newsletter october 2010 -...

September 24th in Toronto, Doris Grinpsun requested that each interest group consider choosing one of the RNAO Best Practice Guidelines (BPG) and be-come a Champion for the BPG of their choice! Are CNSs BPG Champions? Tell us about your experience. Perhaps you would consider writing an article in our newsletter explaining your successes and lessons learned. This would be a tremendous learning experi-ence for us all and a great learning opportunity for the novice Champions. Awaiting with anticipation to hear

your stories. A little reminder ... Mu-

nicipal Elections in Ontario are being held on October

25th, 2010 ! CNSIG encourages you

to vote… CNSs, we need to

hear your voices!

Reality check… Autumn is here! Are clinical nurse specialists (CNS) thriving in this era of fast paced changes? Are you a CNS who is busy at resolving challenges in your work-place, focusing on the ac-creditation process, writing research proposals, devel-oping programs, creating learning opportunities, pro-viding clinical expertise and direct care to patients, available for consultation regarding patient complex care needs, evaluating risk management strategies,

etc. To all the CNSs, THANK

YOU for improving patient and client outcomes, men-toring other members of the interprofessional care team and for all the excellent work that you are achieving and publishing! The world is a better place because you, as a CNS, are making a sig-nificant difference in the lives of your patients, fami-

lies and colleagues. As previously mentioned

in our last newsletter, our interest group is no longer a member of the Canadian Association of Advanced

Practice Nurses (CAAPN) since January 2010. The CNSIG membership fee pre-viously was forty dollars ($40.) and it was distrib-uted in the following man-ner: CNSIG would receive fifteen dollars ($15.) and CAAPN would receive twenty-five dollars ($25.). At the last annual general meeting of the CNSIG on April 17, 2010, it was agreed upon that our membership fee would remain at fifteen dol-lars ($15.) for this coming year 2010-2011. Our fee structure will be revisited at

the next AGM in April 2011. CNSIG provided the fol-

lowing awards in 2010. El-sabeth Jensen and Sarah Benbow were each awarded one thousand dollars ($1000.) respectively for the CNSIG Educational Awards of the Year. Con-

gratulations! CNSIG is busy working

on the revision of its new look & content for the RNAO website! Will keep you in-formed when the updates

will be completed! During the Interest

Groups Chairs meeting on

CNSIG in 2010

Message from the President:

Volume 2010. No 2

Newsletter

October 2010

Inside this issue:

Message of the President.

1

Patient Safety &

CNS Practice.

2

CNS in USA (NACNS confer-ence).

3

CNA web site links.

4

Book Summary: Foundations of CNS Practice.

5 to

7

CNS Association of Canada

8

CNSIG executive 9

Carmen RodrigueCarmen RodrigueCarmen RodrigueCarmen Rodrigue President of CNSIG.

Nuts and Bolts of Patient Safety and CNS Practice.Nuts and Bolts of Patient Safety and CNS Practice.Nuts and Bolts of Patient Safety and CNS Practice.Nuts and Bolts of Patient Safety and CNS Practice. Humans make mistakes and to make mis-

takes is human. For that reason, clinical nurse specialists need to keep abreast of advances regarding patient safety as it relates to quality care. They are well positioned to assist organi-zations to make patient safety a top priority since the application of systems approach models is part of their daily practice. This arti-cle will present a practical review of how to integrate the nuts and bolts of patient safety in

CNS practice.

First, understand the language and basic concepts of patient safety. Error, near miss, incident and adverse event are few examples. Another important preliminary step includes gaining an understanding of values and beliefs held by employees, their organization and the population health care and services are deliv-ered to. Existing gaps and similarities will emerge as a result of this assessment. This information is instrumental in determining next steps and in selecting key efforts that will

bridge autonomy and accountability. Second, understand the impact of safety

incidents. Incidents are undesired at various

levels: a) Patients’ trust in healthcare providers

and its administration is compromised to

various degrees; b) The stigma attached to employees in-

volved in an incident and how it affects

their practice; and c) The organization’s reputation and image

is at risk.

