Improving the care and health of populations through optimal use of clinical nurse specialists.

Patients with complex and chronic illnesses and those who have significant needs related to care coordination and transitions of care are dependent on access to healthcare providers who are skilled at meeting the distinct needs of these populations and are current in the latest evidence-based practices and guidelines. Clinical nurse specialists (CNSs) are uniquely qualified to care for patients with complex illnesses as well as having the skills to optimize care for entire populations with complex needs. The absence of consistent legislative advanced practice registered nurse recognition of CNSs prevents health care systems from optimal use of this advanced practice registered nurse role to improve and provide safe and quality care for these patients. Additional barriers in optimal utilization of CNSs include lack of consistency: in title protection and licensing from state to state; ensuring patient access through identification and tracking of CNS numbers across the United States in order to determine workforce and educational program requirements; and ensuring appropriate reimbursement for care provided by CNSs. Therefore, it is the position of the American Academy of Nursing that addressing public and private sector regulatory, legislative, and policy concerns related to CNSs is essential to achieving optimal population health outcomes across the nation.

Opportunities and strategies in contemporary health system executive leadership.

The contemporary health care environment presents opportunities for nurse executive leadership that is patient and family centered, satisfying to professional nurses and their colleagues, and results in safe quality care that is fiscally responsible and evidence based. This article focuses on the strategic areas of systemness, people, performance, and innovation and offers strategies and tactics to help move nursing in integrated delivery systems from important entity-based services to a system approach where the nursing leadership team and entity chief nursing officers are recognized as major contributors to system success.

Improving reassessment and documentation of pain management.

BACKGROUND: The Joint Commission standards on pain management address the documentation of assessment and reassessment. Yet, little has been published to describe when and how nurses perform and communicate reassessment of pain. In 2005, the University of Wisconsin Hospital & Clinics (UWHC) was inconsistently reassessing pain after interventions, and documented reassessments were primarily confined to pain-intensity ratings. PLAN-DO-CHECK-ACT: A large-scale plan-do-check-act (PDCA) cycle was implemented to improve the documentation of pain reassessments, including development of an evidence-based administrative policy, repetitive education efforts with bedside coaching, changes in daily bedside documentation flow sheets, and audit and feedback. RESULTS: From May 29, 2006, through July 16, 2008, a cumulative rate of 94.9% appropriately documented pain reassessments was achieved. DISCUSSION: Despite implementation of an evidence-based policy to clarify requirements for pain reassessment, repetitive educational efforts, changes in daily bedside flow sheets, direct and extensive leadership involvement in the form of continuous bedside coaching, combined with more timely and persistent audit and feedback and clear accountability and alignment with goals, was necessary for substantial change. Strategies to sustain improvements include daily administrative and monthly staff documentation audits with prompt feedback to clinical nurse managers and staff. Nurses are instructed on the importance of pain reassessments and on the policy and specific documentation requirements. Reassessment of pain is a routine variable displayed on unit and departmental quality dashboards. Further study should examine if the intensity of this requirement for pain reassessment documentation ultimately facilitates the safety and effectiveness of pain management.

Designing a leadership development program for nurse managers: an evidence-driven approach.

The authors describe an evidence-driven approach used in designing a leadership development program targeted for nurses in middle management positions in an academically affiliated integrated healthcare system. A qualitative study was conducted to investigate leadership development needs and experiences of nurse managers across the health system. Study findings were used to inform educational programs and organizational initiatives responsive to needs of both novice and expert nurse managers across diverse clinical settings.

Revisioning nursing scholarship.

PURPOSE: To propose a universal model of nursing scholarship that (a) indicates the importance of professional practice disciplines, (b) incorporates the synthesis of intellectual pursuit with social change, and (c) is holistic in its design. ORGANIZING CONSTRUCT: Scholarship, traditionally viewed as part of or generated in the university enterprise, must be an expectation in all settings in which a community of scholars from both discipline and practice can and do coexist. METHODS: Review and synthesis of the literature on scholarship, nursing scholarship, nursing as a practice discipline. FINDINGS: The history, culture, and intellectual property of nursing comprise an appropriate basis for adopting a universal holistic model of scholarship built upon a set of universal assumptions about nursing scholarship. As a discipline and a profession, nursing should include four connected domains in a universal holistic model of scholarship: knowing, teaching, practice, and service. CONCLUSIONS: Confirmation of this universal holistic model of scholarship can contribute significantly to a larger nursing identity. Use of universal holistic model of nursing scholarship indicates responsibility of the nursing profession collectively and all nurses individually. Additional work is needed to understand how a universal holistic model of nursing scholarship evolves across cultures, domains, and work settings.

Child sex initiation rings.

The workings of child sex initiation rings are outlined in a study of 36 prepubescent children involved in six such rings. Organizational factors include the adult capitalizing on a legitimate role in the children's lives and programming them to provide sexual services in exchange for psychological, social, monetary, and other rewards; operational factors include peer group pressures and secrecy. Symptoms noted in the children prior to disclosure, and affective and cognitive response by parents upon disclosure, are discussed.