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Christi Welter (Host 1): Welcome to Nurses Connect, a podcast from Children's Health dedicated to exploring critical issues and dynamic topics that shape the nursing profession today. I'm Christi Welter, Program Manager of Nursing Communications.

Brennan Lewis (Host 2): And I'm Brennan Lewis, Senior Vice President of Nursing Excellence, Innovation, and Patient Experience. We are your co-hosts for Nurses Connect. We're so happy you've decided to spend time with us today. On this episode, we're discussing an innovative talent pipeline developed to help build our clinical nurse specialist team.

Host 1: We have two guests joining us today, our Director of Clinical Nurse Specialists, Deb Echtenkamp, and one of our clinical nurse specialists, Christina Smith. Thank you both for joining us.

Christina Smith, DNP: Thank you for having us.

Host 2: All right. So to get us started, some people listening may not know what a clinical nurse specialist is. So, first question: what is a CNS, and describe the role.

Deb Echtencamp: So, clinical nurse specialist is an advanced practice nurse. We come at things and we're actually one of the oldest-- or we are the oldest advanced practice role that was designed-- probably one of the least understood. We look at things from three spheres, we call them spheres of impact. So, direct patient care, nursing and nursing practice, and systems and organizations. And so, our ultimate goal is to make improvements across all three spheres that will ultimately improve patient outcomes.

Host 2: Thanks, Deb. So, walk us through a day in the life of a clinical nurse specialist.

Christina Smith, DNP: So, one of the things I love about the role is that all my days look different. I don't ever do the same thing. So as Doug discussed, we work within those three spheres, the nursing sphere, patient and systems. So, one day, I may be working on a systems project where we're looking at the impact of changes that we're making in the organization on alarm fatigue. And the next day, I may be working with some frontline nurses to problem solve on a medically complex patient and how we can prevent pressure injuries when we have limitations on how we can reposition this patient. So, really, it looks different every day and kind of our foundational-- I would call, like the bread and butter-- of CNS, is making sure that we're practicing with the best evidence that's available.

So in all those scenarios, I would look at the literature and see what we find in recommendations and see what our practice looks like and how it correlates with what's supported in the literature.

Host 1: And Christina, I know that you kind of just went through some of the training to become a CNS. What was that like? How are CNSs trained?

Christina Smith: So, we are, as Deb said, advanced practice registered nurses. So, we do go through clinical training as part of our schooling. So, we have multiple clinical classes that work on diagnostic reasoning and prescriptive differentials when you're prescribing, we can prescribe and diagnose like other APRNs with prescriptive authority.

And the training looks like kind of a blend of those spheres, right? So, like some of the patient-facing, more clinical-focused information as well as understanding how change works within a system and some of the implementation science behind change to make sure that I'm going to make a change, but how am I going to make sure it's actually doing what I wanted it to do and following it over time.

Host 1: Okay. Yeah, that makes sense.

Host 2: All right. Deb, tell us a little bit about some of the challenges that you may have faced and other nurse leaders across the country in recruiting clinical nurse specialists.

Deb Echtencamp: So, as I initially had said that we are one of the oldest APRN roles, we're also probably one of the least understood and people think more about a nurse practitioner. And so, we are growing in numbers, but we do not have as many numbers. And different pockets of the country have more clinical nurse specialists available. Some of the challenges we've had recently in our area is one of our programs closed at the university, because they didn't have enough people going in to that particular program. So, we're leveraging working with schools across the country to develop and get more of our nurses that want to go into the role, into the program.

So, it takes a long time. I have had two open positions since January, and I'm just now interviewing for one of them. And we've been actively recruiting with schools and national organizations and encouraging nurses here who have that inquisitive mind and want to maybe not move into leadership, but move into a clinical practice leadership type role. And so, we do that work with our teams.

Host 1: So, I know that you have been doing tons of work around trying to build up the CNSs at Children's Health. What is this new, innovative thing that we're doing here with the talent pipeline for CNSs?

Deb Echtencamp: We have a Grow Your Own Program and we've had that for a while. But we looked at recently making sure that we were incorporating some of the work with the National Association of Clinical Nurse Specialists and their toolbox and their recommendations, which some of our team here worked on, and helped develop that for a national level to develop that program.

But then, we looked at how can we best support and create a safe environment-- because, for our new, we call them clinical nurse specialists interns, we looked at having kind of a dyad preceptor situation. So, we pair them with a clinical nurse specialist and then we pair them with another experienced clinical nurse specialist intern who's, in school, understands the role and the differences of the role because there are things that they can learn while they're going to school and apply what they're learning in school to their work life, but they cannot implement the advanced practice piece of the role until they have graduated from their CNS program and are credentialed within our institution. So, we found that having those three work together, it gives a broader experience, additional mentorship.