Third, know the various organizations whose mandate is centered on patient safety. Safer Healthcare Now, Accreditation Canada and Canadian Patient Safety Institute are few of several organizations that offer a wealth of web-based resources in the form of informa-tion, reports, tools, forms, models and tricks of the trade. In addition, becoming skilled in us-ing popular quality improvement models such

as Plan-do-check-act, Failure mode and effect

analysis and Root cause analysis are beneficial

to improve patient safety systems.

Fourth, integrate systematic strategies to promote a safety of culture in the practice envi-ronment. Such strategies can take the form of processes that promote bi-directional communi-cation among interdisciplinary team members where individuals share common views and en-courage staff to discuss errors, focusing on the “why” rather than the “who.” Other strategies consist of establishing regular discussions through case studies, staff meetings, journal clubs, quality boards, audits and staff sugges-tions’ box to reduce the barriers that prevent

staff to identify risks and propose solutions.

Finally effective use of collaboration with staff, patients and key partners combined with effective communication skills, goal and deci-sion-making sharing and complementary pro-fessional knowledge and skills are part of unique set of skills CNSs can exercise to en-gage others to place patient safety in the fore-

front of their daily practice.

Hopefully these nuts and bolts have provided a review for some and useful information for others of the various strategies CNSs can tap into to ensure that patient safety remains a top

priority at all times, every time.

Sources: Hamric, A. B., Spross, J. S., & Hanson, C. M.

(2009). Advanced practice nursing: An inte-grative approach (4th ed.). St-Louis, MI:

Saunders Elsevier.

www.saferhealthcarenow.ca www.patientsafetyinstitute.ca/ www.accreditation.ca http://www.health.gov.on.ca/patient_safety/ http://www.hc-sc.gc.ca/hcs-sss/qual/

patient_securit/index-eng.php

Dania Versailles

Volume 2010. No 2 October 2010 Newsletter

On March 3rd to March 6th, 2010, I attended the NACNS national conference and annual general meeting in Portland, Oregon, USA. The National Association of Clinical Nurse Specialists is the only national associa-

tion representing the CNSs in the United States.

On the picture [ from left to right ] : On the picture [ from left to right ] : On the picture [ from left to right ] : On the picture [ from left to right ] : ----Stephen Patten, NACNS President-

Elect, -Paul-André Gauthier, Co-Chair of CNS

Association of Canada, and

-Patti Zuzelo, NACNS President.

Information concerning the NACNS : Information concerning the NACNS : Information concerning the NACNS : Information concerning the NACNS : http://www.nacns.org/ The next CNS conference «««« CNS: Your clinical innovation expert » CNS: Your clinical innovation expert » CNS: Your clinical innovation expert » CNS: Your clinical innovation expert » will be held March 10-12, 2011201120112011 at the Bal-

timore Marriott Waterfront Hotel, Baltimore, Maryland, USA. http://www.nacns.org/Conference/2011Conference/tabid/163/Default.aspx

As of March 2010, we were 12 Canadian members of NACNS. The following is a picture of some of the CNSs from Canada who attended the March 2010 conference in Port-

land, Oregon (USA) :

On the picture [ from left to right ] : On the picture [ from left to right ] : On the picture [ from left to right ] : On the picture [ from left to right ] :

-Patricia Roy (BC) [bottom left corner],

-Valerie MacDonald (BC) [middle left], -Paul-André Gauthier (ON) [center], -Anna Fedorowicz (MN) [middle right], -Maylene Fong (BC) [bottom right corner].

On April 26th, 2010, the CNS representatives from BC, AB, SK, MN, and ON met by teleconference to discuss activities of their region. Also, the CNS Associa-tion of Canada will be looking to have representatives from other provinces such as QC, NB, NS, PEI, and NFL. The CNS groups from BC and from Ontario are no longer members of CAAPN (since January 2010 for CNSIG and since 2009 for the

CNS Association of BC).

