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Improving Outcomes Reporting

Fulton, Janet S. PhD, RN, ACNS-BC, ANEF, FAAN

doi: 10.1097/NUR.0000000000000400

Author Affiliation: Indiana University School of Nursing, Indianapolis.

The author reports no conflicts of interest.

Correspondence: Janet S. Fulton, PhD, RN, ACNS-BC, ANEF, FAAN, School of Nursing, Indiana University, 600 Barnhill Dr, Indianapolis, IN 46033 (

Timely and accurate reports of clinical nurse specialist (CNS) practice outcomes help demonstrate the contributions of CNSs to patients and families, the health system, and the public. Assuming this is a noncontroversial statement, then where are the reports? Experience suggests that many CNSs don't prepare outcomes reports for employers, and there are limited publications describing CNS practice outcomes. Anecdotally, CNSs talk about the difficulty capturing their practices, especially the time-consuming process and qualitative elements. For the past 20 years, the National Association of Clinical Nurse Specialists annual conference has featured abstracts highlighting CNS practice culminating in demonstrable outcomes such as protocols, clinical improvements, change projects, and educational programs, outcomes requiring months and years to come to fruition. What of the daily work? The often invisible, time-intensive effort devoted to bedside nurse-nurse consults, equipment troubleshooting, committee meetings, staff development activities, quality data reviews, and any number of tasks, duties, and conversations that may or may not result in an abstract presentation at a national meeting. Although challenging, it is nonetheless important for each CNS to have an individual record of outcomes, and likewise it is important for our collective efforts to be able to demonstrate the contributions CNSs make to the health and well-being of the citizenry. Here are some thoughts for moving forward with improved outcomes reporting.

Confusing the notion of CNS role with CNS practice is one barrier to outcomes reporting. What is the difference between role and practice? A role is a set of expected functions, characterized by a pattern of behaviors in a given social context. Professional roles are learned though academic preparation. Clinical nurse specialist is an advanced nursing role. Practice is the action(s) taken by those persons in the role. Practice reflects a set of competencies that, when put in to action, result in outcomes. Too often the phrase “impact of the CNS role on…” is used when “outcomes of CNS practice…” is the more appropriate phrase. Practice is a verb denoting action; role is a noun denoting person, place, or thing. Outcomes result from actions. A first step to improving outcomes reporting is to make the link between actions and outcomes; practice generates outcomes.

Capturing the totality of CNS practice in one report may not be feasible. Clinical nurse specialist practice encompasses 3 domains—patient/client, nurses/nursing practice, and systems. Further, CNS practice is highly individualized with differing emphasis on each domain, depending on specialty population problems, nursing practice trends, and system priorities. The totality of CNS practice may be of limited interest to others. For example, staff nurses need the CNS to consult on complex patient problems, whereas the administrator counts on the CNS to be a system-wide expert advisor for a specialty population care, and the quality manager depends on the CNS to address quality reports with unit-based initiatives. It's not one job; it's multifaceted with diverse outcomes. I'm reminded of John Godfrey Saxe's poem The Blind Men and the Elephant.1 In the poem, each of 6 blind men interacts with a different part of the elephant, and being blind, each has a unique impression of the animal. Clinical nurse specialist practice is like the elephant, and each committee chair, clinical supervisor, and department administrator being “blind,” experiencing only a small part, unable to understand the whole of CNS practice.

Consider using an “elephant” approach to reporting outcomes. Create several focused reports to address practice outcomes for different priorities. For example, one report may be for specialty unit directors, another report for the safety committee, and yet another report for product evaluation team. The totality of a CNS practice will be seen only by reviewing all the reports, but not all constituencies are interested in all the reports. Focused reports can be summarized in a comprehensive report for performance reviews.

Focused reports help teach colleagues how to think about and talk about CNS practice. Identify and reinforce words associated with CNS practice. For example, when staff nurses ask for help with a clinical problem, say, “My job is to support you. How can I help?” Attach the idea of support and help to CNS practice. Consistently repeating some version of this response will help staff internalize the message. Prepare and post a monthly report for the unit staff enumerating the number of patient consults and summarizing any recommendations for improving clinical care that resulted, such as equipment maintenance, visitor rules, or orientation procedures. The staff will learn to associate CNS practice with help and support for clinical care, and sooner or later you might hear a unit nurse explaining to a new orientee, “He's the CNS. His job is to support us; call him if you need help.”

Try the same focused approach with committee members. For example, in meetings, say, “My job as a CNS is to lead quality initiatives. I'll take responsibility for this project.” At each meeting, preface the project update report with, “My responsibility as a CNS is to lead this quality project. Here is my report on the work to date.” Attach the notion of responsibility for leading to CNS practice. One day, the committee chair will be presenting at the health system's board of directors and might likely say, “The CNS was responsible for leading the project, because CNS practice was connected to the project in the minds of the committee members.”

Reports, whether comprehensive or focused, should be linked to the mission, values, and priorities of the organization. Reports should also reflect job performance expectations as noted in the CNS job description. The job description should reflect professional performance standards and outcomes. Make sure the job description is a reasonable reflection of CNS practice outcome expectations.

The journal is very interested in publishing descriptions of methods, procedures, formats, and other tools for reporting CNS practice outcomes. Improving CNS outcomes reporting starts with good description of what is occurring, be it meager or massive. Consider submitting a manuscript describing challenges, opportunities, ideas, and suggestions for reporting CNS practice outcomes. In lieu of a manuscript, send a letter to the editor with suggestions and examples for reporting practice outcomes. It's important because timely and accurate reports of CNS practice outcomes demonstrate the contributions of CNSs to patients and families, the health system, and the public.

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John Godfrey Saxe (1872)

It was six men of Indostan

To learning much inclined,

Who went to see the Elephant

(Though all of them were blind),

That each by observation

Might satisfy his mind.

The First approached the Elephant,

And happening to fall

Against his broad and sturdy side,

At once began to bawl:

“God bless me!—but the Elephant

Is very like a wall!”

The Second, feeling of the tusk,

Cried: “Ho!—what have we here

So very round and smooth and sharp?

To me 't is mighty clear

This wonder of an Elephant

Is very like a spear!”

The Third approached the animal,

And happening to take

The squirming trunk within his hands,

Thus boldly up and spake:

“I see,” quoth he, “the Elephant

Is very like a snake!”

The Fourth reached out his eager hand,

And felt about the knee.

“What most this wondrous beast is like

Is mighty plain,” quoth he;

“'T is clear enough the Elephant

Is very like a tree!”

The Fifth, who chanced to touch the ear,

Said: “E'en the blindest man

Can tell what this resembles most;

Deny the fact who can,

This marvel of an Elephant

Is very like a fan!”

The Sixth no sooner had begun

About the beast to grope,

Than, seizing on the swinging tail

That fell within his scope,

“I see,” quoth he, “the Elephant

Is very like a rope!”

And so these men of Indostan

Disputed loud and long,

Each in his own opinion

Exceeding stiff and strong,

Though each was partly in the right,

And all were in the wrong!

So, oft in theologic wars

The disputants, I ween,

Rail on in utter ignorance

Of what each other mean,

And prate about an Elephant

Not one of them has seen!

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1. Saxe JG. The Blind Men and the Elephant. 1872. Accessed July 7, 2018.
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