Take notes as you read the following thought-provoking documents. Select two or three ideas that struck you as being particularly interesting or important. In your first sentence identify the points you will discuss. Then thoughtfully discuss the points that you selected. You Assignment submission must be between 20 sentences and be carefully proofread so as to identify and correct any careless errors in spelling, grammar, and proper writing mechanics. Positioning Clinical Nurse Specialists and Nurse Practitioners as Change Champions to Implement a Pain Protocol in Long-term Care Sharon Kaasalainen, RN, PhD, Jenny Ploeg, RN, PhD, Faith Donald, RN(EC), PhD, Esther Coker, RN, MScN, MSc, Kevin Brazil, PhD, Ruth Martin-Misener, RN-NP, PhD, Alba Dicenso, RN, PhD, Thomas Hadjistavropoulos, PhD Disclosures Nurs. 2015; 16(2):78-88. Abstract and Introduction Abstract Pain management for older adults in long-term care (LTC) has been recognized as a problem internationally. The purpose of this study was to explore the role of a clinical nurse specialist (CNS) and nurse practitioner (NP) as change champions during the implementation of an evidence-based pain protocol in LTC. In this exploratory, multiple-case design study, we collected data from two LTC homes in Ontario, Canada. Three data sources were used: participant observation of an NP and a CNS for 18 hours each over a 3-week period; CNS and NP diaries recording strategies, barriers, and facilitators to the implementation process; and interviews with members of the interdisciplinary team to explore perceptions about the NP and CNS role in implementing the pain protocol. Data were analyzed using thematic content analysis. The NP and CNS used a variety of effective strategies to promote pain management changes in practice including educational outreach with team members, reminders to nursing staff to highlight the pain protocol and educate about practice changes, chart audits and feedback to the nursing staff, interdisciplinary working group meetings, ad hoc meetings with nursing staff, and resident assessment using advanced skills. The CNS and NP are ideal champions to implement pain management protocols and likely other quality improvement initiatives. Introduction Inadequate pain management in long-term care (LTC) has been identified as a problem worldwide with rates of resident pain ranging from 30% to 83% (Moulin et al., 2002, Proctor and Hirdes, 2001, Zwakhalen et al., 2009). Despite these high rates, pain is consistently underassessed and undertreated, particularly in LTC facilities (Won et al., 2004). Innovative strategies, such as an interdisciplinary pain protocol, are needed to improve pain treatments and reduce pain in residents living in LTC settings. Kaasalainen et al. (2012)) found that implementing a pain protocol significantly improved resident pain in an intervention group compared with a control group over a 1-year intervention period. In this project, a clinical nurse specialist (CNS) and a nurse practitioner (NP) were identified as key facilitators to the successful implementation of the pain protocol. In Canada, NPs and CNSs are advanced practice nurses (APNs) with "graduate education who work collaboratively in interdisciplinary teams to meet the health needs of individuals, families, groups, communities, and populations" (Canadian Nurses Association, 2008). APNs have been defined internationally as registered nurses who have "acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice" (International Council of Nurses, 2013). NPs also can diagnose, order, and interpret diagnostic tests, prescribe medications, and perform some procedures traditionally associated with physicians (Canadian Nurses Association, 2011). CNSs have expertise in a clinical specialty defined by a specific population, setting, disease, type of care, or type of problem. There is overlap between NP and CNS role responsibilities for clinical practice, education, research, consultation, and leadership (DiCenso et al., 2010). This article reports on a substudy of the pain protocol project that focused on how a CNS and an NP facilitated the implementation of the pain protocol to produce changes in clinical practice. These findings also may shed some light about successful strategies that can be used to implement other types of practice changes in LTC, to ultimately improve the quality of life for residents. Literature Review Clinician beliefs and attitudes about pain may influence their decision making regarding pain management and treatment options within LTC settings (Kaasalainen et al., 2007). For example, research has indicated that health care providers underutilize opioid medications in older people, particularly those with cognitive impairment (Kaasalainen et al., 1998, Mezinskis et al., 2004, Won et al., 2004). Both nurses and physicians are reluctant to use opioids in LTC residents, especially for those with cognitive impairment who are deemed nonpalliative (Kaasalainen et al., 2007). Weissman and Matson (1999)) found a widespread fear of treating pain without understanding its exact cause, along with concern about overmedication and drug toxicity, especially for those older people with cognitive impairment. Unfortunately, the amount of physician contact in LTC facilities is limited due to lack of onsite physician coverage, which creates a challenge for careful monitoring and effective individualizing of pain treatments. A way to overcome this challenge may be to use other health care team members more effectively (e.g., NPs, CNSs, pharmacists) to assess and manage residents' pain. The development and evaluation of innovative strategies, such as an interdisciplinary pain protocol, using models of collaborative care, may lead to more effective pain management while ensuring careful monitoring of drug toxicity. The implementation of innovative interventions is challenging and research clearly shows that instead of passive dissemination, a multifaceted implementation approach is needed that includes audit and feedback, education outreach, and a local opinion leader to address multiple barriers (Grimshaw et al., 2005, Thompson et al., 2006). Baier et al. (2004)) found that a multifaceted collaborative intervention that used audit and feedback, education, training, coaching using rapid-cycle quality improvement techniques, and inter-nursing home collaboration, improved pain management process and outcome measures in 21 LTC facilities in Rhode Island. Using a quasi-experimental, pretest\posttest design, Baier et al. found use of appropriate pain assessments and nonpharmacologic treatments increased significantly (p < .001), but use of pain medications for residents with moderate to severe pain, prescriptions, and change in pain medications did not. Baier et al. suggested that lack of communication between nurses and physicians may have contributed to these poor findings around pain medication use. Bakerjian (2008)) suggests that CNSs and NPs can play a pivotal role in promoting effective communication between physicians and nurses in LTC, as well as acting as "change coordinators" or "change champions." Change champions have been defined as "individuals who dedicate themselves to supporting, marketing, and 'driving through' an innovation" (Greenhalgh, Robert, Bate, MacFarlane, & Kyriakidou, 2005). Given their advanced education and clinical skills, NPs and CNSs are well positioned to facilitate a practice change, such as implementing a pain protocol. In this study, the implementation of the pain protocol was guided by the Ottawa Model of Research Use (Graham & Logan, 2004)—a planned model of change. The preimplementation stage of this model includes an assessment of barriers, which once identified, need to be addressed in order to increase the likelihood of successful implementation of the innovation. To assess barriers, we completed an