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I’m your host, Jamie Davis.
On Nursing Notes Live this month we investigate the expanding role of clinical nurse leaders in healthcare facilities. These nurse leaders are working to implement change and improve patient outcomes in our healthcare system. I got the chance to join a panel discussion on clinical nurse leaders and clinical nurse specialists with Nina Swan, a Clinical Nurse Leader at Iredell Memorial Hospital in North Carolina, Cathy Coleman, clinical nurse leader and adjunct professor at University of San Francisco School of Nursing and Health Professionals, and Peggy Barksdale, a clinical nurse specialist and vice president of the National Association of Clinical Nurse Specialists. Here’s that segment.
Jamie Davis: Cathy, Nina, Peggy, I want to welcome all three of you to Nursing Notes Live and our discussion this month on Clinical Nurse Leaders and Clinical Nurse Specialists. So I’ll guess I’ll start with Peggy. Why don’t you go ahead and share with us a little bit about your background in nursing – why you wanted to become a nurse and your career path through school and what led you to where you are today.
Peggy Barksdale: Thank you, Jamie, so much. Nice meeting you, Nina and Cathy. I started a long, long time ago. I received a nurse doll for Christmas one year. I got a Halloween costume and was in a play that had a nurse’s uniform. I really loved Science and Math. When I went looking for a school of nursing, my high school guidance counselor told me, “I faint at the sight of blood and I did not have the aptitude to be a nurse.” So I went and got my degree in Fine Arts, worked at the Indianapolis Museum of Art for less than a year. And I decided LPNs worked in doctor’s offices, so they probably wouldn’t have to deal with blood. I went through the LPN program. Yes, I did faint at my first clinical. It was a nosebleed. I got over that. I worked 15 years as an LPN in a hospital and loved hospital work. But I had encouragement from two Clinical Specialists. They told me, “Peggy, you need to go back. Get your RN and become a Clinical Nurse Specialist.” So I went back. Because I had a Bachelor from Indiana University, I did the transition LPN to ASN and then from there, I transitioned to the MSN program and got my master’s in Clinical Nurse Specialist, Adult Health. I loved it ever since.
Jamie Davis: I’ll bet. That’s a great story. That’s really great. Nina, how about you? What was your reason for becoming a nurse and how you got to where you are today?
Nina Swan: Well, as a child I was ill and one of the scopes that I had, endoscopy scopes that I had, I remember as they were probably giving me a little bit of medication. My nurse just being there holding my hand, looking down smiling at me and tell me everything was going to be fine. And I just thought, “Well, that’s kind of a cool job to have. Just to make everybody feel good.” And I also had given my grandfather his insulin shots when I was about 10 years old. So I really started knowing at a really young age that I was going to be a nurse. That was it. I went to LPN school, got my diploma, worked as an LPN and then went on to get my Associate’s degree level at the Technical College and then my Bachelor’s. I just enjoy the education side of – I look at every day that I’m learning something new, still today. Whether it’s learning something new about how my nurse at the bedside is critically thinking or she’s missing a piece of critical thinking. So I’m learning like the gaps and really paying attention to that. Actually, when the CNL role came along, I was working on a graduate studies for leadership, in general, and it was actually I was thinking I was going to leave nursing. I was getting frustrated at the bedside with realizing that big pieces of a patient’s story are just getting dropped through the cracks and it was frustrating me and just – I was like, “There’s got to be something better than this.” I’m just getting too frustrated at the bedside. This is irritating me because I knew we give better care than that and I wanted to be the person making sure that better care was being given. And this role actually came along as I was out taking Graduate Leadership Studies with people in the business community. So I was just going to go out and create myself a whole new career on the other side of the fence from healthcare, out in the business world, and this role came along. So I quickly read the white paper six or seven times and picked out the pieces. I was like, “This is it. This is what I’m looking for. This is stimulating. This is going to keep me at the bedside.” Because I knew I loved nursing but I was becoming really frustrated with the fragmentation of it and how that was affecting patients. So this role has kept me in the career that I love and I’m thankful for it.
