN
Practice
3. Communicating with Power
Impacting Patient
Outcomes
Impacting Cardiac
Failure
1. Essential Medical Management: Are we doing the
right things?
2. Essential Nursing Practice: Making a Difference
with Each Encounter
3. Essential Considerations: Circulatory Support
Devices in the Treatment of Heart Failure
Engagement
Thursday, Sept 18,
2014
Engagement
Clinical Leadership:
Monday, Dec 15, 2014 Step Forward
2014
1. Creating Safe Passages
2. Caring Practice
3. Competent Practice: What, Where and Why
23
The Culture of CCU
• CCU organized under a product line Heart Center
Model
• CCU provides care to cardiac medical ICU, progressive
care and step down patients, and patients preparing
for discharge.
• Defining characteristics:
- Three-time Beacon Unit (hoping for #4 soon!)
- Strong Unit Based Shared Governance
- PULSE study
- A rich unit based orientation structure
and process (est. 2000)
2014
24
2014
25
2014
26
The Culture of CCU
• Orientation components:
- Clinical Orientation Pathway for Step down and ICU levels of care
– Daily Score Card for core clinical skill development
– Tools are based on the new RN graduate perspective but individualized for
nurses with experience
– Established application process for preceptors with Committee Peer Review
– Hospital Preceptor Workshop with required refresher every 2 years
– Unit-Based Preceptor Quarterly Meetings consisting of current preceptee
orientation needs, clinical skill builder and role development focus
• Orientation outcomes:
– > 90% one-year post orientation retention since 2008
– Preceptee satisfaction with orientation > 9.0 (1-10 scale) since 2011
2014
27
SPECIFICS OF THE NEW
PARADIGM
2014
28
Competency Changes as Introduced to Staff
• Required organizational competency will
continue.
• General nursing and critical care competencies
as well as competencies related to advanced
skills (i.e. IABP) will continue to be important.
• Unit specific competency is the area of
paradigm shift. The goal is to take cardiac
nursing practice to the next level by focusing
each year on key areas of cardiac nursing
practice.
2014
29
Competency Changes as Introduced to Staff
• Competency will be evaluated continuously throughout
the year as opposed to at a single point in time during
the year.
– A variety of competency activities and assessment will be
completed throughout the year.
– The competency process will be more interactive. Each
professional nurse will assume responsibility for the
documentation of his or her competency in each clinical area.
– Competency assessment will be more closely linked with real
time clinical practice.
• An annual competency meeting will occur as an
opportunity to review documentation of ongoing
competency via the professional portfolio and to set
future clinical goals.
2014
30
Competency Changes as Introduced to Staff
• Each professional nurse will asked to begin a
professional portfolio.
– The professional portfolio will be discussed during
the annual competency meeting and during the
annual evaluation.
– Required content of the professional portfolio
include:
2014
31
Requirements for Professional
Portfolio Content
• Required activities form from annual focus areas
– Exemplars
– Journal article summaries
• Self Assessment of Adherence to Linking Knowledge
to Practice Expectations
• Progress toward established clinical goals
• Continuing education activities (required)
–
–
–
–
2014
Professional nursing practice
General clinical
Critical care
Cardiac specific (Core Curriculum and Beyond the Core)
32
•
Self Assessment of
Linking Knowledge to
Practice Expectations
For each class in the
novice to expert
curriculum there are
expected practice
expectations. These
are distinctly
separate from
objectives.
2014
•
•
•
•
•
In conjunction with your annual competency and
your evaluation this year you are being asked to
complete a self-assessment of the attached
clinical expectations. The purpose of this exercise
is to increase your awareness of the clinical
expectations as well as to assess your current
clinical practice. Please be as honest as you can.
