MSU College of Nursing

NUR862: CNS Role Internship Fall 2019

Documentation of CNS Clinical Competencies, Activities, and Hours

Student Name: Megan Johnson

Date range for submission: Start: 8/28/19 End: 12/3/19

Preceptor: Nikki Taylor
Agency: Michigan Medicine
Clinical Faculty: Dr. Pfander Clinical Faculty Email:
Total Cumulative Internship hours at time of submission: 274 (to be entered by student)

This Section for Preceptors Only

Preceptor Validation of student competency documentation, activities and clinical hours as noted on
this document. Your typed/electronic signature indicates you have reviewed and agree with the
student’s documentation of competency achievement and clinical hours as written. Preceptors, once
validated, please email directly to the clinical faculty.
Signature (electronic/typed): Nikki Taylor, MS, RN, AGCNS-BC
Date: 11/27/19
Comments:

Students are to document how each competency listed below was achieved, label with the
corresponding sphere of influence (patient/patient care, nurse/nursing personnel,
organization/systems) and the date of entry. Statements are to be brief, outcome statements, providing
evidence of completion and associated dates. When the evidence of competency achievement is the
completion of a course assignment (example: history and physical) it is appropriate to document that as
part of the outcome statement.

Course Objectives:
At the end of this course, students will:
1) Demonstrate the ability to engage in critical inquiry and delivery of advanced practice nursing
skills based on theoretical and empirical knowledge to improve nurse sensitive health care
outcomes across populations.
2) Integrate transformational leadership knowledge, skills, and values in promotion of evidence-
based nursing practice innovations.
3) Engage in the teaching and coaching roles associated with the CNS in the design and delivery
of innovative, cost effective, evidenced based educational materials for patients, families, or
health care personnel to achieve outcomes.
4) Assume a leadership role for a unit-based or special population based practice initiative under
the guidance of a clinical preceptor & evaluate the benefits and costs of practice changes in the
 context of complex health care systems.
5) Synthesize ethical principles with advanced health advocacy policy skills.
6) Analyze the role of the CNS in collaboration with members of the healthcare team to inform
practice and improve nurse sensitive patient outcomes.
Provide 2-3 personal objectives for achieving course objectives:
Personal Objective and Planned Learning Evidence Achieved (including date):
Activities / Required Resources: 9/17/19 During “skin day” I educated multiple
 Educate staff about an identified bedside nurses on the product changes that
practice or product change were happening hospital wide. Product
One on one coaching, email, daily changes included blue pads to white pads for
management system (DMS) and staff improved moisture wicking, Sensicare to
meeting to educate direct care staff about Cavilon wipes for improved skin protection
an identified practice change from incontinence, and foam/ABD pads to wet
wipes for environmental purposes.
Computer, textbook, room for meeting

Personal Objective and Planned Learning Evidence Achieved (including date):

Activities / Required Resources:
 Demonstrate critical inquiry of nurse
sensitive health care outcomes as
evidenced by focused assessments
and case studies
Two case studies and multiple focused
assessments during the semester
9/16/19 Focused assessment and chart review
for case study presentation. Identified health
inequality for a vulnerable population (lack of
assessment education for pressure injury
assessments in African American patients)
leading to poorer outcomes and increased LOS.

Computer, textbook, stethoscope, pen

light, patient and chart
Personal Objective and Planned Learning Evidence Achieved (including date):
Activities / Required Resources:


Required Clinical Competencies and tasks for NUR862 CNS Role Development

Direct Care Competencies:

Obtains data about context and etiologies (including both non- disease and disease- related factors) necessary to
formulate differential diagnoses and plans of care, and to identify and evaluate of outcomes
a. Assesses physiological & functional changes associated with aging and development across the
adult life span
Evidence of Achievement (date): 9/16/19
 Focused assessment of middle-aged adult with dark skin tone presenting with a hospital acquired
pressure injury after 20 days in the hospital; stage one went undetected due to complexion and currently
being charted as a stage 2; possible deep tissue injury surrounding open area; due to lack of assessment
education, pressure injuries are detected at a more severe stage leading to poorer health outcomes and
increased LOS; reviewed factors associated with aging including poorer nutritional status, muscle atrophy
after 20 hospital days, increased risk for falls and increased risk for delirium (direct care)
Identifies potential risks to patient safety, autonomy and quality of care based on assessments across the
patient, nurse and system spheres of influence
a. Uses reliable and valid age appropriate assessment instruments to assess acute and chronic health
concerns, including but not limited to mental illness, delirium, dementia & pain
Evidence of Achievement (date): 9/6/19
 Assisted staff nurse in identifying delirium using the CAM tool. Coached staff nurse on how to use the
tool appropriately and with mindfulness. Educated staff on evidenced-based tools to manage delirium
and assisted nurse in placing consults and notifying the provider. (nursing)