Jamie Davis: That’s inspiring. That really is.
Cathy Coleman: Yes. And now you bring all that business and leadership back into the CNL role.
Jamie Davis: Cathy, how about you?
Cathy: Well, I certainly apologize for finishing up a little cold this weekend, so I hope you can hear me. Okay. I am also a diploma grad. Philadelphia, Jefferson. Very seasoned nurse for over 40 years. And I worked as a Nurse’s Aide in a summer many years ago, in high school. And I just fell in love with taking care of the older people. Then I worked at a hospital as a Nurse’s Aide. And in high school, I was in the Future Nurses Club. At Jefferson, I really fell in love with Cancer Nursing because of, back then, we didn’t even give the diagnosis. It was still a big secret, the “Big C” and I was very fascinated with the multidimensional aspects of oncology. So after I went to Jefferson, Philly, I moved up to Boston because all of my friends were there. And did a little bit Med-Surg ER at Cape Cod. And then moved back to California and began to subspecialize in oncology. Never went back to school. I did take courses here and there but I had such good jobs and I was making good money. I never went back. Until later on when I moved to San Francisco and USF had an Open Health and I learned about this wonderful CNL role. In about 2003, I switched over from Breast Center development – my oncology career led me to subspecialize in breast cancer and then subsequently into breast center development as a consultant to help develop breast centers and I also developed a feel on my own working in for-profit and non-profit organizations. I found that the common denominator for making change was quality. If everybody could agree on quality, we could move forward and fight the political battle and put some of the other turf issues behind us. So I began to specialize in performance improvement in 2003 and that’s where I work now. I teach at USF and I work as a consultant for a non-profit in performance improvement in the doctors’ offices. Right now, I’m working on a contract for EHR adoption. About 30 years in breast cancer and Breast Center development and the last 10 years in performance improvement. Now I just love it. And I think the CNL role is such a change agent role. We want to change the system and it came along at the right time. Like Nina, I read the white paper, not seven, unlike she did but maybe once or twice and I was really struck with the work by Godfrey in Microsystems. Because in my performance improvement work, I had learned about Dr. Wasson in Dartmouth. So I was really drawn to the role and where the action is. Not being a bedside nurse, to me, it’s the second best thing to improve patient outcomes which is really by helping the nurses who are on the frontline and the other interdisciplinary staff as well. So that’s my story.
Nina: I think that that performance improvement piece, I never would have dreamed back when I first began the CNL role in 2005 that I was ever going to go on to leadership. And I feel like this is one of the most critical roles, the CNL role, as a stepping stone for future managers or directors of units because we’re able to help translate the information quickly down to the bedside level so that staff are connecting all the dots now with the gaps being filled in by the CNL that’s there with that patient five days a week. And also making staff aware of those performance goals and those performance improvement measures and all the things that, at a system level, are being put in place but it can always get down to that point of care at the bedside to the nurses level. Things get lost in the transition of that. So the CNL would have been real crucial liaison to the system level stuff down to the microsystem point-of-care level.
Peggy: One question I have is, neither one of you looked at the Clinical Nurse Specialist degree program which really kind of surprised me. You read the white paper yet you didn’t read anything about the CNS paper. And a lot of times, I’ll be honest with you, I had to google CNL because here in Indiana, we only have one school and even just to try and find that. But you’re right, quality, good outcomes, evidence-based practice, those are very important. We’re always looking at the bottom line: the patient, the family as well as our nursing system itself. We’re looking for high-quality indicators. Change agents, a Clinical Specialist has always been known to be a change agent. And I think this is great that we’re opening up, all nursing, to consider to look more. The practice has always been for the betterment of the patients.