environmental scan before implementing the pain protocol at the two participating LTC facilities (Kaasalainen et al., 2010). In this scan, LTC staff identified a number of barriers to pain management, including lack of knowledge, lack of interdisciplinary collaboration, poor nurse-physician communication, and poor knowledge transfer with staff in LTC. Based on these scan findings, we designed a multifaceted approach to implement the pain protocol intervention, which was shown to be effective in reducing resident pain in the intervention group (F = 6.35; p = .01; Kaasalainen et al., 2010). One of the key strategies that we used was to position APNs (CNS, NP) as change champions to facilitate the pain protocol intervention. Hence, the purpose of this study is to report on the role of a CNS and an NP as change champions during the pain protocol implementation process. Specifically we addressed the following questions: 1. How do NPs and CNSs facilitate effective change in practice related to the implementation of a pain protocol in LTC? 2. What barriers and facilitators are encountered by the CNSs and NPs in changing team practice related to implementing a pain protocol in LTC? Methods This case study sought to explain how advanced practice nurses—who were positioned as change champions—implemented the pain protocol intervention successfully. We used an exploratory, multiple-case study design to address the "how" of an intervention (Yin, 2009). Setting and Sample Data were collected from October 2008 to September 2009 at two LTC facilities in southern Ontario, Canada that were involved in the implementation of a pain protocol. They were chosen in part because they employed an NP or CNS. The CNS and NP were designated by their respective LTC home management staff to be the change champion to implement the pain protocol. Site 1 employed an NP who had a master's degree and more than 10 years of experience working as an NP, 5 of which were spent at this LTC facility. Site 1 was a for-profit LTC facility and had 130 beds. It employed 62 personal support workers (PSWs), 19 registered practical nurses (RPNs), 13 registered nurses (RNs), 1 nurse educator, 1 director of care, 1 medical director, 1 administrator, 12 offsite physicians who were independently employed, and a number of other health care providers, including a consulting pharmacist. Site 2 employed a CNS who had completed a master's degree and had been practicing in LTC for more than 10 years. Site 2 was a not-for-profit LTC facility and had 110 beds. It employed 45 PSWs, 1 RPN, 27 RNs, a second CNS, 1 medical director, 1 administrator, 5 offsite physicians who were independently employed, as well as a number of other health care providers, including a consulting pharmacist. Data Collection Three methods were used to collect data: 1) diaries in which the CNS and NP recorded activities and processes they engaged in related to implementing the pain protocol; 2) participant observation fieldnotes of NP and CNS activities related to the pain protocol intervention; and 3) interviews and focus groups with various interdisciplinary team members who were responsible for implementing the pain protocol. These data collection methods are described here. APN Diaries. The CNS and NP each completed a diary (after having received instructions how to do so) for the duration of the implementation phase of the pain protocol, recording their activities and processes related to implementation of the pain protocol. Activities were summarized on a weekly basis over the first 3 months as that early phase was expected to be the most intense. After that, they completed diary notes as they felt necessary. At the end of the implementation phase, the NP and CNS were asked to write a two-page reflection on their involvement in implementing the pain protocol, summarizing key strategies used, challenges and facilitators encountered, and an overall sense of their role in the process. Participant Observation. We used moderate participant observation (research assistant was present and identifiable in the study setting and was involved in structured observation, occasionally interacting with participants) with peripheral membership (research assistant interacted frequently and intensely in the study setting to acquire firsthand information and insight) (Dewalt, 2002). Specifically, a research assistant shadowed each CNS and NP for 3 hours, twice a week for 3 weeks. Hence, 36 hours of participant observation was completed, 18 hours per NP and CNS. Fieldnotes were taken using a standardized template in 15-minute segments over each 3-hour period to capture the CNS or NP involvement in activities related to the pain protocol intervention, such as meetings; interactions with residents, family, and staff; mentoring; and other interdisciplinary communications that may have been missed in the diary entries. To facilitate observer consistency, the CNS and NP were initially observed concurrently by both research assistants using the template. After these sessions, we held debriefing sessions with the research assistants to discuss inconsistencies and to reach consensus. After two of these debriefing sessions, no further inconsistencies were noted; the research assistants then completed the remaining observations individually. One of the weekly observation sessions was scheduled in the morning and the other in the afternoon of different days of the week. A short debriefing session was scheduled at the end of each week to provide a summary of observations and a time for reflection on early analysis, methods undertaken to collect data, ethical dilemmas, and observers' thoughts and feelings (Bogdewic, 1999). Interviews and Focus Groups. At the end of the 1-year implementation phase, we conducted interviews with various members of the interdisciplinary teams responsible for implementing the pain protocol. In total, we conducted four focus groups: two with PSWs (unregulated care providers, n = 17), and two with RPNs and RNs (n = 11). Individual interviews were conducted with five members of administration (two administrators and three directors of care), four interdisciplinary team members (pharmacist, physiotherapist, physiotherapy assistant, and restorative care assistant), and the NP and CNS. Each participant was interviewed once, either in a focus group or an individual interview. Focus groups lasted approximately 90 minutes, whereas individual interviews were between 30 and 60 minutes in duration. Unfortunately, all requests to interview a facility physician were denied. The majority of participants (82%) were women with the lowest percentages of women in the pharmacist group (0%). The nursing groups were comprised of mostly women (91%). Participants, on average, had been working in their current position for 8 years (SD = 6.9) and in LTC for 11 years (SD = 10.1). Administrators had been working in LTC for a longer period of time (mean = 17 years; SD = 14.9) than the health care team members (mean = 9 years, SD = 8.2). Data Analysis Within the larger case-study approach, we analyzed the data using thematic analysis (Patton, 2002). Diary records, participant observation fieldnotes, and transcribed interview data were inputted into the qualitative software program, NVivo 8.0, to help organize and analyze the data. Two individuals, who were trained in completing thematic analysis, analyzed all data separately beginning with line-by-line coding and later grouped into larger categories. Initial coding of each transcript was done independently by two individuals to foster credibility and dependability. Any discrepancies were reviewed by the two investigators and discussed until consensus was reached. Once all data were coded, the major themes were identified. Data analysis was conducted in an iterative manner until the research team was all in agreement. All participants were given