CNS Association of Canada & NACNS CNS Association of Canada & NACNS CNS Association of Canada & NACNS CNS Association of Canada & NACNS Paul-André Gauthier


APN – CNA (2008) : http://www.cna-aiic.ca/CNA/documents/pdf/publications/ANP_National_Framework_f.pdf http://www.cna-aiic.ca/CNA/documents/pdf/publications/ANP_National_Framework_e.pdf http://www.cna-aiic.ca/CNA/documents/pdf/publications/Advanced_Pract_January1997_f.pdf http://www.cna-aiic.ca/CNA/documents/pdf/publications/Advanced_Pract_January1997_e.pdf http://www.cna-aiic.ca/CNA/documents/pdf/publications/PS104_Clinical_Nurse_Specialist_f.pdf (French-2009) http://www.cna-aiic.ca/CNA/documents/pdf/publications/PS104_Clinical_Nurse_Specialist_e.pdf (English-2009) CNS article -Nov-2009 : http://www.canadian-nurse.com/index.php?option=com_content&view=article&id=159:NOVEMBRE-

2009-access&catid=24:access&Itemid=32&lang=fr&limitstart=3 http://www.canadian-nurse.com/index.php?option=com_content&view=article&id=159:NOVEMBRE-

2009-access&catid=24:access&Itemid=32&lang=en&limitstart=3

Research CNS & NP—June 2010 : http://www.chsrf.ca/final_research/ClinicalNurseSpecialistsAndNursePractitionersInCanada_f.php http://www.chsrf.ca/final_research/ClinicalNurseSpecialistsAndNursePractitionersInCanada_e.php

http://www.cna-aiic.ca/CNA/documents/pdf/publications/Exploring_New_Roles_ANP-05_f.pdf http://www.cna-aiic.ca/CNA/documents/pdf/publications/Exploring_New_Roles_ANP-05_e.pdf

http://www.canadian-nurse.com/documents/pdf/access/Access_November_2004_f.pdf http://www.canadian-nurse.com/documents/pdf/access/Access_November_2004_e.pdf

CNA- Oct-1993 http://www.cna-aiic.ca/CNA/documents/pdf/publications/scope_nursing_practice_f.pdf http://www.cna-aiic.ca/CNA/documents/pdf/publications/scope_nursing_practice_e.pdf

http://www.cna-aiic.ca/CNA/documents/pdf/publications/senior_nurse_managers_f.pdf (p. 39) http://www.cna-aiic.ca/CNA/documents/pdf/publications/senior_nurse_managers_e.pdf (p. 32) CNSIG (practice page– April –2004): http://www.rnao.org/Storage/13/726_Practice_Page_CNS.pdf


CNA web site; CNA web site; CNA web site; CNA web site; information relevant to the CNS information relevant to the CNS information relevant to the CNS information relevant to the CNS information relevant to the CNS information relevant to the CNS information relevant to the CNS information relevant to the CNS information relevant to the CNS information relevant to the CNS information relevant to the CNS information relevant to the CNS ::::


Fulton, J. S., Lyon, B. L., & Goudreau, K. A. (2010). Foundations of clinical nurse specialist practice. New York, NY: Springer.

This book is comprised of 42 chapters with five ma-jor themes:

1) “promoting innovation, change, and diffusion in practice;”

2) “delivering care to clients;”

3) “the business of clinical nurse specialist prac-tice;”

4) “exemplars of the clinical nurse specialist role in a variety of settings;”

5) “exemplars of clinical nurse specialist practice in a variety of specialty areas.”

These exemplars or vignettes are quite interesting to read. — The three authors / editors have in-cluded content that is believed to be core founda-tional knowledge for CNS practice. Also, they dis-cussed the professional attributes of CNSs, the busi-ness of CNS practice, and how the CNSs bridge the gap between what is known and what is practiced. The contributing authors discussed the three do-mains or spheres of influence; a) client; b) nursing practice / nurse; c) system / organization.

Chapter 1

Evolution of clinical nurse specialist role and practice in the United States. By Janet S. Fulton.