Cathy: Peggy, I have a question for you. I know a lot of Clinical Nurse Specialists and I highly respect CNS’s and Clinical Nurse Educators and Managers. We have such a beautiful tapestry of roles in Nursing. Would you say that, my perception at least, was that the CNS’s were more of a consultant for complicated individual care, not necessarily looking at the systems level changes and the leadership issues that needed to take…
Peggy: Oh, I do. Cathy, I do. Part of the new infrastructure that started about two years ago where the Clinical Nurse Specialists looks at evidence-based practice. She works with the CNE for operations, works with the vice-president of Medical Affairs so that we can key in with the physicians. Also quality and risks, the site leader is part of the quad that we had developed inside of our network hospitals. Of course, originally, the Clinical Nurse Specialist was looked in her specialty area because that’s her hallmark. My specialty was Orthopedics. So developing the standards for joint health programs, looking at other program development that we did. That’s what we originally do. We still do. I still help with the work of my standards for joint health.
Nina: Yes, Peggy, I haven’t work in an institution, has used both roles, I had the influences of CNS’s all throughout my career. And I think one of the reasons why I didn’t look at that role is because they were used system-wide for their specialty area so they only touch the lives of maybe two or three patients out of each unit on any given day. And it was particularly because they were the specialists in cardiology or the specialists in geriatrics or – and whenever we’re having trouble with. I use the CNL and CNS complementary was – I think our CNS’s saw a huge increase in their consults to the bedside on patients that before the CNL role was there, were getting missed and…
Peggy: Well, that’s nice to hear. That’s so nice to hear.
Nina: Yes. So we were pulling them in quicker rather than later and I think that’s where the two roles complement each other because one of the ways we kind of got over the territorial issues at first because everybody was wary when CNL first came on the scene where we actually met with our Clinical Nurse Specialists on a monthly basis when we brought the role into our institution and then we met with them quarterly and they still do to this day. So even though we’re many years out into the role – and this is the former employer where I worked – I’m going to have the joy of precepting two or three students here shortly that are going to be CNL students. So I’m excited for my…
Peggy: Nina, were you at Maine Medical before?
Nina: I was, yes, with Marjorie Wiggins. Our CNS’s were wonderful. Their consults are through the roof now but I think they brought in the cases a lot earlier than what nurses at the bedside were doing because of the staggered 12-hour shifts and everything that nurses do now at the bedside.
Peggy: One of the insights that I have related to the different roles whether it’s CNS or Manager or CNL was from Marjorie Wiggins. I always remember this at the very first CNL meeting that I attended several years ago is that the roles are value-added. The fact that the CNL has a skillset that’s a little different. In my mind, I remember it with something called “ELMOR”: evidence-based practice, leadership, microsystem, outcomes and return of investment. When I heard Marjorie Wiggins originally talk about the role and how she was recruiting, she couldn’t wait for new CNLs to come out, she already had the CNS role integrated. But where the CNL fit in was in looking beyond the unit and really tie in the return of investment, the value proposition, the business case, whatever you want to call it, with what we were doing and across settings. So I really see the CNL role as an advanced generalist, as the white paper points out, but across settings. I think it was borne out of the need for acute care because of the IOM report in 1999 and 2001, however, my students now at USF, one of them last week told me that the CNL is like a broad-spectrum antibiotic. Where they’re advanced generalists and they can take that skillset and I have them at home care, in psych, in inpatient Med-Surg, outpatient, skilled nursing, they’re all over the place and they’re just eagerly wanting to learn more about systems level change and leadership and being more of an informal leader rather than a leader that has positional power and authority. Because once they prove their credibility and their trustworthiness and they can get their arms around a particular projects or problems in a microsystem, then they’re often running if they have the right support from the manager or the CNS collegially or other people that are working in that organization.
Cathy: So, Nina, how can you describe one of your usual day for you? You’re working in North Carolina, working as a CNL, how does your day somewhat goes?
