Clinical Nurse Specialist Leadership in Redefining How We Assess Competency in Nursing

1. 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

2. Opening Thought “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

3. Overview of Project • 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) • Project has been done with support of the CCU Unit Director

4. Why a paradigm shift in competency assessment?

5. 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

6. 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.

7. 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).

8. Components of new competency paradigm

9. 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

10. 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

11. 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)

12. 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)

13. Contextual Factors Impacting Development and Implementation

14. 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

15. Heart Center Core Cardiovascular Curriculum Program Model Linking Knowledge to Practice Critical Thinking Holistic Care Evidence Based Practice Certification Readiness Physiological Basis of Understanding Cardiovascular Patient Novice to Expert Synergy Model Thread through all disciplines and all settings in the continuum of care. Integration with orientation, unit specific education, skill development, and role advancement Connection To: Practice, Research & Quality, Patient Education, Precepting Committees • Goals: • Knowledge Acquisition • Practice Change • Certified Staff • Improved Outcomes

16. Distribution of Core Curriculum 23 Instructors 2013 Instructor Turnover 2/24 = 8.3% 2013 New Instructors: 1

17. 2014 Class Schedule

18. 2014 Class Schedule

19. 2014 Class Schedule

20. 2014 Class Schedule

21. 2014 Class Schedule

22. 2014 Beyond the Core Topics

23. 2014 Level 5 Symposium Topics

24. 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)

27. 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

28. Specifics of the new paradigm

29. 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.

30. 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.

31. 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:

32. 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) • Professional nursing practice • General clinical • Critical care • Cardiac specific (Core Curriculum and Beyond the Core)

33. Self Assessment of Linking Knowledge to Practice Expectations • 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 For each class in the novice to expert curriculum there are expected practice expectations. These are distinctly separate from objectives.

34. 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.

35. * Items I plan to focus on this next year (2013) ** Items for which I have documentation of linking knowledge to practice (2012)

36. 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

37. 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.

38. 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.

39. Competency Focus Areas To Date

40. 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.

41. 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.

42. Pilot Results Cardiac Monitoring

46. 2013 Outcome Assessment

47. 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)

48. Synergy Model Patient Characteristics Nurse Competencies Clinical Judgment Advocacy / Moral Agency Caring Practices Collaboration Systems Thinking Response to Diversity Facilitator of Learning Clinical Inquiry (Innovator / Evaluator) • Resiliency • Vulnerability • Stability • Complexity • Predictability • Resource availability • Participation in care • Participation in decision making

49. 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.