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Written Clinical Exemplar: include the following elements in your written product

1.) Student name, credentials, and title of exemplar 

2.) Identify and describe the clinical event or situation 

3.) Identify clinical setting (inpatient, outpatient, long term care, etc.) 

4.) Describe why this situation was meaningful to you 

5.) How did you feel about this situation 

6.) Identify the challenge you faced 

7.) Describe your evidenced-based interventions to address the clinical situation? 

8.) How did your intervention or treatment affect the outcome 

8.) Why is this situation significant to psychiatric advanced practice nursing? 

9.) What insight did you gain in relation to the PMHNP role? 

10.) What did you learn? 

11.) How did this experience change your perspective or treatment approach? 

 

Example of a psychiatric-mental health advanced practice clinical exemplar

                                            Clinical Scholarship Exemplar for an Advanced Practice Nurse

                                                                Susan L. W. Krupnick MSN, RN, CARN, CS

                                                                   Psychiatric Liaison Nurse Specialist

I have been a psychiatric consultation-liaison nurse specialist (PCLN) for eighteen years, since my graduation from the psychiatric clinical nurse specialist program at the University of Pennsylvania. In my role as a PCLN in both academic and community medical centers, one of my primary concerns has been the lack of knowledge that I have seen in both nurses and physicians caring for the patient with a concurrent substance abuse problem, especially in the acute care environment. For example, during my practice in one former medical center, it was clear that acute care patients with unidentified alcohol withdrawal syndrome (AWS) were at significant risk for harm due to this lack of knowledge; and in turn, nurses caring for them were at risk. During the interview process at my current medical center, questions, and scenarios to which nurses asked me to respond generally involved a patient’ s substance abuse problems. As I practiced in this setting, it became apparent that nurses were troubled by treatments of patients experiencing AWS; again, up-to-date caregiver knowledge was approved to be a factor.

Upon my arrival at Baystate Medical Center in October 1995, I was asked to assist in addressing the problem of improving care for this special and growing population of patients at risk for developing alcohol withdrawal syndrome. Specifically, I was asked to co-lead a quality improvement initiative and to focus clinical consultation on related problems. This was the first time that I had worked in a healthcare environment that was willing to commit resources to actually assess the level of risk that these patients pose to both themselves and to the system when not identified and treated in a focused and individualized manner. My interest in this clinical problem had spanned almost my entire nursing career. Now, I was finally going to have the opportunity to have a direct impact on changing nursing and medical practices to benefit patients and the healthcare system.

One of my first steps in addressing this issue was to use my national networking contacts to obtain new information from the addiction field for use in this acute care environment. For example, I had been a part of a related workgroup within the National Nurses Society on Addictions (NNSA) and had numerous international connections through my work with the International Society of Psychiatric Consultation-Liaison Nurses (ISPCLN). I used contacts to discover new research, unpublished work, and lessons learned by other experts working in academic medical centers. Thus, I would update my own knowledge in this evolving field, and enhance the work of the quality improvement team by providing information on others’ success. The next immediate step was to conduct a chart review audit with team members during a dinner retreat sponsored by the nursing division. The goal was to obtain evidence to validate the extent and better understand the nature of the problem in this setting so that we could focus our efforts.

As part of the Quality Improvement design phase, the QI team members conducted a thorough literature search for assessment tools. Our interdisciplinary contacts proved fruitful and decreased some of our searching and work time. For example, we were able to obtain reports of outcomes of projects initiated in other organizations as well as unpublished information on the reliability and validity of two specific assessment tools. The first tool was needed to screen the patient for substance abuse. The current method of assessment was haphazard and typically reported social use or significant drinking without any quantification for the amount of alcohol or other substance ingested. The CAGE assessment tool1 was selected after reviewing of relevant criteria that team members had agreed upon. Specifically, we wanted to be certain that the tool was user friendly, but it had to have been used and demonstrated to be valid and reliable for use with medical-surgical patients. Although other available tools provided more clinical information, they were not as easy to incorporate and use at the time of admission of the patient as the CAGE, which met all of our criteria. One step that I took in this decision-making process was to evaluate the CAGE based on criteria for assessing the applicability of research findings for practice.