Psychosocial support including patient counseling and spiritual interventions

a. Assess patient, caregiver ability to implement complex plans of care & preferences in relation to cultural,
spiritual, quality of life and life-style choices
Evidence of Achievement (date): 11/4/19
 Worked with pt who was previously suffering from delirium. Pt is now oriented and appears to be
accepting his life with his VAD better. Pt is working through his emotions as he works with his sister who
he has previously not had a good relationship with. We discussed the patients wish for his quality of life
and discussed ways to optimize health (specifically drugs, alcohol and diet). Pt is now able to change the
battery of his own VAD with direction. (patient)

Designs strategies, including advanced nursing therapies, to meet the multifaceted needs of complex patients and
groups of patients
Evidence of Achievement (date): 10/9/19
 Designed strategies with staff to promote reorientation measures and impulse control in a complex pt
with delirium. Strategies included evidence-based reorientation measures, rounding security, patient
attendant at bedside, communication strategies when patient is aggressive or impulsive, implementation
of mobilization to get patient out of his room and implementing nutrition suggestion of socialization
during mealtimes (staff interacting with patient). (nursing and patient)

Prescribes nursing therapeutics, pharmacologic and non- pharmacologic interventions, diagnostic measures,
equipment, procedures, and treatments to meet the needs of patients, families and groups, in accordance with
professional preparation, institutional privileges, state and federal laws and practice acts
a. Develops age specific, individualized treatment plans and interventions with consideration of cognitive
status, sensory function, perception and the environment
Evidence of Achievement (date): 10/22/19
 Worked with staff to develop a plan of care for a patient who was currently being housed in the hospital
due to his acuity. There is currently no accepting facilities and this pt has minimal social support. He is
cognitively impaired after a stroke and is unable to care for himself. This pt is impulsive and will unplug
his ventricular assist device (VAD) which is keeping him alive. Nursing staff are concerned about the
liability with this case and have expressed that they don’t know how to manage his behaviors. We
created a plan of care for this patient to assist in treating his delirium (sleep promotion and reorientation
measures), promoting impulse control (psych MA redirecting behaviors, giving the patient tasks to keep
him busy) and promoting continuity of care which includes having a list of staff who are willing to work
with him. (nursing and patient)

Provides direct care to selected patients based on the needs of the patient and the CNS’s specialty knowledge and
skills
Evidence of Achievement (date): 9/16/19
 Assessed skin using evidence-based interventions including feeling for heat using ungloved hand and
using halogen lighting with inspection. Educated staff nurse on possible deep tissue injury on skin
 surrounding an open sore due to darkening, non-blanching and boggy texture. Assisted with incontinence
care, bathing, applying skin protectant and position changes. (direct care and nursing)

Develops evidence-based clinical interventions and systems to achieve defined patient and system outcomes
Evidence of Achievement (date): 9/11/19
 Developed staff education that included evidenced-based interventions for catching pressure injuries
sooner in dark skin tones. These interventions included using halogen lighting or natural sunlight on
assessment and using an ungloved hand to feel for warmth. (nursing)

Evaluates nursing practice that considers safety, timeliness, effectiveness, efficiency, efficacy and patient-centered
care
a. Intervenes to facilitate transition of care with emphasis on quality, safety and risk avoidance
b. Assists staff in the development of innovative, cost effective programs or protocols of care
Evidence of Achievement (date): 10/21/19
 Evaluated nursing practice regarding skin assessment techniques in preventing pressure injuries. After
identifying the need for improved assessment in patients with dark skin tones, evaluated suggestions
offered in literature. Assisted in developing unit-based, cost-effective protocol for skin assessment
techniques in patients with dark skin tones. See product/practice change paper. (nursing, patient and
systems)