The goal of this exercise not punitive, but, to
develop an understanding of current practice
patterns in CCU. This will help us continue to
develop future programs on the hopes of
enhancing clinical practice and ultimately
outcomes. This tool will become part of your
professional portfolio and progress reviewed
annually. Remember to look at the years of
experience attached with each level to
understand where your level of practice should
be. Please evaluate your clinical practice for
each item utilizing the following scale:
1 = Never performs in daily practice
2 = Rarely performs in daily practice
3 = Occasionally performs in daily practice
4 = Often performs in daily practice
5 = Consistently performs in daily practice
33
Level 1: Beginning Practitioner (0-1 year of clinical experience)
Level 1 is designed for new Heart Center employees. The Beginning Practitioner period lasts approximately one year as the
Beginning Practitioner becomes acclimated to his or her environment, learns policies and procedures, and develops a
baseline understanding of the cardiac patient.
Level 2: Advanced Beginner (1-2 years of clinical experience)
The Advanced Beginner continues to develop more confidence in his or her clinical skills. The Advanced Beginner has coped
with enough real situations to recognize the recurring components of the situation, but continues to require assistance from
a mentor or more experienced nurse to guide actions. The Advanced Beginner level lasts for approximately 1to 2 years.
Level 3: Skilled Practitioner (2-3 years of clinical experience)
The Skilled Practitioner in 2 or 3 years of practice has developed a comfort level with his or her routine bedside practice.
The Skilled Practitioner expands his or her depth of knowledge and critical thinking skills. For the Skilled Practitioner, plans
are established based on conscious, abstract, analytic contemplation of the problem. This deliberate planning helps achieve
efficiency and organization. The Skilled Practitioner lacks the speed and flexibility of the proficient nurse but does have a
feeling of mastery and the ability to cope with and manage the many contingencies of clinical nursing.
Level 4: Proficient Practitioner (3- 5 years of clinical experience or anyone with more years of
experience but not certified)
The Proficient Practitioner has mastered a high level of proficiency in the care of the cardiac patient demonstrating both
efficiency and flexibility, while utilizing critical thinking skills to drive practice. Decision making becomes less labored due to
understanding of the nuances of a situation. The proficient nurse can recognize when the expected normal picture does not
materialize. The Proficient Practitioner provides guidance and direction for other staff.
Level 5: Expert Practitioner (Certified Staff)
Once the Proficient Practitioner has achieved the goal of specialty certification he or she is considered an Expert Practitioner
in the Heart Center. The expert nurse, has an intuitive grasp of each situation and zeroes in on the accurate region of the
problem without wasteful consideration of a large range of unfruitful, alternative diagnoses and solutions. The expert
operates from a deep understanding of the total situation. The Expert Practitioner’s performance becomes fluid, flexible
and highly proficient. When faced with an unfamiliar situation the expert relies on analytical thinking to determine the
appropriate clinical response.
2014
34
Pulmonary
Clinical Practice Expectation
Level 1
Level 2
Part 4
* Items I plan to focus on this
next year (2013)
** Items for which I have
documentation of linking
knowledge to practice (2012)
√ Performs basic blood gas interpretation (assessment for ventilation versus diffusion
abnormality, acidosis or alkalosis as metabolic or respiratory origin, compensation).
√ Reviews respiratory therapy documentation at the beginning of each shift when caring for
patient on ventilator to determine mode of ventilator, settings, and adjunctive therapy.
√ Requests family to bring in home CPAP or BiPAP therapy to continue treatment during
hospitalization. When not possible ask case manager to obtain setting from patient’s home
medical company.
√ Reports any tachypnea in a patient on mechanical ventilation.
√ Assures 100% compliance with oral care.
√ Assures adequate sedation and pain control in all patients who are intubated.
√ Performs daily awakening trial.
√ Identifies a patient who meets weaning criteria.
Self-Assessment of
Practice
4
4
4
5
5
4
3
5 **
Level 3
Part 1
√ Assesses and documents PaO2 / FIO2 ratios on all patients with ABGs/ ventilator therapy.
5
√ Differentiates respiratory failure as either ventilatory or oxygenation failure.
4
Level 4
Part 1
√ Assesses (from respiratory documentation) peak inspiratory and plateau pressures at the
beginning of each shift for mechanically intubated patients..