� In this chapter, the author discusses early histori-cal roots. CNSs emerge in the 1940s and 1950’s, with the first CNS educational program in 1954 under the direction of Dr. Hildegard Peplau. The first recognized CNS specialty was psychiatry. The specialization is the mark of advancement of the profession.

� According to the author, “Understanding the CNS role and practice is tied inextricably to the ability to articulate the value of nursing” (p. 12). When CNSs are able to articulate their role, it improves “clarity” of the role and, furthermore, they are better able to influence nursing care.

Chapter 2

Professional attributes in the context of emo-tional intelligence, ethical conduct, and citizen-ship of the clinical nurse specialist.

By Janet M. Bingle and Sue Davidson.

� The NACNS (2004) presents the CNS scope of practice. The author refers to the seven essen-tial characteristics for influencing and produc-ing change. The CNS can create a spirit of in-novation in a team. Various ethical dilemmas are presented, for example those associated with management processes, hiring the least experienced caregivers rather than appropri-ately experienced nurses. It can be consid-ered as failure to provide appropriate services.

� The differences between an experienced RN and CNS are presented.

Chapter 3

Philosophical underpinnings of advanced nurs-ing practice: A synthesizing framework for clinical nurse specialist practice.

By Frank D. Hicks.

� In this chapter, we can read about ontology and epistemology. The nursing paradigm is dis-cussed in relation to the CNS practice.

� It is mentioned that CNSs “are in a remarkable position to influence the generation of theory that is grounded in practice” (p. 29). Also, the author notes that the unique nursing perspec-tive should not be lost in the advanced nursing educational programs.

� The four patterns of nursing knowledge of Carper (1978) are presented.

Chapter 4 Nurse sensitive outcomes.

By Diane M. Doran, Souraya Sidani, and Tammie DiPietro.

� Nursing outcomes measurement can be a major challenge but it is important to evaluate the im-pact of CNSs in the health care system to dem-onstrate the sensitivity of the CNS role.

Paul-André Gauthier I will briefly outline what you can find in the book beginning with the twelve first chapters.

Chapter 4 (cont’)

� In this chapter, the authors present the CNS focus with direct and indirect care activities. The aim is to achieve “the high-quality and cost-efficient health care” (p. 38). They men-tioned the patient-related outcomes and the nurse-related outcomes. There are various categories that can help CNSs develop a better understanding of their influence. It is sup-ported by many studies presented in 11 pages.

� “CNSs contribute to quality outcomes at the organizational level…. [and] reduced health care costs, reduced rehospitalizations, and reduce the length of hospital stay (p. 54).

Chapter 5

Clinical reasoning model: A clinical inquiry guide for solving problems in the nursing do-main.

By Brenda L. Lyon.

� Dr. Lyon underlines the “nursing required eti-ologies” under two categories: person-related and environmental-related (p. 63).

� She discusses wellness and well-being. She pre-sents the difference between illness and dis-ease, with disease belonging more to the medi-cal domain and illness belonging to the nurs-ing related etiologies and the nursing domain. She explains the clinical reasoning model fo-cusing on phenomena using a nursing holistic contextual lens.

� Also, nursing diagnoses are based on actual or potential symptoms, functional problems, or risk behaviours. So, these etiologies causing or contributing to the clinical problems are key factors in identifying interventions relevant and specific to clients and their needs. The CNSs’ ability to identify these etiologies in various situations and in complex ones, greatly improves the potential for successful out-comes and remedies to problems. “The pur-pose of an intervention is aimed at altering the etiologies contributing to or causing a problem or preventing a potential problem” (p. 70). Assess-ing and monitoring, as such, are not interventions.

� This is a very interesting chapter to read that is grounded in the nursing scope of practice and provides food for thought.

Chapter 6 Designing innovative interven-tions. By Jeannette Richardson.

� The need to maintain or to achieve the highest quality of care is presented. “CNS plays a key role in planning, developing, and encouraging innovative interventions for better patient care outcomes” (p. 75). The author discussed the barriers that CNSs may be faced with when promoting innovation, options to consider and lessons for overcoming resistance. In many cases, practice changes have to be con-sidered and carefully planned and imple-mented. Various characteristics for successful change agents are mentioned. Qualities for innovation are highlighted.