Nina: I moved on into leadership and I can say I’m probably a very different leader than someone who just normally steps from the bedside. I think because of having done the CNL role, the communication about where we’re trying to go just the way that – I make stuff go on this mission with me as far as – it’s a journey and so I came here two months ago and I’ve helped turn this staff that was stagnant and not doing anything new and not having the autonomy or ownership abilities at the bedside anymore. They were waiting to be told everything to do. I’ve turned them around into the more of the inquisitive questioning, “Let’s get our numbers up,” “Let’s prove who we are,” “Let’s give the best care,” kind of champion of all that. And I think that – I’m not sure I would have been the same type of leader. I’m not sure I would have said, “Well, why isn’t this system working?” I would have stayed in that bedside mentality of, “Okay, well, it’s just let’s go to this person and have them fix it for us.” That’s the quick Band-Aid fix thing to do. And I think that’s the rot that a lot of places get into. They quickly fix something but it’s not what’s going to work best at the bedside.
Cathy: But, you know, also today when I came in, I do stay at the bedside. Of course, I got the building. That’s where my charge is, the South Campus. And I went to ICU, talked with my nurses, “How’s your day going? How things going?” Falls are something we’re really trying to work on. We have a 50% reduction but that’s just 50% of a reduction. Falls still are happening and we still have some injuries which are less than 20%. Talking about that, think of ortho, neuro-spine, we have eight joints that are being today. So again I do follow back on that, looking at it. I also have to give information from pharmacy because we’re bringing in a new medication and I wanted to know from pharmacy if there’s a toxicity issue, how is that addressed with that. Going to leadership puddle and just talking about today, we have a new unit that will be moving this afternoon into another part of the hospital. And I’ll help with that. And also met with my student from the University of Indianapolis. She’ll be meeting with me tomorrow and we’ll be asking as a preceptor what she has done. That’s where I’ve been so far. So I have not left my bedside yet I’m at the table with the leadership. I don’t have a…
Cathy: So, Peggy, do you have a home-base in a unit or are you more organization-wide through the Macrosystem?
Peggy: My home-base is South Campus. So I see every unit. I try to make my rounds every other day. I have specific units I do look at. Friday is often leadership where the quad meets, discuss CMS indicators: HCAHPS and, again, falls, SSI, et cetera.
Nina: Yes. I think like how we actually work both roles at Maine Med is kind of what I’m hoping is going on out there in the country because the CNL then, when you walk away, Peggy, after having checked in on people, we’ll make sure the things that you request are get done at the bedside. So they’re kind of like they’re at the point of care staying there the entire 12-hour shift making sure that things are followed through on, and the reason why, making sure everybody understands that. And I would say just after – I just finished walking through our unit doing rounds with our nurses with the Director of Nursing Practice here at Iredell. It was funny because half of my unit of nurses are very confident. They gave us great reports on their patients and the other half not so much. So we’re going to do them again tomorrow with the same staff and start on the opposite end and just see if it’s a comfort thing or is it really a confidence thing. Are they getting rough reports from the former shifts? What’s really missing? And having the…
Peggy: It’s true. The new nurses, we have gotten nurses – we always have people that move in to other roles and, you’re right, that critical thinking is really important and that’s something we need to look at. I do wonder how your role is a little different from being – because right now it’s got a patient care coordinator who works a – and besides of a unit and then, of course, the manager and then we’ve got the director. I come in, yes, mostly it’s consulting and mostly looking at CLABSI, CAUTI, falls, you know.
Cathy: I would say the difference for me, Peggy, is that the CNL is home-based in a unit or in an organizational setting in that microsystem, however, that microsystem is defined where the patients and the people that take are of those patients congregate. I am not familiar with the CNS training in terms of content but I can tell you that in the CNL, there’s a lot of change theory. There’s a lot of principles of spread and leadership, more so than I’ve seen way back in my diploma program for sure. But that’s why and I think the change agent, the system level change agent keeps coming back to me. Not that anything is better or worse, it’s a skillset. It’s a skillset that allows people to really take a fresh look at a problem from different perspective and to train and educate the staff and not make change just for the sake of making change. But have a beginning and have an end and have a return of investment with that so we can prove ourselves and prove the role and then move on to the next big problem in the…
Peggy: Well, you know, Clinical Nurse Specialists is working with theories. Don’t forget you’ve got not only change theory, you also got chaos, complexity, the health belief theory, spouse care. I mean, nursing theories is just changing so fast. But do you have, at facilities, every unit – Ortho, Med-Surg, Critical – each one has a CNL?