√ Trend PaO2/FIO2 ratio on all patients on mechanical ventilation.
√ Verify prolonged expiratory time on mechanically ventilated patients with COPD.
√ Rule out tension pneumothorax on any mechanically intubuted patient who develops
hypotension.
2014
√ Assure adequate volume status prior to adding positive pressure ventilation and / or
3
5
3
3*
35
3*
Suggestions for Professional
Portfolio Content
• Certifications
– CCRN
– CMC
– CHFN
• Community involvement / Volunteer activities
• Formal academic coursework / degree earned
– BSN
– MSN
• Awards / Achievements (Personal and Professional)
• Practice narratives / peer review statements /
specific examples of clinical contributions
• Positive feedback from patient satisfaction surveys / call backs
2014
36
Suggestions for Professional Portfolio
Content
• Attendance and involvement in:
– Unit based shared decision making
– Heart Center committees
– Organizational shared decision making
– Professional organizations
• Certificates
– ACLS
– Fundamentals of Critical Care Support
Sample portfolios are here for your review.
2014
37
Using the Portfolio to Move from “Annual”
Assessment to Continuous Assessment
 Competency in nursing practice is
performed 24/7 on a continuous and real
time basis.
 Competency assessment is moving to a
real time evaluation of daily clinical
practice to assure the highest level of
excellence in nursing practice.
 Encouraged to capture evidence of
competency on a concurrent basis and
include in portfolio.
2014
38
Competency Focus Areas To Date
2011
2012
2013
Core Clinical Business:
Cardiac Monitoring
Cardiac Monitoring
Cardiac Monitoring
Building on Patient
Education: Teach Back
Cardiac Rehabilitation
Heart Failure
New Focus Areas Based
on Identified Gaps :
Pulmonary
Patient Education for
Acute Coronary Syndrome
and Heart Failure
2014
Hemodynamics
Assessment
Antiarrhythmic
Pharmacology
39
For each focus area: Nurses are
required to bring evidence of
competency in their portfolio. There
are some required activities and there
are some activities where nurses are
given a choice.
2014
40
Your Choice Activity: Choose One of the Activities
below to fulfill cardiac monitoring competency.
Obtain or maintain certification as a CCRN and / or
CMC, or CHFN
Submit a peer review written statement for your
portfolio demonstrating how you have shown clinical
leadership in the area of cardiac monitoring
Submit a self written reflective practice statement for
your portfolio on how you have positively impacted
clinical practice in the area of cardiac monitoring
Read an evidence based cardiac monitoring journal
article and bring to your individual competency
meeting.
Attend a Heart Center Clinical Practice Committee
Meeting.
2014
41
Pilot Results
Cardiac Monitoring
2014
42
Number of Alarm Banks
Reviewed
Pre
Intervention
Data
Post
Intervention
Data
93
125
# / % patients with Clinically
Significant Arrhythmias
14/93 = 15.05% 26 / 125 = 20.8%
#/% of Clinically Significant
Arrhythmias Posted to Chart
9/23 = 39.13%
#/% Clinically Significant
Arrhythmias Documented in ICU
Flow
# /% of Clinically Significant
Arrhythmias With Provider
Notification
2014
Percent
p-Value
Improvement
N/A
0.28
21/27 = 77.78%
38.5%
*0.005
8/23 = 34.78%
15/27 = 55.6%
20.82%
0.14
5/16 = 31.25%
9/22 = 40.9%
9.65%
0.54
43
Number of Nurses Assessed
Number of Charts Reviewed
Accuracy of V Lead Placement
27
31
91
106
N/A
44/84 = 52.38%
81/102 = 79.4%
 27.1%
(p=.08)
Accuracy of Limb Lead
43/84 = 51.19%
73/102 = 71.6%
 20.41%
74/86 = 86.05%
96/103 = 93.2%
 7.15%
2/13 = 15.38%
19/28 = 67.9%
 52.5%
Placement
Appropriate Documentation
of QRS Width
Appropriate Documentation
of BBB
Accuracy of QTc
(p=.07)
57/80 = 71.25%
74/79 = 93.7%
 22.45%
33/68 = 48.53%
47/67 = 70.1%
 21.57%
Documentation
V lead ST Segment Alarms at
1 mm above and 1 mm below
2014
baseline
44
1. The new competency assessment program recognizes my
knowledge and skill related to cardiac monitoring.