a two-page summary of findings and asked for feedback to assess the truthfulness of the findings and ensure data were interpreted correctly (Crabtree & Miller, 1999). We used cross-case analysis by first creating a "word table" that displayed the data from the two cases (sites 1 and 2) separately; each data were labelled in terms of its location, timing, and source (Yin, 2009). In this manner, each case was treated as a separate study, with its own developed codes and categories (Yin, 2009). Data from all sources were then integrated and analyzed together to develop the overall themes using thematic analysis that involved the research team. Ethical Considerations We obtained approval from a university-affiliated research ethics board as well as ethics boards at the participating LTC homes. Written consent was obtained from each interview or focus group participant before collecting data. Results Overall, the CNS and NP used a variety of strategies to help implement the pain protocol in LTC (see Table 1). They were seen as change champions and active in • educating staff about pain management and pain protocol implementation; • phasing in use of the pain protocol; • providing reminders and prompts to nursing staff; • using audit and feedback • organizing and facilitating interdisciplinary practice (e.g., pain team meetings) to reinforce the pain protocol and provide "check-ins" with staff to identify barriers to implementation; • assessing residents using advanced history and physical assessment skills, conducting in-depth pain assessments, and prescribing pain medications as needed; and • creating a positive relationship with staff to implement practice changes. Barriers to implementing the pain protocol included lack of follow-through from nurses, competing demands and heavy workload of LTC staff, and staff resistance to change. Educating Staff About Pain Management and Pain Protocol Implementation The NP and CNS educated staff about managing pain in older adults in general and the process of implementing the pain protocol. The education was delivered in two different ways: 1) providing one-on-one educational outreach to staff, and 2) organizing and facilitating scheduled educational sessions. Providing One-on-one Educational Outreach to Staff. The CNS and NP each provided one-on-one outreach to educate staff about completion of the protocol forms (e.g., checklist, protocol steps). The NP and CNS listened to staff and considered their input about ways to reduce workload related to implementing the pain protocol or make it less cumbersome to use (e.g., replacing the current prn medication flow sheet on the medication administration record with the protocol form to eliminate double documentation) and make the implementation process smoother. As well, they provided staff education about residents' diagnoses and associated pain, recognition of typical and atypical pain responses, and use of pain medications: A staff came to me with questions about a resident behavior and we attempted to determine if it was pain related which ended up involving some education to staff. (NP diary, site 1) [The NP] was like the library, to help us understand the pain protocol a little better, the pain assessment a little bit better. Understanding the resident, with the different diagnoses, the reasons for having different pain…or maybe expressing pain in a different way. (RN/RPN focus group, site 1) One thing about [the NP] is that [the NP] explains things to us … right to the last detail. If you ask [the NP] a question [the NP] will explain it, [the NP] will even bring it up on the computer and show you. (PSW focus group, site 1) At site 1, the NP consulted with a nurse regarding a resident who was identified as having pain: • Nurse said she never asked resident to use number scale, rather she assigned a number based on the information the resident provided (e.g., "scored" resident a 4 for moderate pain). • The NP discussed how scales should be used (must go by what resident says or use different scale if the number scale is not appropriate). • Nurse completed new initial pain assessment and reviewed findings with the NP. (Participant observation notes, site 1) In another encounter, the NP worked with a nurse who was struggling with how to use the pain protocol in practice: • RPN expressed frustration with pain protocol, takes too much time to do assessments, and interferes with medication administration. The NP spoke with RPN re: use of pain protocol and helped explain how to use it by going through it with RPN step by step. • RN asked questions about the protocol. The NP explained how to use it by using a specific resident example and had the nurse problem solve what to do. (Participant observation notes, site 1) At site 2, the CNS met with clinical leaders at each clinical area on a daily basis to discuss pain management issues for residents and to answer questions. The following is an example of an encounter: • CNS met with a clinical leader to discuss pain management of residents on unit. • Talked to nurses about using a standardized pain assessment tool. • Distributed the pain protocol resource binders and binders for interdisciplinary staff members; CNS informed the staff in each clinical area of the following related to the protocol: purpose of the study, and contents of the protocol resource binder, including brief summaries of the journal/research articles found in the binder. (Participant observation, site 2) In subsequent encounters, the CNS captured learning opportunities by asking staff specific questions about residents' pain to promote critical thinking (e.g., Could the resident's behavior be related to pain? Do residents verbalize the effectiveness of the current pain medication? If the resident is nonverbal, how do the nurses know if the pain medication is effectively managing the resident's pain?). This collaborative approach to problem solving is illustrated here: If the staff came to me questioning a resident's behavior, we would attempt to determine if it was pain-related together. (CNS diary, site 2) Organizing and Facilitating Scheduled Educational Sessions. In addition to one-on-one educational outreach, the NP and CNS organized and frequently facilitated scheduled education sessions for staff about gaps in knowledge that were discovered when using the pain protocol. These education sessions were organized on an ad hoc basis when the need or request from staff arose. Specifically, staff requested more information about different types of pain that older adults experience (site 1 only) and about using pharmacologic and nonpharmacologic interventions to manage pain (sites 1 and 2). At both sites, the CNS and NP organized a session on pharmacologic management of pain. They recruited the pharmacist who worked at each LTC facility to present information about using different types of pain medications, common side effects in older adults, and adjuvant therapies to offset some of the side effects. The NP developed and facilitated interactive educational in-service for team (RNs, PSWs, physiotherapist) re: types of pain (participant observation notes, site 1). The CNS facilitated an in-service with the "med nurses" (RPNs) to go over the pain protocol and using pain medications, covering each step and form, used resident examples to explain the protocol pain. (Participant observation notes, site 2) Phasing in Use of the Pain Protocol The CNS and NP discussed how it can be overwhelming for staff to implement a new change in practice and the strategy of "starting small and then expanding later" (NP diary, site 1) seemed to help offset some of the negative feelings of staff and allowed time to "work out the kinks" before implementing it facility-wide. Piloting the pain protocol or "phasing it into practice" was a strategy used by both the NP and CNS but more so by the CNS. For instance, at