Writing DNP Clinical Case Narratives: Demonstrating and Evaluating Competency in Comprehensive Care

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The book covers important topics such as the development of DNP clinical competencies, performance objectives, utilizing evidence-based practice, a DNP approach to adolescent care, caring for the chronically ill, mental health care, adult health care, and many more.

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The main purpose of this book is to provide DNP faculty and students with a reliable and detailed guide to use when implementing a format to document care provided. The case narratives presented in this book differ from the traditional case study format: students delineate all aspects of the decision-making process, identify the evidence that supports the decision, discuss the robustness of the evidence, analyze the effectiveness of the clinical decision, and critically reflect on the overall case.

This detailed format captures the complexity and details of clinical practice.


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Test Drive. Subsequent implementation has contributed to reconfiguration in health care delivery, accelerated the demand for health care along with a shortage of key health care professionals, and opened up new and expanded roles for nurses under new care delivery models. Aimed at extending health insurance coverage, there are many provisions of the ACA, including those designed to emphasize prevention and wellness, improve quality and system performance, and curb costs.

Notable among these aspects are the creation of health homes and integration of care for persons with chronic illnesses, improvements in care coordination, emphasis on prevention and primary care, investment in health information technology, and testing of new delivery and payment systems. Authorized under the ACA for Medicare reimbursement, the Centers for Medicare and Medicaid Services CMS has implemented an initiative to reward acute care hospitals with quality-of-care incentive payments for the quality of care delivered to Medicare patients.

The goal is to link payment to a value-based system that improves quality of care and is not just based on volume of services. Nurses hold the central ground for quality, safety, and improving the patient experience. For example, having quick care clinics affiliated with a hospital can decrease nonemergent patients seeking health care on weekends and nights in the emergency department and increase patient satisfaction with not having to wait.

However, to run smoothly, nurse clinical leadership is needed to coordinate and integrate care with affiliated sites such as laboratories, imaging centers, and pharmacies. Leadership in nursing is highly valued. The Institute of Medicine 3 noted that nurses need to be prepared to lead in all aspects of health care.

Clinical leadership is defined here as the process of influencing point-of-care innovation and improvement in both organizational processes and individual care practices to achieve quality and safety of care outcomes. McCausland 5 noted that new interdisciplinary models of care that cross traditional boundaries of ambulatory, inpatient, and community settings need credible clinical leaders.

Thomas and Roussel 6 noted that clinical leadership is about clinicians augmenting care for safety and quality by using innovation and improvement. This places the opportunity for health care leadership at the clinical level within the realm of each direct provider of care, especially nurses who are at the direct care level. Clinical leadership uses the skills of the RN and adds components of general leadership skills, skills in management of care delivery at the point of care, and focused skills in using evidence-based practice for problem solving and outcomes management.

There is clearly a need for clinical leadership in nursing because of the many and varied point-of-care implementation problems that arise. For example, patient safety may be compromised if there is poor team communication. When nurses are busy or short-staffed, hand-off communications may be compromised, creating gaps in care Huber et al, unpublished data, Discharge transitions may not be smooth if both sending and receiving areas do not communicate well.

Medication administration may be less than smooth when multiple disciplines caring for a patient do not coordinate prescribing and transcribing practices. This is true in acute care and across the continuum. Resolving ongoing care gaps requires energetic actions based on best practices, teamwork, care coordination, and clinical leadership competencies at the point of care. There is a body of evidence demonstrating the relationship between nursing leadership and patient outcomes.

Their systematic review of 20 studies from to on the relationship of nursing leadership practices and patient outcomes demonstrated a positive relationship between relational leadership and multiple patient outcomes. A connection between supportive leadership styles and positive patient safety outcomes was noted. Among the 20 studies reviewed, transformational leadership was the most frequently used leadership theory. Transformational leadership is an evidence-based theory used as a strategy and manifested as a style for working within the complexity of care and the use of interdisciplinary teams.