Chapter 7 Evaluating interventions.

By Kelly A. Goudreau.

� How can we ensure that our interventions are effective? This is a question that should be kept in mind while reading this chapter. Nurses need to document the effectiveness of their nursing interventions. The author pre-sents many alternatives / options to consider.

Chapter 8 Using complex adaptive systems theory to guide change. By Kathleen Chapman.

� In this chapter, the transformational role of the CNS is examined. Principles of complex adaptive systems are presented : relationships, self-organization, and nonlinear predictability.

� In the complexity matrix, various aspects or situations can be classified as simple, complex, and chaotic. Under the complexity lens, uncer-tain or unpredictable situations will happen and they cannot be avoided, surprises are in-evitable. In these situations, CNS can encour-age risk-taking and can encourage flexibility and creativity.

“If we are truly committed to quality, almost any reasonable method will work. If we are not, the most elegantly constructed of mechanisms will fail” (Chap. 12, cited in p. 160- from Danobedian, 2005, p. 406).


are pointed out. Nursing is an evidence-based discipline. “CNSs use evidence in their individual clinical decisions in the patient sphere of influ-ence and facilitate and lead other nurses, and organizations use evidence to achieve the best outcomes” (p. 145).

Chapter 11

Transformational leadership as the clinical nurse specialist’s capacity to influence.

By Brenda L. Lyon.

� We need as CNSs to close “the gap between what is known and what is done in practice and by resolving systems level problems that impede effective patient care” (p. 149). A role that CNSs can fulfill as graduate nurses. Nursing leader-ship can enhance nursing care and improve cli-ent outcomes; these can be seen for example in infection rate, in the number of cases with skin breakdown, and falls.

� The personal attributes of a leader are discussed in details. Difficulties are viewed as challenging opportunities. Leaders are pioneers and, inno-vators that work with others as a team. “A true leader’s behaviour is consistent with those values and is evidenced by spending time with those you are leading… being there in uncertain times” (pp. 154-155). A leader can inspire a shared vision.

Chapter 12 Creating a culture of quality.

By Nancy Benton.

� In this chapter, Benton describes how quality of care is defined, measured and improved. She mentions Nightingale and Donabedian.

� A statement that resonates for me is: “If we are truly committed to quality, almost any reason-able method will work. If we are not, the most elegantly constructed of mechanisms will fail” (cited in p. 160- from Danobedian, 2005, p. 406).

� Quality is presented throughout the chapter and how it relates to the three spheres of influence in the CNS practice. Quality indicators have been developed to assist nurses in their evaluations. She concludes by discussing the CNS strategies for creating a culture of quality.

Chapter 8 (cont’)

� What are the facilitators and the barriers? Un-der which spheres are they present? Strategies that can enhance the positives and mitigate the negatives are discussed. How can nurses improve the effectiveness of nursing practice?

� A better understanding of evaluation tools, of the monitoring process, and of the staff resis-tance will enable nurses to improve nursing care. CNSs are well “positioned to groom the environment for successful and enduring change” (p. 99).

Chapter 9 Engaging staff in learning.

By Christine M. Pacini.

� Three components need to be assessed: knowledge, skills, and practice. Depending of the needs, CNS can assist nurses with their specific requirements. A variety of types of support would be required to assist nurses in the own nursing practice setting. We cannot assume that the learning need is related to the-ory. Motivation and readiness are two factors to be considered when implementing educa-tional programs that encompass safe and evi-dence-based practices.

� The author presents the concepts from novice to expert (novice, advanced beginner, compe-tent, proficient, and expert) from Benner in the CNS context. A nurse who has achieved a “competent” level has the ability to anticipate a course of events and to respond appropri-ately; her language is more problem-focused. At the expert level, CNS has extensive experi-ence, intuitive grasp of clinical situations, can detect subtle changes, etc. Many more ele-ments are presented to facilitate the develop-ment of these levels.