site 2, the CNS started the pain protocol on one unit first and then gradually expanded to other units. The CNS had a particular strategy that seemed to work for that site: I asked the clinical leaders on each floor to identify one resident who they knew was in uncontrolled pain and we used the pain protocol on that resident to see how it worked and to help them get used to using the protocol. … On their next clinical day, clinical leaders used the protocol on all residents on whom they were doing their quarterly updates and also will use it on all new residents as they move in. (CNS diary) On another unit: The CNS met with another RN to discuss plans to roll out pain protocol implementation. They decided to start the pain protocol on two patients first and then start on three more patients at the end of the month. (Participant observation notes, site 2) Providing Reminders and Prompts to Staff The NP and CNS were often engaged in reminding or prompting staff to implement the pain protocol; for example, checking in with the nurses during daily rounds and reminding them to think about the pain protocol and about resident pain itself, and posting newsletters with information about pain and about the study to facilitate its use. At site 1, the NP, along with the clinical educator, created an educational poster board that included the study summary, list of pain team members, pain facts, various pain-related resources including a pocket for journal articles, and handouts from previous education sessions. The CNS at site 2 incorporated the pain assessment tool in the electronic charting system to facilitate use: I think putting those [pain assessment tools] onto a computerized version was just a lot easier for the staff too as a reminder to automatically do that. And it just made them think of it, too. It just made a lot of people more aware of pain and what it looked like. (CNS interview, site 2) Sometimes the presence of the CNS or NP on the units reminded staff about implementing the pain protocol. Examples of this were reflected at both sites in all three sources of data: diary entries, participant observation notes, and focus group interviews: I did my usual weekly round on each floor asking them [staff] if anyone is experiencing new or uncontrolled pain. (CNS diary, site 2) CNS walked to each floor and asked nurses how the pain protocol was going and inquiring if they had any concerns or questions. None were reported at this time pain. (Participant observation notes, site 2) [The CNS] would catch somebody with new pain and she would ask us questions like "by the way, is she on the pain protocol yet?" Like remind us that you need do the proper assessment or intervention. [The CNS] put it into focus. (RN/RPN focus group, site 2) The NP talked to charge nurse about starting pain protocol for a resident who had leg pain and told the oncoming nurse about this resident and to reassess more often using pain protocol. Notes left in residents' charts to remind other nurses when pain assessments need to be completed for each resident (e.g., "assess pain re: contractures every day × 3 days"). (Participant observation notes, site 1) Using Audit and Feedback The NP and CNS used audit and feedback as a way to prompt staff either to continue what they were doing well and sustain the change or to bring attention to areas that required improvement: I [NP] reviewed and audited charts to determine if staff were completing the pain protocol appropriately. I [NP] asked staff to add more details or further explain in their charting about resident pain. (NP diary, site 1) The NP met with the charge nurse and an RPN and reviewed initial pain assessment for a resident to look for learning gaps: • For location of pain—right side documented, wants more specific description for location • Need explanation of exacerbating factors (listed decrease in appetite) • More specific re: bowel habits (listed "poor") • Reviewed these gaps with charge nurse and RPN. (Participant observation notes, site 1) The CNS highlighted errors and added notes and new protocol documentation on to charts for nurses. (Participant observation notes, site 2) Organizing and Facilitating Interdisciplinary Practice The CNS and NP were responsible for organizing and facilitating monthly interdisciplinary pain team meetings with staff to help implement the pain protocol and problem solve issues together. At the beginning, these sessions were focused on how to implement the pain protocol most effectively but later became more focused on concerns about specific residents who had challenging pain problems. Here is an example of an issue discussed at a pain team meeting at site 1: • 10 people in attendance + 2 research assistants: social worker, RPNs, NP, nurse educator, nurse manager, physiotherapist, recreational therapist. • The NP introduced the meeting and went over agenda. • The NP asked, "Who in the room is involved in the pain protocol?" • Any suggestions with using the protocol? • Physiotherapist suggestions: not sure of follow-up and where they are expected to chart. The NP was disappointed about the lack of follow-up regarding a specific patient whose pain was put off by the RPN as "weather related." Resident approached front desk to ask if something was going to be done about her pain and it was dismissed as if she just had memory issues. • The NP asked, "Why is pain not being followed up?" • Group responded: need more education and staff. (Participant observation notes, site 1) At another pain team meeting at site 1: The NP developed a case study (for discussion at a pain team meeting) to work through pain protocol and enhance application of knowledge and problem-solving ability. The NP went through entire medication list (explaining why patient is on each med, dosage, and possible side effects). Example of pain medications: fentanyl patch 100 mcg (3 patches) Q72h, oxycontin CR 40 mg Q12h, oxycocet 5/325 2 tabs po Q4h prn. (Participant observation notes, site 1) At site 2, the CNS held pain team meetings with staff using a communication tool called Situation, Background, Assessment, and Recommendation (SBAR) to identify residents who have pain and for whom the pain protocol should be initiated. CNS set up SBAR meeting on pain, involving PSWs and RNs on unit. CNS engaged group by asking specific questions: 1. Is resident in pain? 2. How would you know resident is in pain? 3. Showing any nonverbal signs? 4. Any resident guarding or grimacing? 5. Can resident tell you where pain is? 6. What do you think pain comes from? 7. Are PRN medications effective at all? (Participant observation notes, site 2) The SBAR … was a communication tool originally used for physicians so the situation, the background assessment and recommendation. … So who's in pain, what's the background related to pain, what's the assessment, what are our findings, where do we go from there if we thought someone was in pain. So we just took that time, which was about half an hour a month for each unit, or each home area. (CNS interview, site 2) Assessing and Treating Residents Using Advanced Clinical Skills The NP at Site 1 was also involved more clinically than the CNS to implement the pain protocol by completing history and physical assessments as well as advanced pain assessments, prescribing analgesics (NP only), ensuring follow-up with treatments, and enhancing communication with the interdisciplinary team. Advanced practice skills in assessing and treating patients were described: The NP assessed resident with pain related to lung cancer, reviewed resident's medications and chart, completed initial pain assessment. (Participant observation notes, site 1) [The NP] was like a resource to help us with medications because [the NP] could actually order medication. (RN/RPN focus group, site 1) Creating Positive Relationships with Staff to Implement Practice