For example, the American Organization of Nurse Executives AONE 10 has identified five core nurse executive competencies: leadership, communication and relationship-building, business skills, knowledge of the health care environment, and professionalism. Transformational leadership directly addresses some of the competencies in the first category of leadership.

There is a solid body of evidence that transformational leadership is related to effectiveness, 9 — 12 which is especially important for working with interprofessional teams, managing the coordination of care, and innovating roles and functions as structures are changing. Clinical leadership roles are often thought of as targeted to the development of nurse managers and executives.

Given the need for clinical leadership development at all levels, the focus here is on the development and education of nurses as leaders who are prepared to lead at the unit, program, or microsystem level and across the continuum of care. Nurses in direct care roles deliver care to and coordinate the care of patients and clients. Yet, there are organizational and systems imperatives for quality and safety initiatives and innovations designed and executed by nurses.

Thus, to fully enact the direct care role, nurses must be prepared to address all situations that arise at the intersection of clinical practice provider with patient and family with the context and environment of care organizations and groups of multiple care providers and disciplines.

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This is the imperative of clinical leadership. For example, the leadership and management of care transitions, both within and across settings and sites of care, is a crucial function under implementation of the ACA and its VBP financial aspects. The traditional preparation of nurses has not emphasized these roles and functions, but rather mastery of the psychomotor and conceptual skills needed to deliver entry-level care as an RN. The US health care system has been predominantly acute care driven. Thus, there has been heavy emphasis on learning directed to acute care practice and disease-specific knowledge rather than management of populations, chronic conditions management, care integration, and care coordination among multiple disciplines and in multidisciplinary team care delivery models.

In studying new and elevated roles for nurses as care integrators, Joynt and Kimball 1 identified the following examples: serving as team leaders, CNLs serving as unit-based care managers, nurse practitioners serving as primary care providers in clinics, and nurse coaches managing transitions across settings. Since these emerging roles support the ACA, we will discuss the preparation and developmental opportunities for these roles. As the health care environment has been changing and care is shifting to population management and outpatient settings, the care coordinator role has emerged as a new twist on case management and a new model of professional nursing practice.

Nurses are often responsible for coordinating care for a group or population of patients. For example, nurses may manage populations of patients with diabetes or cardiovascular disease in acute care. In the new and emerging models, nurses are and will be managing many types of carved out populations with chronic illnesses or behavioral health conditions across settings and sites and for long time frames.

New roles and jobs have been the natural result. Contemporary names are care coordinators, health coaches, navigators, or care managers. These roles have arisen in conjunction with shifts to patient-centered medical homes and accountable care organizations under the ACA and reimbursement shifts that have put renewed emphasis on care coordination, care management, and prevention strategies related to VBP aspects.

Case managers have a long and distinguished history of service delivery in nursing and social work. Education for the care coordinator role arises from education within the discipline eg, nursing or social work and often includes specialty knowledge and experience in case or population health management.

Writing DNP Clinical Case Narratives: Demonstrating and Evaluating Competency in Comprehensive Care

There is no generally acknowledged curriculum for education and training of care coordinators or case managers, but there is a text that is a core curriculum for addressing the case manager certification exam. It issues standards of practice and links with transitions of care organizations.

Case managers practice within a variety of professional disciplines. The top two work settings for case managers are health plans They use field-tested role and function studies as the basis of their certification, qualifications, and test plan. CCMC has identified eight essential activities of case management: assessment, planning, implementation, coordination, monitoring, evaluation, outcomes, and general aspects. The six core components of case management are: 1 psychosocial aspects; 2 health care reimbursement; 3 rehabilitation; 4 health care management and delivery; 5 principles of practice; and 6 case management concepts.

They can be used to guide studying for the exam. In addition, CCMC offers many other resources for case management practice, such as a code of ethics called the code of professional conduct. These authors call for new settings and contexts for experiential learning activities for care coordinators to enable collaboration and skill development across the continuum of care versus traditional settings and approaches.

