Integration of acute care CNS and case manager roles.

To be effective in the new environment of managed health care, APNs must have a transformed outlook on providing nursing care. Accountability for day to day care that leads to shorter hospital stays and at the same time improves the quality of care is essential. The nurse's focus can no longer be on each small piece of care, but rather on a broad perspective of the entire continuum of care. The expert skills of the critical care CNS are still needed to manage the complex care required of patients in this setting. However, their focus needs to be broadened so that the larger picture remains in sight. Coordination of the activities of multiple care providers to achieve the ultimate goal of providing cost effective, quality care will be a primary responsibility of the CNS-NCM. This transition requires new thinking. Educational programs that include perspective transformation are needed for CNS role transition to become expert in the NCM role.

Advanced nurse practice. A model for collaboration.

The authors present an argument for separate advanced practice nursing roles. A model is presented for collaborative practice between two advanced practice nursing roles--a nurse practitioner and a clinical nurse specialist/case manager. The model was developed from the clinical practice of the authors' work in a community health center. A clinical example is provided that explicates the distinct and separate roles of each provider and demonstrates their collaboration to provide excellent, cost-effective healthcare.

Integration of the clinical nurse specialist into the nurse case manager role.

The focus of healthcare is changing from treatment of illness to promoting optimal wellness in a cost-effective manner. With this change, the role of the nurse also must change. The traditional role of the clinical nurse specialist (CNS) is being eliminated from many hospitals, leaving a gap is nursing expertise. The role of the nurse case manager (NCM) is developing rapidly. A logical movement is for the CNS to move into the NCM role. Because of distinct differences between these roles, the CNS must learn new skills. This paper discusses the role differences between the NCM and the CNS and suggests areas of education needed to make a successful transition. But more importantly than just learning new skills, the CNS must undergo a transformation in perspective to function in the new reality of managed care.

Fostering critical thinking in nursing students in the clinical setting.

Critical thinking is an important outcome of baccalaureate education in nursing. The authors explore the relationship between critical thinking and the nursing process and propose a model to foster critical-thinking abilities of nursing students in the clinical setting.

The nursing assessment decision grid: tool for delegation decision.

The ability of registered nurses to delegate patient care to nurse extenders has become an important skill. This study measures the effectiveness of the Nursing Assessment Decision Grid to teach RNs delegation skills. The ability of 93 staff nurses to analyze tasks and problems found in two patient vignettes and then delegate some care to an LVN working in a dyad was measured before and after exposure to the Nursing Assessment Decision Grid. A paired sample t test was used to compare mean pretest and posttest scores for the three parameters. Analysis of variance was used to examine the effect of professional and personal experiences on this decision making ability. RNs showed a statistically significant increase in their ability to identify nursing tasks and patient problems embedded in two vignettes. They were then able to make delegation decisions about the care of the patients in the vignettes. Primary language of the study subject may have had an effect on the ability to perform patient problem analysis.

Delegation decision making: development of a teaching strategy.

The ability of registered nurses to delegate nursing care to lesser-skilled nurses has become an important component of nursing practice. However, neither education programs nor clinical experience has prepared staff nurses to function in the delegation-decision role. A tool developed to meet this need is the Nursing Assessment Decision Grid. With its use, registered nurses learn to analyze the nursing tasks and patient problems inherent in patient vignettes and then gauge which level of nurse can safely carry out the patient care required.

Clinical practice and new technology: prostate-specific antigen (PSA).

In response to a marked increase in the use of an available test, Group Health Cooperative of Puget Sound (GHC) evaluated the use of prostatic specific antigen (PSA) as a screening test for prostate cancer. A project team reviewed the literature and determined that PSA did not meet GHC's criteria for screening. An implementation team then developed a comprehensive program to educate staff, facilitate practice change, measure outcomes and provide continuing feedback to physicians. These efforts are described and preliminary reports reported.

Ureteral obstruction in postmenopausal woman with endometriosis.

A case of ureteral obstruction occurring in a postmenopausal woman treated with long-standing unopposed estrogen is reported.