Changes Participants spoke about how the type of relationship they had with the NP or CNS facilitated knowledge transfer related to implementing the pain protocol. They said that the CNS and NP were dedicated to the topic and positive about the change, which facilitated buy-in and motivated staff. The NP and CNS were able to gain respect, develop trust, and establish credibility with nursing staff by displaying a higher level of knowledge and understanding. Participants said that the CNS and NP knew the residents well, enhanced communication, and promoted teamwork. The NP and CNS were described as being innovative, curious, creative, willing to try new things, and were accessible and approachable. I think that [NPs] are able to display a higher level of knowledge and understanding and so they gain the respect of the nurses who see them that way and not necessarily just another pair of hands. So I think because [the registered nursing staff] have road tested and can see the value of what [NPs] have to offer that I think that has probably helped as well. So [the registered nursing staff] will automatically know if something is not really clear to them say well maybe we need to talk to [the NPs], maybe they need to come and see the resident. (Administration interview, site 1) It really is being there, being around, having your ears opened for what is happening as well as responding when people come to you. But it's a constant presence, right, you don't just sort of drop something one day and say oh, here you go. Some people you can, some people just need the information and they are able to sort of run with that. And other folks it's a little more of a struggle, it's a companion you know. In our particular model we have the nurses doing a lot of tasks, your mind isn't free to think beyond the medication cart. So just having that extra mind there to say, "Why don't you try this?" "Have you thought about that?" Or "Can I do this for you?" It can't just be a parachute sort of thing. It's this constant daily walk together, I think, that makes the difference. (Administration interview, site 2) Barriers and Facilitators for CNSs and NPs as Change Champions A number of barriers and facilitators for implementing the pain protocol were identified (Table 2). No barriers were identified specific to the CNS's or NP's implementation of the protocol. Barriers specific to the protocol included lack of RN follow through and the belief held by staff that the protocol is too rigid and it "assumes LTC nurses cannot think for themselves" (CNS diary, site 2). At times, the pain protocol was not viewed as a priority by the nursing staff and it was seen as increasing the amount of paperwork they had to do, making their job more complicated. The CNS and NP stated that timing was a challenge due to competing demands of other larger projects that were concurrently being implemented. They also stated that it was difficult getting all staff educated about the pain protocol, particularly the part-time and night staff. Staff resistance to change, staff turnover, and use of external agency staff were other reported barriers. Facilitators to implementing the pain protocol included having a dedicated NP or CNS who was committed to and persevered with implementing the pain protocol, the ability of the NP to order certain pain medications, having support from administration for the project, and having CNS or NP support for educating staff about pain assessment and management and use of the pain protocol. Discussion The findings from this exploratory, multiple-case study provide a new understanding about the important role that NPs and CNSs play when implementing practice guidelines, in this case a pain protocol in LTC facilities. We evaluated the truthfulness of our data in a number of ways. Specifically, we aimed to achieve multiple perspectives by including participants from a variety of disciplines. Also, we used journals to examine our own biases and beliefs that we reflected on throughout the analysis. Moreover, we used multiple and independent coders during the analysis and used a number of data collection methods (i.e., interviews, diaries, observation) for data triangulation. These strategies helped promote the overall truthfulness of the study findings. The study findings highlight that both the NP and CNS worked closely with staff in various activities to facilitate successful implementation that focused on providing education and reminders to staff while maintaining positive working relationships. The CNS and NP played similar roles but the NP was more engaged in providing direct care while implementing the pain protocol. Bakerjian (2008)) found similar results in her review of the literature, in that NPs were more involved in providing primary care to LTC residents, whereas both CNSs and NPs were active in providing consultation, education, case coordination, and change coordination. The CNS and NP roles as change champions were clearly supported by this study. These study findings add to the growing body of literature about the nature of these roles in changing practice (Greenhalgh et al., 2005, Ploeg et al., 2010). Ploeg et al. found similar results in their study, which examined how nursing best practice champions influence the diffusion of guideline recommendations in a variety of settings. Specifically, they found that champions influence the use of guidelines most readily by 1) disseminating information through education and mentoring, 2) being persuasive at interdisciplinary meetings, and 3) tailoring the implementation to the organizational context. According to Graham and Logan (2004)), change is more quickly adopted when it is compatible with current practice and values. An understanding of organizational routines is important when implementing evidence-based innovations in practice (Cranley, Birdsell, Norton, Morgan, & Estabrooks, 2012). The CNS built on this understanding by integrating the pain protocol into an already established practice at the LTC facility—the SBAR sessions. This was a change enabler as staff was already familiar with the SBAR process, and needed to only slightly adapt current practice to include the new pain protocol. Through interactive educational discussions, like the SBAR session, practice change is more likely to occur as opposed to passive dissemination approaches (Thompson et al., 2006). Additionally, if the intervention is implemented within a multifaceted approach using educational outreach visits, reminders, audit and feedback, change champions, local consensus processes, and social marketing, the likelihood of a successful intervention is greater (Grimshaw et al., 2005), which was the case with this pain protocol intervention. The two most frequently reoccurring themes—the NP and CNS organizing interactive educational meetings and engaging interdisciplinary members in discussions regarding the pain protocol—highlight important strategies for changing practice. In this study, the CNS and NP involved LTC team members in training and activities, building a sense of shared values and community engagement related to the pain protocol. When viewed as partners in the change process, individuals are more engaged and empowered, contributing to a sustained practice change (Scalzi, Evans, Barstow, & Hostvedt, 2006). Through organizing interactive educational interventions and outreach visits, the NP and CNS were able to address the potential barriers to change, including lack of knowledge or skill and negative attitudes (Graham & Logan, 2004). For instance, through engaging the interdisciplinary members in discussions about the pain protocol and pain management, the CNS used transformative knowledge translation strategies (McWilliam, 2007). The CNS began each SBAR session with probing questions to challenge the group to reflect on current practice. Questions such as "is