Initiation of interdisciplinary team meetings, consultations and other communications to benefit patient care
Evidence of Achievement (date): 10/22/19
 Placed consult for psychiatric CNS and facilitated a team meeting with cardiology, neurology, psychiatry,
social work, the VAD team and family to discuss plan of care and delirium treatment for pt with limited
social support, new VAD and stroke diagnosis. The purpose of the meeting was to discuss the plan of care
for this patient and begin discharge planning. The outcome of the meeting was that nursing staff would
work on delirium treatment and prevention and try to educate patient on care of VAD. Social work would
work with family and outside care facilities to determine what discharge options exist for this patient.
(System and patient)

Participates in development of evidence-based plans for meeting individual, family, community, and population
needs; Coordinates care with other healthcare providers and community resources with special attention to the needs
of the non-verbal, developmentally and cognitively impaired patient and frail older adult
Evidence of Achievement (date): 10/21/19
 Prepared for interdisciplinary team meeting for patient with delirium, new VAD and new stroke
diagnosis. Prepared evidence-based interventions to help with reorientation measures including family
pictures, clock and large-font calendars, sleep and wake cycle, mobilization around the unit with staff and
socialization during mealtimes to ensure adequate nutrition. (patient, systems, nursing)

Coaching Competencies:
Mentors health professionals in applying the principles of evidence-based care
a. Mentor to develop expertise in the care of the vulnerable adult including the frail elderly patient
Evidence of Achievement (date): 9/6/19
 Provided behavioral management in-service to staff nurses dealing with an aggressive and staff-splitting
patient. Walked them through consulting the psych CNS and social work to create a behavioral contract.
Coached staff regarding possible delirium diagnosis and evidenced-base ways of preventing/combatting
delirium such as a sleep wake cycle, refraining from using certain medications (opiates, benzo’s,
anticholinergics) and encouraging family presence. Nurses verbalized appreciation for this new
knowledge. Nurses agreed that the patients behavior would be more manageable knowing these
 resources exist. (nursing)

Mentors nurses to translate research into practice

Evidence of Achievement (date): 11/12/19
 Implementation of new skin assessment techniques for assessing pressure injuries in dark skin tones.
Mentored nurses at the bedside showing them proper use of the halogen light and proper use of
palpation technique, answered questions and showed them proper documentation for assessment.
Nurses verbalized appreciation of this new knowledge and agreed the halogen lighting was a valuable
tool for assessment. (nursing and systems)

Completes a needs assessment as appropriate to guide interventions with staff

Evidence of Achievement (date): 9/24/19
 Completed needs assessment at fellowship project meeting with other health care professionals to
identify what was needed by the staff nurses to reduce unit acquired pressure injuries. Topics for
education and supplies were identified. Topics included assistance in identifying stage 1 pressure injuries
in patients with dark skin, wound care education for patients with open sores, consulting with the wound
nurse after hours/weekends and the importance of nutrition in sore prevention. (nursing and systems)

Implements staff development and continuing education activities; Provides programs for the development of
healthcare provides, students, caregivers that incorporate age specific cultural competence and skill
Evidence of Achievement (date): 11/5/19
 Assisted with the planning and implementation of multiple patient care tech retreats. These retreats
consisted of continuing education for staff regarding pressure injury prevention, falls, CAUTI/CLABSI and
availability of security for staff and patient safety. Facilitated the portion of the meeting that included an
interactive learning activity and the use of a simulation room. (nursing and systems)

Designs health information and patient education appropriate to the patient’s developmental level, health
literacy level, learning needs, readiness to learn, and cultural values and beliefs
Evidence of Achievement (date): 11/12/19
 Worked with CNS and bedside nurse to create step-by-step instructions to assist post-stroke patient to
change the battery of his new VAD. Went to bedside and taught patient how to change the battery and
used the teach-back method to have him follow the directions step-by-step. Although the patient is
impulsive and aphasic, he was able to follow the written instructions with cues to stay on topic. (patient)

