Clinical Nurse Specialist: A Critical Member of the ICU Team

Objectives To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist–led quality improvement and research that resulted in improved patient outcomes is provided. Data sources Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical-Care Nurses, and National Association of Clinical Nurse Specialists. Study selection Not applicable. Data extraction Not applicable. Data synthesis Not applicable. Conclusions The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

Evaluation of the impact and implementation of a national clinical programme for the management of self-harm in hospital emergency departments: study protocol for a natural experiment

BackgroundA National Clinical Programme for the Management of Hospital-Presenting Self-Harm (NCP-SH) was introduced in Ireland in 2014. This involved the development of a model of care to standardise the management of self-harm in emergency departments, to be delivered by dedicated clinical nurse specialists. The core components of the programme were to: ensure an empathic and timely response, conduct a biopsychosocial assessment, involve family members in assessment and discharge planning, and provide a bridge to next care. The overall aim of the programme was to reduce the rate of repeat self-harm. This multistage study will evaluate the impact of the NCP-SH on hospital-presenting self-harm and to identify determinants influencing its implementation.MethodsEmploying a sequential mixed methods design, the first stage will use data from the National Self-Harm Registry Ireland to examine the impact of the NCP-SH on self-harm repetition, along with other aspects of care, including provision of psychosocial assessments and changes in admissions and postdischarge referrals. A cost-effectiveness analysis will assess the cost per repeat self-harm attendance avoided as a result of the NCP-SH. The second stage will identify the influences of implementation fidelity—adherence to the programme’s core components—using a combination of document analysis and semistructured interviews with staff of the programme, guided by the Consolidated Framework for Implementation Research.Ethics and disseminationThis study has received full ethical approval and will run until August 2023. This study is novel in that it will identify important factors influencing successful implementation of complex programmes. It is expected that the findings will provide important learnings for the integration of mental health services in general hospital settings and will be disseminated via peer-review publications along with reports for clinicians and policy-makers.

Implementing a surgical first assistant role into that of a clinical nurse specialist at an orthopaedic specialist hospital

Background: Clinical nurse specialists (CNSs) are experienced senior nurses with advanced clinical knowledge, communication and leadership skills and commonly take on extended roles to optimise care delivery within health and social care. Aim: To critically explore the experience of one clinical nurse specialist who undertook an enhanced qualification to become a surgical first assistant. Methods: A case-study approach based on Gibbs' reflective model is used to reflect on the experience, its benefits to patient care and the challenges and facilitators related to taking on advanced surgical roles. Findings: Long-term benefits can be achieved by investing in CNSs educated to hold the enhanced surgical first assistant qualification. Advanced roles enhance evidence-based service delivery, while also benefitting the clinical nurse specialist, the patient and the trust.

Examining the impact of video-based outpatient education on patient demand for a rheumatology CNS service

Background: Patient demand for education and access to the clinical nurse specialists (CNSs) during the rheumatology clinic at one hospital in Ireland was increasing. Alternative methods of providing patient education had to be examined. Aims: To explore the efficacy of video-based outpatient education, and its impact on demand for the CNSs. Methods: A video was produced to play in a rheumatology outpatient department. A representative sample of 240 patients (120 non-exposed and 120 exposed to the video) attending the clinic was selected to complete a questionnaire exploring the effect of the video. Data were analysed using chi-square tests with Yates' continuity correction. Findings: Demand for the CNSs was six times higher in the non-exposed group compared with the exposed group (non-exposed: 25%, exposed: 4.8%) (χ2=15.7, P=0.00007), representing a significant decrease in resource demand. Conclusion: High-quality educational videos on view in the rheumatology outpatient department provide patients with information sufficient to meet their educational needs, thus releasing CNS resources.

Developing guidelines for the management of brain tumour related epilepsy

Aims Brain Tumour Related Epilepsy (BTRE) has a significant impact on Quality of Life with implications for driving, employment and social and domestic activities. Management of BTRE is complex due to the higher incidence of pharmacoresistance and the potential for interaction between anti-cancer therapy and anti-epileptic drugs (AEDs). Neurologists, oncologists, palliative care physicians and clinical nurse specialists treating these patients would benefit from up-to-date clinical guidelines. We aim to review the current evidence to adapt current NICE guidelines for Epilepsy and to outline specific recommendations for the optimal treatment of BTRE, encompassing both primary and metastatic brain tumours. Method A comprehensive search of the literature from the past 20 years on BTRE was carried out in three databases: Embase, Medline and EMCARE. A broad search strategy was used and the evidence was evaluated and graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Results All patients with BTRE should be treated with AEDs. There is no proven benefit for the use of prophylactic AEDs, although there are no randomised trials testing newer agents. Seizure frequency varies between 10-40% (Class 2a evidence) in patients with Brain Metastases (BM) and from 30% (high-grade gliomas) to 90% (low-grade gliomas) (Class 2a evidence) in patients with Primary Brain Tumours (PBT). In patients with BM, risk factors include number of BM and melanoma histology (Class 2b evidence). In patients with PBT, risk factors include frontal and temporal location, oligodendroglial histology, IDH mutation and cortical infiltration (Class 2b evidence). There is a low incidence of seizures (13%) after stereotactic radiosurgery for BM (Class 2b evidence). Non-enzyme inducing AEDs are recommended as first line treatment for BTRE, but up to 50% of patients with BTRE due to PBT remain resistant (Class 2b evidence). Conclusion The review has highlighted the relative dearth of high quality evidence for the management of BTRE, and provides a framework for further studies aiming to improve seizure control, quality of life, and indications for AEDs.