the resident in pain?" and "how would you know the patient is in pain?" encourage group members to reflect on their current practices, and consider how the care they provide may be changed. Questions related to identifying pain and nonverbal behaviors trigger group members to be more conscious about addressing pain in everyday practice. These clinical triggers encourage practitioners to question their practice and rationale, thus stimulating change (DeBourgh, 2001). The CNS and NP acted as the interface between the research team and frontline staff to implement the pain protocol intervention, which was facilitated by the positive relationships they developed with staff. For practice change to be successful, the change champion must be well connected to the staff, respected and trusted in their "expert" role (Thompson et al., 2006). It was evident that both the CNS and NP had strong communication and interpersonal skills, were highly respected within their respective organizations. and were viewed as clinical opinion leaders by staff, thereby contributing to their influential role as change champions (Borbas, Morris, McLaughlin, Asinger, & Gobel, 2000). Limitations There are some limitations to this study. First, we sampled only two LTC facilities in southern Ontario. Second, only one CNS and one NP led the implementation of the pain protocol in their respective LTC facilities. Hence, the study findings cannot be applied to other LTC facilities where the number and type of staff or role of the NP or CNS may vary. Also, it is possible that more constructive feedback about the CNS or NP roles was not shared during the focus groups and interviews due to the complex relationships among staff. It also should be noted that our results might be skewed because most participants interviewed in this study were women. Further work is needed to examine the implementation of a pain protocol in larger and smaller LTC facilities that use a variety of care models and staff mixes and the types of changes that would benefit the most from the use of NPs and CNSs as change champions. Conclusion Clearly, resident pain is an ongoing challenge for LTC staff to manage effectively. However, instituting changes in practice to improve pain management are difficult to initiate and sustain over time due to competing demands for staff. NPs and CNSs may possess different skill sets that help them advocate for change in innovative ways using a multifaceted and interdisciplinary approach, which is needed to foster a comprehensive change. Acting as the interface between the researchers and frontline staff, the NP and CNS encouraged practitioners to question current practice and embrace evidence-based innovations. The knowledge gained from this study will enhance nursing practice regarding the implementation of practice changes through knowledge transfer and exchange in the LTC setting, illuminating the influential roles of the CNS and NP as change champions. Nurses Advocating for Patients ________________________________________ By University Alliance Nurses play many vital roles in the care of their patients, including that of advocate – someone who acts or intercedes on behalf of another. Typically the healthcare professional with the most interpersonal contact with the patient, themay be in the best position to act as the liaison between patient and family and other team members and departments. To perform this function adequately, the nurse must be knowledgeable about and involved in all aspects of the patient’s care and have a positive working relationship with other team members. The American Nurses Association (ANA) defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of individuals, families, communities, and populations.” The ANA addresses the importance of advocacy in its Code of Ethics, including Provision 3: “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.” Three core values help form the basis of nursing advocacy: preserving human dignity; patient equality; and freedom from suffering. • Preserving Human Dignity: Every person has the right to be treated with honor and respect. Patients and their families are often confused, anxious and frightened. At such times, they need an advocate to help navigate the unfamiliar healthcare system and facilitate communication among caregivers. This may include interpreting tests, procedures and instructions from physicians in terms the patient can understand and follow. It also may be necessary for nurses to educate the patient on the need for tests and procedures, as well as to provide emotional and physical support during the process. Nurses are in a position to integrate all aspects of the patient’s care and ensure that concerns are addressed, standards of care are met and a positive outcome for the patient remains the goal of the healthcare team. Cultural and ethnic beliefs can be of great importance to patients and families and must be respected by the nurse. Although those beliefs may not be understood or appreciated by the nurse, they must be considered and accepted in all interactions, especially since they may have an impact on the patient’s physical and emotional well-being and comfort level. In order to be an effective advocate, the nurse must be considerate of patient privacy issues and regard patient and family information as privileged and confidential. Nurses must adhere to organizational, state and national laws when discussing or disclosing healthcare or other personal information. • Patient Equality: As the healthcare profession evolves in response to funding changes, technological advances and governmental regulations, disparities in the provision and delivery of care may become more defined. The ANA Code of Ethics directs nurses to practice “with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.” Nurses must provide care for all patients with the same degree of compassion and professionalism, without allowing personal biases to influence their practice. • Freedom from Suffering: Many nurses list a desire to help others as a major factor in their decision to enter the profession. Helping to prevent or manage suffering – whether physical, emotional or psychological – is perhaps the most important aspect of care from the patient’s perspective. Nurses may also be called upon to provide emotional support, or simply offer a friendly ear. That requires a commitment on the nurse’s part to be available to patients and their families. The role of advocate can require a nurse to act as a communicator, liaison, educator, interpreter and caregiver. Choosing a career in nursing means making the choice to fill that role while providing optimal care and striving for positive outcomes for all patients. Should Nurses Blow the Whistle or Just Keep Quiet? Carolyn Buppert, MSN, JD June 24, 2014 Confused? I'm Not Surprised Apparently, a lot goes on in healthcare that makes nurses uncomfortable, because I am asked this question, in some form, frequently. The answer is complicated. People may differ in their opinions of what falls into the realm of incompetent, unethical, or unsafe practice, and the laws of every state are different. And even though I read law every day, I had trouble figuring out what to advise, given the current law governing nurses. No wonder nurses aren't sure what to do. Nurses are told that they have a duty to protect patient safety. They learn this from language such as this, in one state's (Maryland) nursing regulations. Under "Ethical Responsibilities," it says: "A nurse shall...Act to safeguard a client and the public if health care and safety are affected by the incompetent, unethical, or illegal practice of any person." The implication is that when a nurse becomes aware of a patient safety threat, the nurse is supposed to do something. Maryland is not alone in making such pronouncements. Here is language from the Texas Board