Provides education to individuals, families, groups and communities to promote knowledge, understanding
and optimal functioning across the wellness-illness continuum
a. Facilitates decision making regarding treatment options with the patient, family, caregivers and or health
care proxy
b. Modifies health information, patient education programs and interventions for patients with sensory,
perceptual, cognitive and physical and mental illness
c. Facilitates access to and use of information and care technology based on assessment of the ability
and preferences of patients across the age spectrum
Evidence of Achievement (date): 10/24/19
 Worked with patient’s family to come up with possible long term options for patient with new VAD/new
stroke diagnosis. The goal was to have different plans of care and options that were amenable to the
patient’s family that would depend on the patient’s self-care ability post-delirium/prior to discharge.
Discuss possible needs of this patient in the future. Educated family on ways they can assist with delirium
treatment such as visiting, pictures and eating/talking with him during mealtimes. (patient)
Uses coaching and advanced communication skills to facilitate the development of effective clinical teams
Evidence of Achievement (date): 11/13/19
 Coached staff on three units to assist in implementing and reinforcing the new skin assessment
techniques for dark skin tones. Besides from the education given to all staff on how to assess dark skin
for pressure injury and charting, these staff members were educated on how to assist in reinforcing the
education on the unit through assistance at the bedside. The outcome of creating this team is that these
staff members will be the unit “champions” and will assist in data collection. (nursing)

Collaboration Competencies:
Provides leadership for establishing, improving, and sustaining collaborative relationships to meet
clinical needs
Evidence of Achievement (date): 10/24/19
 Facilitation of diversity, equity and inclusion meetings with staff and other health care providers to
improve relationships among staff and healthcare providers. Improving communication and cultural
awareness will assist diverse groups in sustaining relationships. (systems)

Practices collegially with medical staff and other members of the healthcare team so that all providers’ unique
contributions to health outcomes will be enhanced
Evidence of Achievement (date): 10/24/19
 Participated in facilitation of diversity, equity and inclusion meetings with staff and other health care
providers. The meetings were aimed at discussing scenarios staff have experienced to open-up these
uncomfortable conversations and talk about resources available, and ways co-workers can support each
other. These meetings are based off the importance of valuing every member of the healthcare team
because diversity is proven to be affective in creating innovation. To improve health outcomes, diversity
among healthcare staff must be valued. (systems)

Assesses the quality and effectiveness of interdisciplinary, intra- agency, and inter- agency communication and
collaboration
Evidence of Achievement (date): 9/6/19
 Collaborated with interdisciplinary team members (cardiologist, office of health equity, administration
etc.) and leadership team members to discuss implementation of diversity, equity and inclusion (DEI)
teams, cultural rounds and the need for cultural competence training regarding different ways pt’s
express pain and the way nursing staff judges that expression. Identified a need for leadership to take an
active role in facilitating communication around culturally diverse care. Identified a lack of effectiveness
of implementation of DEI teams and offered suggestions for making them more effective. (systems)

Consultation Competencies:
Provides consultation to staff nurses, medical staff and interdisciplinary colleagues
a. Assist healthcare team members to integrate the needs, preferences and strengths of the patient and
healthcare plan in order to optimize health outcomes
Evidence of Achievement (date): 10/28/19
 Assisted staff members in working with a large, difficult family. Assisted staff in acknowledging the
family’s anxiety regarding the patient’s hospitalization and diagnosis, determined that the family was not
splitting staff, and that they just wanted to make sure the patient received care. Assisted staff in having
difficult conversation about who the contact person would be for the family and to direct all other family
members to that contact. Worked with medical team to agree to a daily phone call during rounds to
 update contact on progress and plan of care. (nursing and patient)

Initiates consultation to obtain resources as necessary to facilitate progress toward achieving identified
outcomes
Evidence of Achievement (date): 9/6/19
 Consulted with psych CNS to create behavioral plan for an aggressive and possibly delirious patient;
delivered behavioral management in-service with psych CNS to staff nurses regarding behavioral
contracts, delirium prevention and management and consultation resources offered for similar
situations. (nursing and systems)

Communicates consultation findings to appropriate parties consistent with professional and institutional standards
a. Provide consultation to the interdisciplinary team regarding the patient’s mental status, home
environment, mobility, functional status, self-care and caregivers abilities
Evidence of Achievement (date): 9/6/19
 Communicated with medical service team regarding psych CNS consultation and possible hospital
delirium; worked with medical team to modify orders to implement evidence-based delirium
management (sleep promotion, medication reconciliation). (nursing and systems)