Chapter 10 Shaping practice: Evidence-based practice models. By Lisa Hopp.

� Evidence-based practice is comprised of the best available evidence, the clinical expertise, client preferences, available resources, etc. The author explains the PARISH model and the JBI model. Many other models are mentioned in the text. The RNAO-BPGs are highlighted on p. 142. The barriers for not using the EBP


Paul-André Gauthier

Brief Background Information for Clinical Nurse Specialists (CNS):

The Canadian Association of Advanced Practice Nurses (CAAPN) has been the officially recognized group by CNA. This association was to be the primary voice and overseeing organization for APNs in Canada. CAAPN included in their membership CNS (RNs with Masters in Nursing preparation), and NPs (both RNs with Masters in Nursing preparation and RNs without Masters' preparation but with extended class licensing). With the federal and provincial governments focusing on primary care reform, NPs have been one of the major strategic initiatives that have been both financially and structurally supported for about the last 10 years. The universities needed to respond to the educational preparation of NPs with some exclusive development of graduate programs for NPs. Provincial licensing bodies for RNs ensured that "NP" was a protected nursing title. This further ensured that any nurse calling themselves an NP was duly licensed to do so. CAAPN has spent the majority of their efforts in focusing on NP’s within their or-ganization and structure. Only several years ago, did CAAPN acknowledge the need to also recognize CNS as the other APN role; thus, the formation of CNS Council and the NP Council. This appeared to be a positive move. However, the infra-structure support remained minimal for CNS's Council. The CNS groups from BC and Ontario are no longer group members due to lack of what their members expected from CAAPN. The CNS voice has no collective Canadian voice. Due to changes in provincial legislation, the CNS Association of BC (CNSABC) became a registered non-profit society. CNSIG is the Ontario CNS association. Furthermore, the National Association of CNS (NACNS) which officially represents the voice of CNSs in the United States is in the process of developing an international association with the col-laboration of Canadian CNS.

Reasons for joining the CNS Association of Canada:

The CNS Association can be the voice of the all CNS across Canada.

The benefits for joining the CNS Association include the following:

� Raise awareness among the public and all health care professionals about the value of CNS as APNs and the impact that their

work has on positive health outcomes at the individual, population and system levels;

� Provide a formal forum for CNS to discuss CNS issues;

� Advocate with educational institutions and licensing bodies for standardized graduate education as a clinical nurse specialist, in-

cluding clinical practicum in a CNS role;

� Be a liaison between educational institutions and licensing bodies to ensure that the educational competencies for CNS are ac-

quired and met. This would include a Masters of Nursing;

� Promote the advancement of nursing skills, and ongoing educational opportunities for CNS;

� Promote enhanced accessibility to CNS programs in nursing in Canada;

� Work collaboratively with the Canadian Nurses Association (CNA) and provincial regulatory colleges and/or nursing associations;

� Engage the provincial licensing bodies in recognizing CNS and moving towards protected title;

� Promote CNS as champions in and for nursing;

� Dialogue with decision makers about health care issues (political action); the ability of CNS to prevent readmissions, and improve

clients' and patients' outcomes;

� Promote the need to have a sufficient number of CNS to maintain an appropriate nursing workforce;

� Support the development of CNS leadership within health care institutions;

� Provide a centralized, collaborative communication network for CNS (e.g. newsletters, website) and organize CNS national con-

ferences which would include AGM meeting for CNS.


The CNS Association of CanadaThe CNS Association of CanadaThe CNS Association of CanadaThe CNS Association of Canada

You can contact us [email protected] Rodrigue, President. Web Site:

www.cnsig.org

cns-listserv-

[email protected]

2009-2011 CNSIG Executive Members

Picture (from left to right) :

� Mitzi Mitchell, Director of Education and Membership. � Dania Versailles, Director of Communications. � Carmen Rodrigue, President. � Paul-André Gauthier, Director of Finance.

We thank you for

your continuous

support of our

CNS association.

We invite you to

write an article

for our next

newsletter.


newsletter october 2010 -...

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