of Nursing Website: Situations involving potential risk of harm to patients or the public are referred to as "violating the nurse's duty to the patient" because all nurses have a duty under Rule 217.11(1)B to maintain a safe environment for patients/clients and others for whom the nurse is responsible. It makes sense to tell nurses that they are expected to safeguard patient safety. It would be even better if nurses who try to do something were better rewarded for their efforts. However, according to nurses I hear from, when a nurse reports a patient safety problem, the nurse often is surprised to find that he or she is considered the "bad guy." A nurse who raises quality issues that require a change of policy, practice, or staffing can be seen as a disruptor rather than someone who is making constructive criticism. Some nurses who have identified problems have found themselves out of a job. This is bothersome. It's perfectly legal for a hospital to terminate a nurse, for any reason or for no reason. The only job protections are those granted by contract between the nurse and the hospital (whether it is an individual contract or a contract offered through a labor union) and those granted by the US Constitution and civil rights laws. The latter include the right to be free of discrimination on the basis of age, sex, national origin, race, sexual orientation, and religious preference. If the hospital isn't firing the nurse because of age, sex, national origin, race, sexual orientation, or religious preference, in general the firing is legal. A possible exception is a whistleblower law, which may, in some situations, provide protection for nurses who report patient safety problems. We will get to that shortly. Although it is legal to fire a nurse for raising a patient safety issue (with a possible exception of whistleblower laws) it is not a situation one would hope for, from a patient's perspective. Blowing the Whistle, Fighting the System The following story is an example of a case in Texas where nurses were very concerned about the care being provided by a physician at their hospital, did something about it, and suffered as a result. Two nurses, one of whom was the hospital's compliance officer, reported a hospital physician to the state medical board, citing patient safety issues. The problems, according to the source listed below, included the following: (1) The physician was taking patients with serious diagnoses off their medications and instead recommending herbal remedies, for which he was the vendor; (2) the physician was performing surgery, including a skin graft, in the emergency department, even though he wasn't a surgeon; and (3) the physician almost never read patient charts nor ordered diagnostic testing, preferring instead to diagnose on the basis of history alone. The nurses who reported him essentially were relaying the observations and complaints of many nurses. The nurses filed an anonymous report with the medical board. Once the medical board contacted the physician, the physician enlisted his friend, the sheriff, to do some digging, and the sheriff found out who had filed the complaint against the physician. The physician then filed a complaint, with the sheriff, against the nurses, for harassment. The sheriff arrested the nurses, and the local prosecutor charged them with "misuse of official information," a felony punishable by 10 years in prison. (They had accessed patient charts to describe, specifically, the threats to patient safety.) The prosecutor had a few conflicts of interest. He was not only the doctor's personal attorney, but also the personal attorney for the sheriff and the hospital's counsel. The physician convinced the hospital to fire the nurses. Eventually the case went to trial against one of the nurses, and she was found not guilty. Charges against the other nurse were dropped before her trial, for reasons unspecified. As of 1 year later, the physician still was working at the hospital. Much later, the sheriff, the hospital administrator, and the prosecutor all were prosecuted for misuse of official information (the same charge that had been applied to the nurses), and all were found or pleaded guilty. The nurses sued the hospital and received a settlement. Eventually, the physician too was charged with misuse of official information and retaliation. He pleaded guilty. The full story can be heard on the radio program Old Boys Network, which originally aired on June 3, 2011. A transcript is also available. The nurses in this case were vindicated, but both went through several years of extreme stress, joblessness, and legal fees. Reportedly, neither wants to be a nurse any longer. Whistleblower Laws A nurse who is fired for bringing up a patient safety issue may think he or she is protected against retaliation under a "whistleblower law," but in fact, the nurse may not be protected. Whether such protection exists depends on exactly what the state's whistleblower law covers; whether the nurse followed the dictates of the law precisely; and whether there was any other reason, aside from reporting the patient safety issue, for which the hospital could reasonably have fired the nurse. The following case illustrates what can happen when a nurse tries to rely on a whistleblower law.[3,4] A hospice nurse reported to her supervisors that starter packs of controlled drugs were being given to patients without a physician's order. She was worried because some of the patients were children and because she feared the drugs would be misused. Shortly after she complained about this practice, she was fired. She was denied unemployment compensation because she had been fired. She protested the denial of unemployment and filed for wrongful termination, hoping to use the state's Health Care Worker Whistleblower Protection Act. The nurse found that the purpose of that law wasn't to protect nurses, but to protect employers against frivolous whistleblower actions filed by disgruntled former employees. A judge found that she hadn't conformed with a provision of the law, so the law didn't apply. (She hadn't reported the problem to an outside agency -- only to individuals within the agency.) The state's highest court reversed the finding of the lower court, holding that it was enough to have reported the problem internally, and essentially said she could avail herself of the whistleblower law. However, when the case was tried, a jury believed the hospice, her employer, who argued that they terminated the nurse for a reason other than the complaint about the starter packs. The jury believed that the nurse was right in making the complaint, but that didn't help the nurse, ultimately. The nurse spent $150,000 on her legal efforts. Maryland's Whistleblower Protection Act didn't work for that nurse, but let's look at another state's whistleblower protection for nurses. It appears that Texas law has some protections for a nurse who reports a quality issue : A nurse may report to the nurse's employer or another entity at which the nurse is authorized to practice any situation that the nurse has reasonable cause to believe exposes a patient to substantial risk of harm as a result of a failure to provide patient care that conforms to minimum standards of acceptable and prevailing professional practice or to statutory, regulatory, or accreditation standards. For purposes of this subsection, an employer or entity includes an employee or agent of the employer or entity. A person may not suspend or terminate the employment of, or otherwise discipline, discriminate against, or retaliate against, a person who: (1) reports in good faith under this section; or (2) advises a nurse of the nurse's right to report under this section. This law was added in 2011, after the Texas case described earlier. The key is to research the law of your state, so you know up front whether you have