Research Competencies:
Analyzes research findings and other evidence for their potential application to clinical practice
Evidence of Achievement (date): 9/6/19
 Used Cochrane library and PubMed to search for literature available on assessing for pressure injuries in
patients with dark skin tones; found recommendations from 2014 by the National Pressure Ulcer
Advisory Panel (NPUAP) that are not being utilized and discussed how to implement these
recommendations. (systems)

Integrates evidence into the health, illness, and wellness management of patients, families’ communities and
groups
Evidence of Achievement (date): 10/21/19
 Prepared evidence-based interventions to help with reorientation measures including family pictures,
clock and large-font calendars, sleep and wake cycle, mobilization around the unit with staff and
socialization during mealtimes to ensure adequate nutrition. (patient and nursing)

Applies principles of evidence-based practice and quality improvement to all patient care
a. Facilitates the incorporation of evidence-based practices, products and technology that are age specific to
adult-older adult populations into clinical practice and policies
Evidence of Achievement (date): 11/13/19
 Educated staff on proper palpation technique, use of an ungloved hand to assess temperature, and use
of halogen light to assist in identifying pressure injuries in patients with dark skin tones. (nursing, patient
and systems)

Disseminates expert knowledge

Evidence of Achievement (date): 11/15/19
 Provided education at tech retreat on prevention of hospital acquired conditions. Explained why we
provide the care that we do and how it is monitored via our documentation. Reinforced education using
interactive learning assessment. Technicians on multiple floors reported back to their supervisors and
 directors that the retreat was informative and helpful. (nursing, patient and systems)

Designs programs for effective implementation of research findings and other evidence in clinical practice
Evidence of Achievement (date): 9/30/19
 Developed staff education to be used for quality improvement project. Using the adult learning theory,
developed a pocket card and slides to educate staff on evidence-based technique for assessing pressure
injuries in dark skin tones and how to document their findings accurately (nursing and systems)

Systems Leadership Competencies: Unit Level:

Determines nursing practice and system interventions that will promote patient, family and community safety.
Evidence of Achievement (date): 9/24/19
 Collaborated with fellowship group to discuss quality improvement project. This conversation included
developing a protocol (nursing practice), supplies and charting (system interventions) that will help
nurses in identifying pressure injuries sooner in vulnerable populations. We identified patient safety
concerns such as hand hygiene, positioning, HIPAA, cleaning of supplies and “education before touching”
and discussed how we would ensure this when implementing the new protocol. (nursing and systems)

Considers fiscal and budgetary implications in decision making regarding practice and system modifications
Evidence of Achievement (date): 10/21/19

 Worked with preceptor, unit manager and value analysis team to determine the cost of implementing a
practice (dark skin assessment) and product (use of halogen light) change. Determined the cost to be
minimal compared to the savings for the patient and the hospital (see practice/product change paper).
(Systems)

Evaluates use of products and services for appropriateness and cost/benefit in meeting care needs
Evidence of Achievement (date): 10/8/19
 Worked with preceptor and fellowship leader to evaluate the use of halogen light in skin assessments.
After literature recommended the use of halogen light in skin assessments, we compared the use of LED,
fluorescent and halogen light on dark skin patients with known pressure injuries. After obtaining consent,
pictures were taken for staff education purposes (no identifiers). LED lighting made blue and red hues on
the skin, fluorescent lighting was not enough to even visualize color change and halogen lighting showed
obvious color change on areas of pressure. (Systems)

Conducts cost/benefit analysis of new clinical technologies

Evidence of Achievement (date): 10/8+21/19
 Worked with preceptor, unit manager and value analysis team to determine the cost of implementing a
practice (dark skin assessment) and product (use of halogen light) change. Determined the cost to be
minimal compared to the savings for the patient and the hospital (see practice/product change paper).
(Systems)

Participate in the development, implementation and evaluation of clinical practice guidelines that address needs
across the adult age spectrum
Evidence of Achievement (date): 10/28/19
 Updated practice guideline on the use of cardiac monitoring/vital signs for assessment of tamponade
post pacer wire removal. Benchmarking was done for similar surrounding hospitals with a large variation
 in the monitoring of vital signs. Literature did not support a specific amount of time and instead
suggested that symptom assessment (sweating, chest pain etc.) was more effective in identifying
tamponade. (nursing and systems)