2. The new competency assessment program identifies
opportunities for improvement of my practice related to
cardiac monitoring.
3. The new competency assessment program reflects
important issues in clinical practice.
4. I am more likely to engage in ongoing learning activities
related to cardiac monitoring as a result of the new
competency assessment program.
5. I am more likely to change my clinical practice as a result of
the new competency assessment program.
4.5
5.0
4.5
4.0
4.0
6. The new competency assessment program will increase my
confidence in my rhythm interpretation skills.
4.0
7. The new competency assessment program will provide me
2014
autonomy
in evaluating my competency.
4.5
45
2014
46
2013 Competency Outcome
Assessment
• Accuracy of electrode placement for cardiac
monitoring (follow up to initial evaluation)
– Assessment of sustainable change
• Synergy Model Competencies and Outcomes
Assessment for two key areas:
– Cardiac Monitoring (Core Business)
– Teach Back (Unit Based Quality Initiative to Expand
on 2011 Patient Education and 2012 HF Focus)
2014
47
• Resiliency
• Vulnerability
• Stability
• Complexity
• Predictability
• Resource availability
• Participation in care
• Participation in decision
making
2014
• Clinical Judgment
• Advocacy / Moral Agency
• Caring Practices
• Collaboration
• Systems Thinking
• Response to Diversity
• Facilitator of Learning
• Clinical Inquiry (Innovator /
48
Evaluator)
Our Methodology
• AACN Synergy definitions were used as the framework.
• Three reviewers with two reviewers who were blinded
to the nurse identification and characteristics.
• Exemplars were read and evaluated for demonstrated
Synergy competencies.
• Synergy competencies were evaluated for novice to
expert level (level 1, 3 or 5) per AACN Synergy criteria.
• All three reviewers needed to be in agreement for final
assigned competency category.
2014
49
CLINICAL JUDGMENT
Level 1 Competent
ADVOCACY/MORAL
AGENCY
Level 1 Competent
CARING PRACTICES
Level 1 Competent
Level 3
Level 5 Clinical reasoning, which includes clinical decision-making, critical thinking,
Expert and a global grasp of the situation, coupled with nursing skills acquired
through a process of integrating formal and experiential knowledge
Level 3
Level 5 Working on another's behalf and representing the concerns of the patient,
Expert family and community; serving as a moral agent in identifying and helping
to resolve ethical and clinical concerns within the clinical setting
Level 3
COLLABORATION
Level 1 Competent
Level 3
SYSTEMS THINKING
Level 1 Competent
Level 3
RESPONSE TO DIVERSITY
Level 1 Competent
Level 3
CLINICAL INQUIRY
Level 1 Competent
Level 3
FACILITATOR OF LEARNING
Level 3
Level 12014
Competent
Level 5 The constellation of nursing activities that are responsive to the
Expert uniqueness of the patient and family and that create a compassionate and
therapeutic environment, with the aim of promoting comfort and
preventing suffering. These caring behaviors include, but are not limited
to, vigilance, engagement, and responsiveness
Level 5 Working with others, (eg, patients, families and healthcare providers) in a
Expert way that promotes and encourages each person's contributions toward
achieving optimal and realistic patient goals. Collaboration involves intraand inter-disciplinary work with all colleagues
Level 5 The body of knowledge and tools that allows the nurse to appreciate the