any protections when complaining about a patient care issue. In a recent article  a nurse-attorney and a social worker who have experience with whistleblowers discourage nurses from whistleblowing, for their own good. Federal whistleblower protection acts exist, which are meant to encourage reporting of healthcare fraud, and if the nurse follows the exact provisions of these laws, the nurse may share in the government's recovery of money. That is a different subject, however, and not addressed here. The Nurse's Duty to Protect Patient Safety What if a nurse doesn't report a quality of care or patient safety issue? Is he or she likely to be disciplined? Let's look at Texas law on reporting. It appears that reporting of a patient safety issue involving an agency or facility problem is optional ("may report"), but reporting of another nurse is mandatory ("shall report"). Here is the language that says reporting a facility is optional : In a written, signed report to the appropriate licensing board or accrediting body, a nurse may report a licensed health care practitioner, agency, or facility that the nurse has reasonable cause to believe has exposed a patient to substantial risk of harm as a result of failing to provide patient care that conforms to: • (1) minimum standards of acceptable and prevailing professional practice, for a report made regarding a practitioner; or • (2) Statutory, regulatory, or accreditation standards, for a report made regarding an agency or facility. Here is the language that says reporting a nurse is mandatory in Texas: • (1) "Conduct subject to reporting" means conduct by a nurse that: o (A) violates this chapter or a board rule and contributed to the death or serious injury of a patient; o (B) causes a person to suspect that the nurse's practice is impaired by chemical dependency or drug or alcohol abuse; o (C) constitutes abuse, exploitation, fraud, or a violation of professional boundaries; or o (D) indicates that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior. A nurse shall report to the Board in the manner prescribed under Subsection (d) if the nurse has reasonable cause to suspect that: • (1) another nurse has engaged in conduct subject to reporting; or • (2) The ability of a nursing student to perform the services of the nursing profession would be, or would reasonably be expected to be, impaired by chemical dependency. Under Texas law, therefore, the nurse may, but has no obligation to, report a facility to the appropriate licensing board, when the nurse has reason to believe that a patient has been exposed to substantial risk for harm. But a nurse must report another nurse. Here is what Texas law says about failure to report: "(a) A person is not liable in a civil action for failure to file a report required by this subchapter. (b) The appropriate state licensing agency may take action against a person regulated by the agency for a failure to report as required by this subchapter. In Texas, the Board of Nursing could take action against a nurse who failed to report, but isn't required to do so. Let's go back to the state law language cited earlier that implies that nurses must safeguard patient safety. A search of the disciplinary actions of the Maryland Board of Nursing indicates that the language "a nurse shall act to safeguard a client..." is invoked when it is the nurse who is incompetent or unethical. The nurse is supposed to report him- or herself, but not necessarily report someone else, or a facility. I found no cases where that clause was used to discipline a nurse who discovered that someone else was incompetent, and failed to report it. I could find no disciplinary actions reported on the Texas Board of Nursing Website against nurses who had failed to report a patient safety issue. Other states may have different law on this, or no law on this, but it is becoming clear that a nurse doesn't have to report a facility and will do better personally if he or she does not. So, Don't Report? Am I recommending that nurses adopt the "see nothing, hear nothing, speak nothing" attitude? No. I am saying that under current law, it is safer for a nurse not to report than to report. That surprises me, and it may be right- or wrong-minded, but it's the way it is. To argue the hospital or facility's side, a facility can't have every nurse they fire come back and say he or she was fired because the nurse complained about a patient safety issue. Hospitals will lobby legislators for laws that protect the hospital. And a hospital is going to defend itself against allegations of breach of patient safety, even if that means firing a nurse and discrediting the nurse. In all fairness, with every safety issue that a nurse might identify, there usually is an opposing argument that it isn't a safety issue or is a necessary risk. And some nurses are vulnerable to being discredited because they don't have spotless records. My purpose in this article is to inform nurses of the things they must do to protect themselves, before complaining, both within their company and to outside agencies. First, check your state's Nurse Practice Act for any law on reporting patient safety issues. Also check the state's Board of Nursing Website for any direction on this. Then, look at the whistleblower laws for your state, if there are any. If you decide to blow the whistle, follow the dictates of the law, exactly. Gather your evidence. Keep detailed records. I urge nurses to conduct a safety analysis on themselves before blowing the whistle on safety problems in the workplace, and even before complaining. I don't like to see nurses get nowhere with their patient safety concerns and also suffer personal setbacks. It is smart to consult an attorney who is experienced in whistleblower cases before complaining. (I am not an expert on whistleblower cases.) It may be best to line up your next job before complaining to higher-ups. Think before you act. Spend some time thinking about how to raise the issue, and with whom to raise it. Read some of the many books about the ins and outs of workplace communication. Watch and listen, and observe individuals in your workplace who seem skilled at working with others to effect change. It may be best to frame complaints as volunteering to help solve a problem. I don't know of a "charm school" for nurses, but if there is one, I would enroll and would encourage others to do so. Consider your risk. Be sure that your own practice is in order. If you complain about a policy or practice at your facility and someone wants to get back at you, what would they say? What are your vulnerabilities? Assess the gravity of the problem. If the problem you have identified is putting a patient or employee at imminent and serious risk, you may need to put all thoughts of yourself aside and report it. If the risk isn't so serious or isn't so imminent, then perhaps volunteering to problem-solve is in order. Assess the administration and your supervisors. Is there someone you can talk to in confidence whom you trust? Is there a financial reason why the problem is present? If so, be prepared for a struggle, unless you can suggest a legal, more cost-effective alternative. Taking a big-picture view, I recommend that nurses, throughout their careers, safeguard their ability to find another job, if they need to. Cultivate people who will give you positive references throughout your career, and do the same for them. This means treating colleagues professionally, not sharing personal dramas at work, keeping up with the latest developments in the field, handling disagreements in a way that doesn't leave others feeling bruised, and going up the chain of command when necessary. Conduct periodic self-assessments to identify your own vulnerabilities, and make a plan to minimize them. The bottom line is: It's always better to prevent problems, in law as well as healthcare.