Nina: I can speak for my former employer at Maine Medical Center, most units had a CNL. So when we were the first group that went through the system, when we had a patient travel off of our unit, so I was initially on a 46-bed medical telemetry unit. Among the fresh MIs, all the ICDs, all the pacemakers, those kinds of things, I would follow my patients. So if a heart failure patient then, because of their age, moved on to the AGE unit which was our Geriatric unit, I would follow that patient down there initially until – if the CNL on that unit was too busy or involved in a project where she didn’t feel like she could follow that patient as well and/or I would pass off directly to a CNL who I knew who was going to be there five days a week so she could keep every bedside nurse informed on this really complex patient every day. And so depending – not every unit has a CNL but you either follow the patient from start to finish through their entire stay and beyond into the nursing homes or into the rehab center…
Cathy: So just like a Clinical Nurse Specialist, you work as a team member?
Nina: Right. Yes.
Cathy: Thank you.
Peggy: Exactly. Yes. But I think too that Cathy Rick who’s head of the – she might still be, I guess, the head of the Nursing for the VA, she was one of the early adopters and innovators related to the role. I think her goal is to have a CNL on every unit in the VA by 2015 if I’m not mistaken. But let me not give any false hope here. In California where I am, they’re just starting now FTEs to be filled with CNLs. It’s part of our own challenge to sell the role, to build the credibility around the role and create those jobs in the future. I’ve been told Nurse Practitioners weren’t initially accepted either and we’re seeing that diffusion of change over time where, you’re right, Peggy, it is a team and it’s a value-added team and if you’re lucky enough to have funding which is why I really remember what Marjorie Wiggins said. She said, “I have no trouble justifying paying for my CNL because I’m tying it to return on investment related to a problem whether it’s a never-event or a meaningful use measure.” Something that is going to speak to the administration in terms of the cost and the value of this role which I have never forgotten that. And so when my students, some of them were in the OR, so whether they do a project in the OR or – they always figure out, “What is that basic unit of cost and what they’re doing to decrease waste and translating that into not only the clinical outcomes but the financial outcomes, educational outcomes, the technology outcomes in their role?”
Cathy: Well, I appreciate you being on board. But really and truly outcomes does define the Clinical Nurse Specialist from the patient, the nurse, the system. There’s data out there that is brought forward, have their differences. I really do appreciate a partner as far as, you know, that just to make that quality care, those positive outcomes, from evidence-based practice.
Peggy: Absolutely. Evidence-based practice is the building block. I think too, as nurses, our profession is going to be a house divided if we don’t welcome new roles and learn how to complement in terms of the ultimate goal, however, we define that outcome, the clinical outcome.
Cathy: I agree with new roles but, please, why would you shove something that has been working for decades?
Peggy: I don’t think anybody has suggested that. No. I never heard that.
Cathy: We want to keep that support.
Jamie Davis: Yes. I think that it’s important for us to give nurses opportunities to expand their roles in many directions. In some facilities, some roles are going to be more available than others or are more popular than others in the way that that facility’s administrative set-up is organized. At least, that’s been my experience. So we have to wrap up. I’d love to sit here and have this conversation. And it sounds like the rest of you are passionate as well about this. But we do have to kind of wrap up the discussion at some point and I thought it would be nice to close out with each of you giving some advice to that nurse or maybe that nursing student here that’s thinking about what they would do in an expanded role of nursing. Maybe advance their career in another direction doing something whether it’s a Clinical Nurse Specialist or Clinical Nurse Leader. I guess, Peggy, I’ll go ahead and start with you. Could you just share some advice on what they might want to try to do to begin exploring that role for themselves?