Expert care environment from a perspective that recognizes the holistic
interrelationship that exists within and across healthcare systems
Level 5 The sensitivity to recognize, appreciate, and incorporate differences into
Expert the provision of care. Differences may include, but are not limited to,
individuality, cultural differences, spiritual beliefs, gender, race, ethnicity,
disability, family configuration, lifestyle, socioeconomic status, age values,
ad beliefs surrounding alternative/ complimentary medicine involving
patients, families, and members of the healthcare team
Level 5 The ongoing process of questioning and evaluating practice, providing
Expert informed practice and innovating through research and experiential
learning. The nurse engages in clinical knowledge development to promote
the best patient outcomes
Level 5 The ability to facilitate patient and family learning
Expert
50
Clinical Judgment
• Level 1: Collects basic-level data; follows
algorithms, decision trees and protocols with
all populations and is uncomfortable deviating
from them; matches formal knowledge with
clinical events to make decisions; questions
the limits of one's ability to make clinical
decisions and delegates the decision-making
to other clinicians; includes extraneous detail
2014
51
Clinical Judgment
• Level 3: Collects and interprets complex
patient data; makes clinical judgments based
on an immediate grasp of the whole picture
for common or routine patient populations;
recognizes patterns and trends that may
predict the direction of illness; recognizes
limits and seeks appropriate help; focuses on
key elements of case, while sorting out
extraneous details
2014
52
Clinical Judgment
• Level 5: Synthesizes and interprets multiple,
sometimes conflicting, sources of data; makes
judgment based on an immediate grasp of the
whole picture, unless working with new patient
populations; uses past experiences to anticipate
problems; helps patient and family see the "big
picture"; recognizes the limits of clinical judgment
and seeks multidisciplinary collaboration and
consultation with comfort; recognizes and
responds to the dynamic situation
2014
53
2013: Distribution of Your Choice Activities
Competency Area: Antiarrhythmic Medications
Activity Option
CE Offering
Journal Article
Review
LexiComp Drug
Review
Certification
Status
Percent Distribution
1.9%
43.5%
38.0%
16.7%
Competency Area: Hemodynamics
Activity Option
CE
Offering
Journal Article
Review
Square Wave
Test
Percent Distribution
12.6%
67.0%
1.9%
Clinical
Practice
Committee
1.0%
Certification
Status
17.5%
Competency Area: Pulmonary
Activity Option
CE Offering
Journal Article
Review
Exemplar
Certification
Status
Percent Distribution
7.0%
61.0%
14.0%
18.0%
2014
54
Accuracy of Lead Placement
2010 – 2013
• 2013 Sustained Practice Sample Size: 493
• Hardwire: 35
• Telemetry: 458
Electrode
Percent Correct
Placement: Pre
Competency
Implementation
Left arm
51% (Limb leads combined) 72% (Limb leads combined)
84%
Right arm
51% (Limb leads combined) 72%
(Limb leads combined)
86%
Left leg
51% (Limb leads combined) 72%
(Limb leads combined)
86%
V1
52% (V leads combined)
79% (V leads combined)
86%
V3
52% (V leads combined)
79% (V leads combined)
78%
2014
Percent Correct Placement:
Post Competency
Implementation 2011
Percent Correct
Placement: Sustained
Results 2013
55
2013 Exemplar Reviews
Number of