The CNL has been described as a front-line innovator. CNL education helps prepare nurses for opportunities to make improvements in systems at the point of care, where changes closely impact patients and families. The CNL curriculum framework centers on the domains of nursing leadership, clinical outcomes management, and care environment management.

CNL education prepares nurses to focus on transforming care at the point of care.

CNLs have advanced knowledge, skills, and abilities in quality improvement, outcomes measurement and management, systems management, and changing leadership to bring to bear on transforming care. According to Binder, 22 little is known about structures and processes that influence successful integration, and components that influence or hinder effectiveness and sustainability of the CNL role.

Therefore, the intentional framework serves to provide enabling education to influence role effectiveness Figure 1. APRNs are prepared, by education and certification, to assess, diagnose, and manage patient problems, to order diagnostic tests, and to prescribe medications. State licensing laws define the permissible scope of practice for RNs, as promulgated by state Boards of Nursing. All states regulate advanced practice nurses in some manner. Some license nurse practitioners; some grant authority to practice through certificates, recognition, or registration.

These include graduation from approved educational programs and certification examinations. Many states rely on national certification programs to measure competency. APRNs typically are educated at the graduate level with in-depth preparation for a specialty practice, then take a certification exam, then comply with individual state licensing requirements. However, considerable variation remains from state to state. Under the consensus model, all APRNs must pass a national certification exam. APRN practice is seen as building on the competencies of RNs, demonstrating a greater depth and breadth of knowledge, greater synthesis of data, increased complexity of skills and interventions, and having greater role autonomy.

APRNs have found jobs in acute care hospitals, managing care for specialty populations. They are also embedded in primary care as primary care providers. For example, rural health clinics in Iowa rely on senior clinical personnel such as physicians, physician assistants, and nurse practitioners to provide care coordination, care and case management, and identification of high-risk patients.

For example, unit-based APRNs working in collaboration with a physician-hospitalist to manage patients on a general medicine unit in an academic medical center was the focus of a new unit-based role for APRNs at Vanderbilt University Medical Center. Team effectiveness was a major focus. There has been considerable research done to compare patient outcomes of care provided by APRNs and physicians.

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Writing DNP Clinical Case Narratives: Demonstrating and Evaluating Competency in

The conclusion is that outcomes of care by APRNs in collaboration with physicians are comparable, and in some instances better, than care by a physician alone. A systematic review concluded that APRN care is safe, cost-effective, and results in similar clinical outcomes and patient satisfaction as compared to care by physicians alone for the populations and in the settings of the reviewed studies. That being said, intentional leadership development will be required for current and future APRNs Figure 1. Health care systems and organizations must constantly gauge environmental forces and trends in patient care delivery to determine competency gaps within the workforce.

Strategic and intentional development of clinical leaders can occur through education and training. The evidence base from business management research proves that leadership knowledge, skill, and abilities can be taught. Now it is clear that they should be taught in health care. Thus, intentional leadership development is an important opportunity.

Wilmoth and Shapiro 28 have called for the adoption of a common framework for intentional leadership development that will enable nurses to lead at any level in any health care organization. Intentional leadership development can be conceptualized as new curricula, additional education, enabling innovation, use of reflective narratives about leadership roles, engaging in research on interdependency, and trialing of thinking strategies Figure 1.

Intentional leadership development needs to be designed based on perceived educational needs and practice gaps to enable clinical leadership development at the point of care. It is exciting to see new roles emerge for nurses as the US health care delivery system reconfigures to address cost, quality, and access issues.

Nursing has been a profession rich in opportunities to grow and enrich the delivery of patient care services. Nurses find many practice settings and sites need the unique skills of an RN. The emergence of care coordination, CNL, and APRN roles has occurred in part because of the need for continuity of care and management of care transitions that were not well addressed in an acute care focused, episodic delivery system. Care was disconnected, chronic diseases were not well managed, and patients experienced gaps when only acute medical episodes were the focus.