Peggy: I hope the nurses or those who are thinking about nursing have that passion. It includes helping others. But more important, it’s just making a change in someone’s life and either making their symptoms a little more relieved. Making sure their function is to their optimal. When you find something, and it’s a passion for you or it’s an interest, continue to pursue that dream but also look every day, make sure learning is in your little toolbox so that you grow. And the more you grow, the more we need your leadership here in the future. Look for a mentor/coach that really can help and encourage you or even point out and give you some feedback. I think that kind of support is really, really important.
Jamie Davis: Thank you, Peggy, I appreciate that. Nina, how about you? Do you have some thoughts you’d like to share with the nurses that are looking in expanding their role and advancing their career?
Nina: Well, Peggy stole those, they’re really good. I would agree in everything she said. I think that the push for everyone right now is to go back and get education and what I’m seeing lately is many nurses are in school but not really knowing where they’re going for a path. And that’s okay to a certain point but I would really just reiterate what Peggy said about – make sure that it’s something you’re passionate about. Like I said, when I was looking for this, when the CNL role came along, I was actually going out of nursing. Not because I didn’t enjoy patient care and loved taking care of people at the bedside and what the role taught me on my journey through the CNL piece of my career was that I love being a leader. I love the whole leadership side of getting staff to think like CNLs thinks. So really ingraining that in staff and that’s kind of what put me on the leadership track. And I would say that you really have to be self-reflective. Go home every day when you’re at the bedside and self-reflect on – well, what if you have done A first and C second instead of B second and how would that have change the dynamics of your day, your shift? So same thing with conversations you have with people. If you really track down the problem for a patient but you might not have the most decent conversation with another discipline during the whole process, go over that and be self-reflective in your mind to make it a better conversation the next time you have it. So you got to have the passion. You got to really want to do what’s best for patients and families out there. That’s what our business is about. And whether you’re doing it right at the bedside, at the point of care or whether you’re doing it at a leadership level, it’s all going to make a difference in the end.
Jamie Davis: Cathy, you get the last word and maybe some thoughts you’d like to share with nurses about following that passion and getting their education.
Cathy: Sure. Well, I’d like to just reiterate the importance of what Peggy said about the mentor and the coach. Particularly early on, that’s really important. I had a nurse in nursing school who advised me to float for six months because I didn’t want to jump in to subspecialization as a new grad. That was probably one of the most valuable things that I ever learned because it taught me flexibility and I was exposed to the burn unit, the ER, everything. Then after six months, I began to specialize in Oncology and then Breast Center development over the course of my career. So the mentorship, the coaching is really important. Somebody that you trust. And that you look up to and you respect. What Nina said about the self-reflection is also very key. We don’t want to burn out nurses. We don’t want them to “eat their young.” There is some terrible bullying going on out there. So I think it’s really important that nurses have courage, they self-reflect, that they don’t forget that what differentiates our profession is that we’re rooted in the essence of caring. And so there is a song called “[Take] your passion. Make it happen.” I think it was Irene Cara. I agree with that. Find your passion. Is it taking care of patients and be a care provider as a nurse practitioner? Or is it being a system level change agent as a CNL? Like we heard from Nina who gets a lot of positive energy from changing the team to move in a different direction? Or something like Peggy who has a real macro-system level role and also gets the benefit of direct patient care, in those complex patient care. So nurses have a new beginning and we need to build from Florence up until the next generation of nurses and never forget that that essence of caring is what differentiates us, the science and art. And I’m proud to be a nurse.
Make sure you check out the entire November, 2013 issue of Nursing Notes, where we examine the role of clinical nurse leaders around the country. You can read the entire issue online at www.discovernursing.com and don’t miss the other Nursing Notes Live episode this month bringing you a special interview with our Get to Know Nurse this month, Clinical Nurse Leader Barbara Edwards. Barbara is a clinical nurse leader at St. Lucie Medical Center in Florida. You’ll find this and other episodes of Nursing Notes Live in the podcast area on iTunes.