Registered Nurses
Percent Distribution
1 (Beginning
Practitioner)
2 (Advanced Beginner)
16
16.3%
7
7.1%
3 (Skilled Practitioner)
4 - Beyond the Core
(Proficient Practitioner)
19
38
19.4%
38.8%
Certified Staff (Expert
Practitioner)
18
18.4%
Curriculum Level
2014
56
Teach Back Exemplars:
Level 1
Competency
Number
Level
Percent
Facilitator of Learning
28
1
67.8%
3
28.6%
5
3.6%
1
100%
3
-
5
-
1
100%
3
-
5
-
1
100%
3
-
5
-
1
100%
3
-
5
-
(Beginning Practitioner)
•16 participants
• 32 Exemplars
• Exemplars with no
teach back addressed:
4 (12.5%)
• Outcomes: 31
Response to Diversity
Systems Thinking
Caring Practice
5
1
1
Outcomes
Patient
learning
27
Family
Learning
4
2014
Clinical Judgment
1
57
Teach Back Exemplars:
Level 2
(Advanced Beginner)
• 7 Participants
• 14 Exemplars
• Outcomes: 18
Competency
Number
Level
Percent
Facilitator of Learning
14
1
57.1%
3
42.9%
5
-
1
44.4%
3
55.6%
5
-
Response to Diversity
9
Outcomes
Patient
learning
14
Family
Learning
4
2014
58
Teach Back Exemplars:
Level 3
Skilled Practitioner
• 19 Participants
• 38 Exemplars
• Exemplars with no
teach back addressed:
2 (5.3%)
• Outcomes: 42
Outcomes
Competency
Number
Level
Percent
Facilitator of Learning
36
1
44.4%
3
55.6%
5
-
1
66.7%
3
33.3%
5
-
1
33.3%
3
66.7%
5
-
1
100%
3
-
5
-
1
100%
3
-
5
-
Response to Diversity
Systems Thinking
Collaboration
Patient
learning
35
Family
Learning
6
Family
comfort /
2014
satisfaction
1
Advocacy
15
3
2
1
59
Teach Back Exemplars:
Level 4 – Beyond the Core
Proficient Practitioner
• 38 Participants
• 77 Exemplars
• 8 Exemplar efforts not
satisfactory
•No teach back
addressed: 4 (5.2%)
• Outcomes: 78
Competency
Number
Level
Percent
Facilitator of Learning
66
1
62.1%
3
31.8%
5
6.1%
1
54.5%
3
27.3%
5
18.2%
1
37.5%
3
37.5%
5
25%
1
50%
3
-
5
50%
1
-
3
100%
5
-
Response to Diversity
Systems Thinking
Caring Practice
22
8
2
Outcomes
Patient
learning
62
Family
Learning
13
Family
comfort /
satisfaction
2014
3
Collaboration
Advocacy
1
1
1
-
3
100%
5
Note: One example of uncaring practice.
-
60
Teach Back Exemplars:
Certified Staff (Expert)
• 18 Participants
• 36 Exemplars
• Exemplars with no
teach back addressed:
3 (8.3%)
• Outcomes: 38
Outcomes
Competency
Number
Level
Percent
Facilitator of Learning
33
1
66.7%
3
21.2%
5
12.1%
1
71.4%
3
21.4%
5
7.1%
Response to Diversity
Systems Thinking
Caring Practice
Patient
learning
31
Family
Learning
5
Family
comfort /
2014
satisfaction
2
Advocacy
14
4
3
3
1
50%
3
50%
5
-
1
33.3%
3
66.7%
5
-
1
100%
3
-
5
-
61
Cardiac Monitoring
Exemplars:
Level 1
(Beginning Practitioner)
• 16 participants
• 32 Exemplars
• Exemplars with
Outcomes = 68.8%
Competency
Number
Level
Percent
Clinical Judgment
30
1
76%
3
24%
5
-
1
100%
3
-
5
-
1
100%
3
-
5
-
1
50%
3
50%
5
-
Advocacy
Collaboration
5
5
Outcomes
Change in
Immediate
Treatment
19 = 59.4%
Clinical Inquiry
1
Change in
4 = 12.5%
Overall Plan
of Care
* N for outcomes = number of exemplars. Some exemplars may be > 1 outcome.
2014
62
Cardiac Monitoring
Exemplars:
Level 2
(Advanced Beginner)
•
•
•
•
7 participants
14 Exemplars
2 Exemplars unsatisfactory
Exemplars with Outcomes
= 35.7%
Competency
Number
Level
Percent
Clinical Judgment
9
1
66.7%
2
33.3%
3
-
1
80%
2
20%
3
-
1
100%
2
-
3
-
1
-
2
100%
3
-
1
-
2
100%
3
-
Advocacy
Collaboration
5
5
Outcomes
Change in
Immediate
Treatment
4 = 28.6%
Change in
1 = 7.1%
Overall Plan
of Care
* N for outcomes = number of
exemplar. Some exemplars may
be
> 1 outcome.