Care coordination has been demonstrated to be an important solution, common to all three roles. However, there are challenges to enabling creativity, problem solving, and innovation at the clinical leadership level for care coordination.


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These challenges arise in part because of the nature of knowledge acquisition in science-based professions, training in psychomotor skills that focus on repetitive task learning, and the use of structured clinical practice protocols, all of which tend not to expand and enable creativity and innovation. As health care professions focus on their ever-expanding discipline-specific knowledge base, there is less time to teach and learn interdependence-based skills and have creative think time.

The need to reduce variation through evidence-based practice and standardized protocols and the countervailing need to rapidly solve complex practice issues, such as when a serious event occurs like a fatal medication error due to a flaw in the process or poor communication, will cause a dynamic tension at the point of care. With a complex and rapidly changing health care environment, clearly the interconnection of evidence-based practice with ingenuity is essential to address and solve clinical practice problems, especially within multidisciplinary teams.

Innovation and interdependency are two core concepts that serve as an opportunity to better inform clinical leadership development, education, and practice. Innovation is defined as use of a new mindset in a different context to enable creative linkages that will generate a solution or adaptation to a practice problem. Innovation requires that there be a wrap-around support system or environment that incubates innovativeness.

Solutions for the practice environment are evolving toward evidence-based practice as the standard. Evidence-based practice, defined as unifying research evidence with clinical expertise and patient values and preferences, 31 is being adopted by nurses and used as a marker of excellence. However, when implementing evidence-based practice, contexts will differ and best solutions may need to arise from innovation.

This will require that leaders use a new mindset to successfully adapt recommendations for implementation. For example, under VBP, prevention of readmissions is an imperative. Thus the implementation of enhanced discharge planning is an evidence-based response. However, contexts differ, such as the degree to which electronic health records systems are compatible with each other and across settings and are adapted to discharge communication effectiveness.

If poorly implemented, crucial medication administration information, such as discontinuing a medication when going home, may be lost between acute care and home care systems. The potential for catastrophic outcomes is significant. Clinical leadership is needed to generate innovative solutions. Another example is the use of a smartphone application for weight loss in overweight primary care patients.

As new issues emerge, creative solutions are needed. There may not be enough time to use incremental change strategies, such as in situations of sentinel events or serious safety near misses. If there is adequate time, the solution still may be complex. For example, technology solutions to access issues include implementation of telehealth. Use of strategies to enable creativity and problem solving will be critical Huber et al, unpublished data, According to Berrett, 33 there are various types of thinking approaches to enable problem solving for creativity and innovation.

The key to problem solving is making unique connections. He discussed two thinking concepts that, if used intentionally, may support clinical leadership development. These include divergent thinking, which allows the clinical leader to come up with alternative ideas and theories to solve problems generating creative ideas by exploring many possible solutions , and abductive logic, which relies on inference when information is incomplete a medical diagnosis is an example. These two forms of scientific reasoning offer the clinical leader a novel way to reflect on and analyze problems, situations, and the context for implementation of strategies to achieve outcomes.

Use of expanded thinking allows the individual to yield a large number of possible answers and make creative leaps in situations. Developing a workplace context to support and enable a mindset for innovation will be essential. According to Joseph, 30 a culture and climate for innovativeness is needed to spark and sustain the inquiry needed for innovation. Seven organizational antecedents are required to enable a culture and climate, so workers can innovate.

These include organizational identification, organizational support, organizational values, relational leadership, nurse—nurse relationships, and nurse—nurse leader relationships. These findings illustrate that the work environment must be conducive to enabling innovation as an important element to reduce serious safety and quality issues and workforce shortages in health care. The author presented unit-level, interdepartmental-level, and system-level actions for all levels of leadership to enable innovation.