Uses effective strategies for changing clinician and team behavior to encourage adoption of evidence-based practices
and innovations in care delivery
Evidence of Achievement (date): 11/18/19
 Staff education for use of halogen light including modeling assessment techniques at the bedside and
showing pictures of the difference in lighting. Staff currently using new techniques and documenting.
(nursing and systems)

Evaluates impact of introduction or withdrawal of products, services, and technologies

Evidence of Achievement (date): 9/17/19
 Educated staff on multiple product changes and discussed with them the intended benefit. Evaluated
with staff the product changed and most of them agreed with the product changes. The white pads seem
to hold moisture better, keeping linens dry and not bunching under patients. The white pads could also
be used to lift patients, so staff did not need to use draw sheets. This also benefits the patient because
they have less stuff underneath them, so this reduces their risk for skin breakdown. (nursing)

Ethical Competencies:
Facilitates interdisciplinary teams to address ethical concerns, risks or considerations, benefits and outcomes of
patient care
Evidence of Achievement (date): 10/22/19
 Facilitated a team meeting with cardiology, neurology, psychiatry, social work, the VAD team and family
to discuss plan of care and delirium treatment for pt with limited social support, new VAD and stroke
diagnosis. Discussed the ethical concerns of having sister be granted DPOA when she admits that they
had limited contact with each other prior to his hospitalization due to her having to evict him from their
parent’s house. Service team agrees that she has his best interest in mind and is supporting her in
obtaining DPOA/guardianship of patient until he can care for himself. (patient)

Promotes a practice climate conducive to providing ethical care

Evidence of Achievement (date): 10/22/19
 During team meeting for VAD patient who cannot currently care for himself, brought up ethical
considerations to team regarding the relationship between the sister and the patient, and her ability to
make care decisions for this patient. (patient)

Applies ethical principles to resolving concerns across the three spheres of influence
Evidence of Achievement (date): 10/22/19
 Applied ethical principles during team meeting for VAD patient who cannot currently care for himself. In
the patient sphere, autonomy was discussed as this patient will hopefully return to an oriented state and
he will want to make his own decisions and care for himself. In the systems sphere, the ethical
implications of the VAD placement was discussed as he was not really a candidate for one due to limited
resources and social support. In the nursing sphere, nonmaleficence was discussed (restraints) as nursing
struggles to deal with this patient’s difficult behaviors. (nursing, systems and patient)

Considers the impact of scientific advances, cost, clinical effectiveness, patient and family values and
preferences, and other external influences.
 Evidence of Achievement (date): 10/21/19
 When preparing for team meeting regarding VAD patient with delirium, discussed with preceptor the
cost (financial and physical) of housing patient at the hospital since he will not be accepted at a facility.
Discussed the lack of resources for this patient and the strain his care will put on his sister who lives one
hour away. Keeping him in the hospital is not only costly financially, but increases his risk for delirium
(again), infection, falls and pressure injuries. (patient)

Fosters professional accountability in self or others.

Evidence of Achievement (date): 11/4/19
 Fellowship leader was overwhelmed after meeting regarding quality improvement project; took the lead
on making data collection tools to help-out. Asked for guidance when needed and learned how to make
data collection tool autonomously. (nursing)

Promotes the role and scope of practice of the CNS to legislators, regulators, other health care providers, and the
public.
Evidence of Achievement (date): 10/15/19
 Met with legislators at Advocacy day and asked for their help in creating a bill to expand the scope of
practice for APRNs in Michigan, including having their title added as a provider in the mental health code.
Received great feedback about how to get the most support for a bill like this: get the support of a
republican member since they are the majority. (nursing)

Communicates information that promotes nursing, the role of the CNS and outcomes of nursing and CNS
practice through the use of the media, advanced technologies, and community networks.
Evidence of Achievement (date): 10/15/19
 Used email communication to thank the legislatures I met with at advocacy day and reinforce “the ask”
(added as a provider in the mental health code). (nursing)

Advocates for the CNS/APRN role and for positive legislative response to issues affecting nursing practice
Evidence of Achievement (date): 10/15/19
 Met with legislators at Advocacy day and asked for their help in creating a bill to expand the scope of
practice for APRNs in Michigan, including having their title added as a provider in the mental health code.
Received great feedback about how to get the most support for a bill like this: get the support of a
republican member since they are the majority. (nursing)