2014
Caring Practice
Systems Thinking
2
1
63
Cardiac Monitoring
Exemplars:
Level 3
(Skilled Practitioner)
•
•
•
•
19 participants
39 Exemplars
2 Exemplars unsatisfactory
Exemplars with Outcomes
= 64.1%
Competency
Number
Level
Percent
Clinical Judgment
34
1
47.1%
3
52.9%
5
-
1
50%
3
50%
5
-
1
66.7%
3
-
5
33.3%
1
50%
3
50%
5
-
Advocacy
Collaboration
6
6
Outcomes
Change in
Immediate
Treatment
23 = 59.0%
Clinical Inquiry
6
Change in
4 = 10.3%
Overall Plan
of Care
* N for outcomes = number of exemplars Some exemplars may be > 1 outcome.
2014
64
Cardiac Monitoring
Exemplars:
Level 4
(Proficient Practitioner)
•
•
•
•
38 participants
76 Exemplars
3 Exemplars unsatisfactory
Exemplars with Outcomes
= 75%
Outcomes
Change in
Immediate
Treatment
Competency
Number
Level
Percent
Clinical Judgment
70
1
61.4%
3
34.3%
5
4.3%
1
55.6%
3
27.8%
5
16.7%
1
15.8%
3
47.4%
5
36.8%
1
-
3
50%
5
50%
1
53.8%
3
30.8%
5
15.4%
1
100%
3
-
5
-
1
100%
3
-
5
-
Advocacy
Collaboration
Caring Practice
Clinical Inquiry
18
19
2
13
50 = 65.7%
Change in
13 = 17.1%
Overall Plan
of Care
* N for
outcomes = number of exemplar.
2014
Some exemplars may be > 1 outcome.
Systems Thinking
Facilitator of Learning
1
1
65
Cardiac Monitoring
Exemplars:
Level 5
(Expert Practitioner)
• 18 participants
• 39 Exemplars
• Exemplars with
Outcomes = 69.2%
Competency
Number
Level
Percent
Clinical Judgment
37
1
43.2%
3
45.9%
5
10.8%
1
50%
3
33.3%
5
16.7%
1
25%
3
25%
5
50%
1
50%
3
-
5
50%
1
14.3%
3
57.1%
5
28.6%
66
Advocacy
Collaboration
12
12
Outcomes
Change in
Immediate
Treatment
19 = 48.7%
Change in Overall
Plan of Care
8 = 20.5%
Increased staff
knowledge
1 = 2.6%
Caring Practice
* N for
outcomes = number of exemplar.
2014
Some exemplars may be > 1 outcome.
Clinical Inquiry
2
7
2014
67
Outcome Definitions
Immediate Treatment
• Medication and/or dose
changes
• Electrolyte replacement
(labwork)
• Consults
• Central line placement
2014
Change of Overall Plan of Care
• Cancellation of
tests/procedures
• Change in code status
• Cancellation of discharge
• Emergent procedures (heart
cath/PCI/OHS)
• Change in level of care
68
Cardiac Monitoring Exemplars with
Outcomes
80.00%
70.00%
60.00%
# Exemplars:
76
# Exemplars:
32
# Exemplars:
39
# Exemplars:
39
50.00%
40.00%
# Exemplars:
14
30.00%
% Outcomes
20.00%
10.00%
0.00%
Level 1
2014
Level 2
Level 3
Level 4
Beyond
Core
Certified
69
Exemplars with Change in Immediate
Treatment
% Change Immediate Treatment
70.00%
60.00%
50.00%
40.00%
30.00%
% Change Immediate
Treatment
20.00%
10.00%
0.00%
Level 1
2014
Level 2
Level 3
Level 4 Certified
Beyond
Core
70
Exemplars with Change in Overall Plan
of Care
% Change in Overall Plan of Care
25.00%
20.00%
15.00%
10.00%
% Change in Overall Plan
of Care
5.00%
0.00%
Level 1 Level 2 Level 3 Level 4 Certified
Beyond
Core
2014
71
2014
72
Expert in Clinical Judgment
15.00%
10.00%
5.00%
% Expert
0.00%
Level 1
2014
Level 2
Level 3
Level 4
Beyond
Core
Certified
73
Expert in Advocacy
20.00%
15.00%
10.00%
% Expert
5.00%
0.00%
Level 1
2014
Level 2
Level 3
Level 4
Beyond
Core
Certified
74
Expert in Collaboration
50.00%
40.00%
30.00%
20.00%
% Expert
10.00%
0.00%
Level 1
2014
Level 2
Level 3
Level 4
Beyond
Core
Certified
75
Expert in Clinical Inquiry
30.00%
20.00%
10.00%
% Expert
0.00%
Level 1
2014
Level 2