The second assessment tool was needed for identification of the stage of patients’ alcohol withdrawal based on concrete and observable symptoms. I had previously used the Clinical Institute Withdrawal Assessment-Alcohol-revised scale (CIWA-Ar)3 in my practice as a critical care nurse, but I wanted to search out any comparative tools that might have been developed specifically for medically ill patients. So again I turned to the literature and research colleagues at major academic addiction research centers in the US, United Kingdom, and Canada. After reviewing new tools that were created within critical care environments or modified from the CIWA-Ar, discussion with team members, and consultation with another PCLN in the midst of implementing the CIWA-Ar on similar medical units, it was decided to select the CIWA-Ar scale to quantify AWS. However, based on the evaluation of this tool using our criteria for assessing the applicability of research findings for practice, we recognized that it was not as well-substantiated as the CAGE. We decided to use it because it fits our needs, but we planned to pilot it to assess whether it provided expected data. A meta-analysis4 of pharmacologic treatment of AWS provided further substantiation for our guideline recommendations about screening and assessing AWS.

The next step in the process was the development of a treatment guideline to individualize sedation management of patients experiencing AWS. Once again, a review of research was conducted, and an intense discussion ensued about the often-conflicting information regarding how much medication and which benzodiazepine agent would be best for the medically ill patient. Data from our medical record review had informed us of the predominant current, and less desirable from a scientific view, treatment choices of physicians. I continuously focused the group on the level of evidence that was available to facilitate an appropriate choice for the guideline … and one that could be supported by science when it was disseminated. My medical colleagues reminded me that in the process of change, incrementalismat times more effective and that our initial choice of dosage could be piloted to obtain evidence to make further change.

For implementation, I collaborated with the clinical director, a nurse manager, and CNS from medicine to obtain their support for a pilot test on a general medical unit. I provided classes for nurses, as well as on-unit consultation and precepting. In turn, I worked with both the nursing and medical staff to understand their concerns about the symptom-triggered sedation management model. After the month-long pilot, we collected formal and informal feedback from staff and again reviewed charts. Based on this internal evidence, the QI team revised the guideline to decrease the level of monitoring while increasing the initial dose of medication that patients would receive. One major concern that was frequently articulated actually revealed a need for additional knowledge about physiological tolerance. I then worked shoulder to shoulder with nurses to demonstrate the model and its outcome, that is, how individualized benzodiazepine replacement for alcohol does not usually lead to over-sedation. Several reinforcement sessions helped me to increase the nurses’ confidence that they were practicing safely and not placing the patient in a potentially harmful situation. By discussing the inter-rater reliability between my scores and those of a staff nurse, I was able to role model critical thinking about important differentiation in the assessment. As the innovation moved forward, the QI team obtained support, because of nursing and medicine leadership’s value for evidence-based practice, for the inclusion of the CAGE in a redesigned admission assessment form − despite the initial reaction of some nurses that such questions were unnecessary and even intrusive.

I believe that having the Nurse Specialist in Evidence-Based Practice within the Division of Nursing has been a significant contribution for an organization that wants to move practice from “it’s the way we do it here” to practice based on clinical research outcomes and internal evaluative evidence. The ability for me to collaborate with this specialist when I became concerned about a conflicting research finding or how best to encourage early adopters to assist their colleagues in this evidence-based practice change was a support for me as I am developing my clinical scholarship skills. Additionally, this specialist assisted me to stay focused on the need to communicate this information and outcomes within the professional community. Presently, I am collaborating with the psychiatric consultation physician in writing an article describing both the process and the clinical outcomes of this project. The initial pilot outcomes and project process also have been presented at local schools of nursing and at the American Academy of Psychosomatic Medicine, at the American Society of Addiction Medicine, and the American Nurses’ Association annual convention.

In summary, the use of the evidence-based practice has increased nurse and physician knowledge related to an alcohol withdrawal syndrome and implemented a focused method of assessment and treatment that is preventing stage 3 withdrawal. This use of clinical research and QI evidence, as well as my continuous curiosity, has helped me to further develop my own practice while helping to improve care in this critical area

References

American Journal of Medicine, 82, 231-235.

Bush, D. Shaw, S., Clearly, P., et al. (1987). Screening for alcohol abuse using the CAGE questionnaire. The Nursing Outlook, 42, 15-25.

Stetler C. (1994). Refinement of the Stetler/Marram model for application of research findings to practice.

The revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). British Journal of Addictions, 84, 1353-1357.

Sullivan, J., Sykora, K., Schneiderman, J., Naranjo, C., & Sellers, E. (1989). Assessment of alcohol withdrawal: guideline. Journal of the American Medical Association, 278, 144-157.

Mayo-Smith, M. (1997). Pharmacological management of alcohol withdrawal: a meta-analysis & evidence-based use of antithrombotic agents. Chest, 102, 3055-3115.

Cook, D., Guyatt, G., Laupacis, A., & Sackett, D. (1992). Rules of evidence and clinical recommendations on the

SCIENCE
HEALTH SCIENCE
NURSING
MN 676

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