Curious about Clinical Nurse Specialists (CNS)? The article What is a Clinical Nurse Specialist Anyway? raises awareness about the CNS role in Alberta. Upon interviewing Humeira Dhanji for the Member Spotlight, it became evident that she was an exemplar CNS. We are lucky to have Humeira as a UNA 115 member working at Foothills Medical Centre. In this interview, Humeira describes what it means to be a CNS working for the Acute Pain Service.
Q: Many nurses are not aware of what a Clinical Nurse Specialist is. Could you give us some examples of how you apply the Canadian Nurses Association (CNA) competencies: clinical care, systems leadership, advancement of nursing practice, and evaluation and research?
A: The CNA defines the CNS as a registered nurse who holds a Master’s or Doctoral degree in nursing with expertise in a clinical nursing specialty; uses in-depth knowledge and skills, advanced judgement and clinical experience in a nursing specialty to assist in providing solutions for complex health-care issues.
The role of the CNS is diverse and comprises 5 key components:
- Clinician: I have advanced knowledge in acute pain management nursing and work with Anesthesiologists in managing acute pain for surgical, trauma, cancer pain & some complex medical patients (e.g. sickle cell crises, burn patients, etc). As a team, we follow all patients with non-obstetrical epidural infusions, intrathecal morphine, single shot peripheral nerve block patients, continuous peripheral nerve block infusions, implantable intrathecal ports inserted for palliative patients and other patients with complex pain issues that are challenging to treat.
- Educator: I’m always trying to promote a learning environment for patients, nurses, students and other healthcare professionals. Some of the topics I teach include: Pain Talk among nursing students; Basic Pain Workshop which certifies nurses to manage patients with regional anesthesia; Pain Lecture to medical students about the different types of pain, assessment of pain and the various treatment options available to the patient; Low Dose Ketamine Intravenous Infusion certification for analgesia; Lidocaine Intravenous Infusion certification for analgesia; Intravenous Patient Controlled Analgesia Train-the-Trainer program to Clinical Nurse Educators. I have also delivered lectures at conferences regarding the Pathophysiology of pain, neuropathic pain, and basic pain principles.
- Consultant: As an expert in acute pain management, I get asked to see patients whose pain trajectory does not follow a typical course. In collaboration with the anesthesiologist, I discuss the various options for the patient. This may include equianalgesic conversions of the patient’s opioid medication, commencement of adjuvant medications, initiating ketamine / lidocaine infusions & considering the patient’s eligibility for regional analgesia if applicable.
- Researcher: I use evidence-based practice to guide my role as a CNS & acute pain expert. Whenever there is a procedure change or introduction of a new practice, I am guided by research. I go through the current literature to determine the most specific application of a particular practice. An upcoming project I am collaborating on with anesthesiologists and other CNSs is an opioid tapering brochure for patients. Healthcare and our population has changed markedly over the last 20 years that I have been in the nursing profession. Surgical procedures are being done for ailments we never thought would be possible. Many patients have a history of chronic pain pre-operatively and are on opioid analgesics and therefore opioid tolerant. Post-operatively, these patients have acute-on-chronic pain and end up on higher doses of opioid analgesia. Several patients end up being discharged home on opioid doses significantly higher than what they were admitted into the hospital with. A lot of these patients do not have a family physician that can assist them with tapering their opioid dose, thus putting them at risk for opioid dependency. Our goal is to develop a brochure that will facilitate a self-weaning process among patients.
- Leader: I consider myself to be a change agent, as I am always looking for ways to advance nursing practice. Not only my own practice, but the profession of nursing in general. This in turn will increase the quality of healthcare available to individuals. Examples of how I have led a change in practice include: (a)After a critical incident involving a patient’s Methadone regimen, I collaborated with Anesthesiologists and nurse practitioners and launched the development of Methadone Guidelines for the Calgary Zone. It outlines a safe approach in continuing / replacing a hospitalized patient’s Methadone treatment. (b)Pain management can be challenging among some patients due to opioid tolerance or opioid refractory pain. This requires using adjuvants for analgesic therapy. An adjuvant analgesia that Acute Pain Service in the Calgary Zone has introduced last year is Lidocaine Intravenous Infusion for Analgesia. Working with my APS nursing colleagues and Anesthesiologists, I led the development of the Protocol and Learning Module for Lidocaine Intravenous Infusion for Analgesia. It is being used on patients whose pain is not managed well due to opioid tolerance, neuropathic pain or opioid sensitivity.
Q: Recently, the College and Association of Registered Nurses of Alberta (CARNA) published a short article on the history of ANP in Alberta where the author, Jananee Rasiah, identified common challenges facing APNs in Alberta such as role overlap, lack of awareness of scope, role confusion and lack of funding. What do you think is the biggest challenge facing Clinical Nurse Specialists today?
A: I think there are a few challenges facing Clinical Nurse Specialists today. One of the main challenges is role ambiguity. I find it beneficial to have the Canadian Nurses Association identify our role and state the 5 domains of our nursing practice. However, not all health care professionals have a clear understanding of the CNS title. Therefore, in job postings or even performance evaluations, we lack role clarity. There is inconsistent use of the CNS title. This impedes role implementation. Reporting structure is important. It is vital for a manager to have a clear understanding of the CNS practice domains, allowing for realistic expectations at work and appropriate work distribution. I am fortunate to work with Nurse Clinicians who have a clear understanding of my role & their own. This allows me to carry out my responsibilities as a CNS.