Level 3
Level 4
Beyond
Core
Certified
76
Expert in Caring Practice
50.00%
40.00%
30.00%
20.00%
% Expert
10.00%
0.00%
Level 1
2014
Level 2
Level 3
Level 4
Beyond
Core
Certified
77
Cardiac Monitoring Exemplar
• Beyond the Core Level Nurse
• Competencies (Level 5)
-Clinical Judgment
-Advocacy
-Collaboration
-Clinical Inquiry
2014
78
Cardiac Monitoring Exemplar
• Beginning Practitioner (Level 1)
• Competencies (Level 3)
-Clinical Judgment
-Clinical Inquiry
2014
79
Teach-Back Exemplar
• Beyond the Core Level Nurse
• Competencies
– Facilitator of learning (level 5)
– Caring practice (level 5)
– Diversity (level 5)
– Advocacy (level 3)
• This next exemplar made us smile!
2014
80
Conclusion
2014
81
Initials Insights
• A more holistic perspective
• Shift in accountability to the individual
registered nurse
• Brings to light the scope of knowledge and skill
required for competence at the point of care
• Direct observation of specific individual
practice is necessary to identify gaps that may
not be identified by more global quality
indicators (NDNQI, Core Measures, etc).
• Majority of nurses are willing to embrace
structures and processes that raise the bar for
clinical practice standards
2014
82
2013 Unexpected Discoveries
• Physician resistance to nurse expertise
• Many nurses are novice in writing about
competency, not comfortable with self
reflection
• Gap in knowledge and skill regarding tobacco
cessation counseling
• Honesty regarding self assessment of linking
knowledge to practice expectations
2014
83
2013 Insights
• Capturing clinical judgment at the point of care
provides recognition for the complexity of clinical
decision making.
• Bringing to light previously nonncaptured
associations and non measured outcomes
– Self reflection statements and clinical examples within
the portfolios capture application of knowledge at the
point of care that would otherwise not be
acknowledged.
• Telling the story of nursing practice
2014
84
2013 Insights
• A nurse may be at a different level of development for
different competencies
• Years of experience alone does not equate to expert
level of practice
• Portfolio was objective validation of subjective preassessment
• After 3 years of mentoring and coaching – ready to
step up the level of expectation for satisfactory
competency
• Competency assessment is basis for clinical goal
development and for inclusion in evaluation process
for clinical performance
2014
85
Future Goals
• Clarity regarding level of quality for portfolio
components and progress toward goals.
• Balance between evaluator and coach/mentor.
• Move forward with less “content” and more focus on
evidence of excellence in practice.
• Balance between recognizing certification and
continuing to develop certified nurses.
• Opportunity to recognize specific nursing strengths for
future growth and development.
• Correlate competency assessment with advancement in
skill training and other opportunities.
2014
86
Concluding Thought
This recognition results in either deep
professional satisfaction from knowing the full
extent that one’s work is worthwhile, or it
provides the catalyst for future growth and
development.
2014
87
Rfleischman@aultman.com
Karen@cardionursing.com
Cindy@cardionursing.com
2014
88