To Do or Not to Do… Primary Health Care Professionals Experiences With Mothers With Children Born of Sexual Violence

Mothers and their children born of sexual violence are at heightened risk for developing an insecure attachment relationship. These mothers and their children often enter care late or not at all, as they are not identified by health care professionals. In this qualitative study, semi structured interviews were conducted with sixteen professionals in primary care for pregnant women and/or young mothers with the aim to identify the status quo in knowledge and skills, challenges, and opportunities. Participants included among others professionals working at Youth Services, psychologists, and clinical nurse specialists. Through a thematic analysis, five themes were identified: the knowledge of the professional, discussing the sexual violence, suitable interventions, points of attention during care, and recommendations. Analysis revealed that three groups of professionals can be distinguished, based on their level of awareness of this target group and their available knowledge and skills. To improve primary care for mothers with children born of sexual violence an increase in awareness, knowledge, and skills is a necessary prerequisite. Scientifically based best practices are therefore necessary for health care professionals to provide adequate care for mothers with children born of sexual violence.

Characterisation and outcomes of patients referred to a regional cancer of unknown primary team: a 10-year analysis

Background In the United Kingdom, national guidance published in 2010 recommended the establishment of specialist teams to improve clinical pathways for patients presenting with malignancies of undefined primary origin (MUO) and cancer of unknown primary (CUP). This study sought to define outcomes of patients referred to a regional MUO/CUP service. Methods Data were collected prospectively on all patients (n = 1225) referred to a regional CUP team over a 10-year period. Patient demographics, clinical, pathological and outcome data were recorded and analysed. Results Confirmed CUP (cCUP) was diagnosed in 25% of patients. A primary metastatic cancer was identified in 36%, 5% were diagnosed with provisional CUP (pCUP), 27% retained the diagnosis of MUO and in 8% a non-cancer diagnosis was made. Median survival was low in all patients with a final malignant diagnosis: primary identified 9.0 months, cCUP 4.0 months, pCUP 1.5 months and MUO 1.5 months. Conclusions Patients presenting with MUO have poor outcomes irrespective of the final diagnosis. These patients need a patient-centred, streamlined, rapid diagnostic pathway. There are clear benefits to primary and secondary care teams having access to a dedicated, multidisciplinary MUO/CUP service, with clinical nurse specialists supporting the patients, to help facilitate this pathway and ensure early oncology review.

Understanding the physiology of bowel obstruction and its implications for patient assessment and management

Bowel obstruction causes acute abdominal pain, and, if untreated, leads to strangulation of the bowel and may lead to the patient's death. The aetiology of small bowel obstruction and large bowel obstruction can involve mechanical (dynamic) or non-mechanical (adynamic) causes, as well as pseudo-obstruction, abdominal hernias and postoperative ileus. Assessment techniques include history taking, physical examination, imaging, biochemistry and endoscopic assessment. Intervention options include symptomatic, endoscopic and conservative management, as well as surgical treatment and palliative care. Clinical nurse specialists in colorectal, stoma and palliative care play essential roles in meeting the holistic needs of these patients.

Advanced Practitioners as Allies and Advocates

Advanced practitioners (APs) are a growing proportion of the health-care team. As of 2019, there were approximately 325,000 nurse practitioners, 7,000 clinical nurse specialists, and nearly 140,000 physician assistants in the United States (American Academy of Nurse Practitioners, 2021; National Association of Clinical Nurse Specialists, 2020; National Commission on Certification of Physician Assistants, 2019). Although this totals up to 500,000, it is hard to say how many of these APs focus their practice on hematology/oncology, as certification is not required, which is a major method to track these data. Pharmacists are also integral members of the health-care team. As of April 2021, there were 3,600 board-certified oncology pharmacists (BCOP), although this underestimates the number of pharmacists who practice in hematology and oncology who are not BCOP certified (Board of Pharmacy Specialties, 2021).