And then, anybody who's in our CNS intern program, another one of our CNSs who have graduated from the program actually has a reflection time. So, that is a free space. They can go and they can talk about the challenges, the frustrations, the wins. And so, really trying to help support them on both an emotional and psychological level, as well as providing them with experiences and mentors to help them grow and develop in their career.

Host 2: One of the things I love about our Grow Your Own CNS Program is that it gives an avenue for clinical nurses who know they want to progress in their profession, but they don't really know what direction. And after, many of them work with a clinical nurse specialist on their unit or maybe they do an evidence-based practice fellowship. They get interested. And when you're talking to them about their career goals, it really aligns with the CNS role. So, it's a way that our organization is able to not only recruit clinical nurse specialists, but also retain our clinical nurses as experts in that role. So, Christina is one of our newest, most recent graduates from our clinical nurse specialist intern program. So, Christina, I'd love for you to share your experience.

Christina Smith: Yeah, I actually, it's kind of funny because my experience is very much what you discussed. Brennan was actually my clinical nurse specialist on my unit when I was a newer nurse. And in the time we worked together, we developed a patient family education role. So, I worked with her closely for that role in the inpatient pulmonary unit. And years later, I was thinking about what I wanted to do and where I wanted to go, because I'd been a nurse for 10 plus years and I was kind of feeling like I wanted more challenge. So, I participated in the EBP fellowship program at that time, which I loved and realized that this thing that I was doing in my free time, I could do in all of my time, which was kind of a thrilling moment, right? When you're like, "Oh, I can do this all the time. That sounds lovely."

So, I talked to Brennan and also my mentor who happened to be a CNS as well about what It looked like to go back to school, what kind of the coursework entailed, and ask some questions about the Grow Your Own Program. And I pretty shortly after that applied to a CNS program and was accepted, and I just finished in May. I finished my doctorate of nursing practice as a pediatric clinical nurse specialist. It still feels a little weird to think of myself as a doctor. But, you know, you gotta own your credentials, right? I worked really hard for those letters, so I have to try to own them.

But one of the things I loved about the Grow Your Own Program is that I was able to have assignments in class and use those assignments for things that I already need to work on on my unit or across the system, and really, like, immediately apply the information that I was getting in school into something I was doing, which we've all been in a class where you're listening and it's not really absorbing. But when you immediately go and do it, it really absorbs and you retain that information really well.

So, I'm one of the dyads that Deb was discussing. We have one of our newer CNS interns that has an experienced CNS, and then I was her CNS intern mentor. And we worked really well talking through how to balance coursework and work-work and how to make it all kind of go together as well as possible.

Host 1: What was it like trying to balance your coursework with your professional life?

Christina Smith: Now that I'm on this side of it, I can say that it requires a lot of planning. I think anyone who goes back to school and works full time, it requires planning. And I was fairly strategic when I picked my clinical settings, I tried to pick clinical settings that I worked within. So, I was familiar with the patient population and then some of the work I was doing in class crossed over to the work I need to do in my units that I support.

And then, the other piece of advice I give all of our new people is do not be afraid to take a day off to work on schoolwork. Don't try to be super human and do it all because we're just people. We're just doing our best we can to get through. So if you have a really heavy semester, I recommend to everyone to take the day off before you have a big assignment due or a big test or something that you're preparing for, because we have enough stressors in our day to day with life and work and school and families and all of the things.

Host 1: Yeah, no kidding. I have a question for Deb. I know that, you know, there's probably some interest out there for nurses to become CNSs. Why should they do it, and what would it do for their career?

Deb Echtencamp: If they're passionate about working with a particular population and within a specialty, even within a unit, and they really want to improve outcomes for that particular specialty, whether it's Pediatrics or Geriatrics or Med-Surg, this role, it's very varied. That's what I've always loved about it. Like she said, each day is different. I never get bored, but I know what I'm doing makes a difference for the population that I'm serving, because I can help drive patient care improvements. I bring that evidence and help elevate the bedside staff so you can work directly with the patients and you can work directly developing nurses and helping them break down barriers and the workarounds that we always do as nurses. But I can also take a project from the beginning to the end from my system that makes a bigger impact on patient care across the system.

And so, I think that's what I love about the role. But bottom line, it gets back down to everything that I do, every person that I encounter. Whether I'm doing a systems project or working with a nurse, I'm really, in my mind, as a systems thinker-- trying to decide how does that benefit an individual patient that I touch, and how can I make that better for each that come through our doors.

Host 1: Yeah, it sounds like a really impactful role.

Host 2: So, we've had about four successful Grow Your Own clinical nurse specialist interns now transition into their clinical nurse specialist role. So, we'd love for you to talk about, like, what outcomes are you most proud of that our CNSIs have done or, Christina, something that you've done in your CNSI role that you're most proud of.

Christina Smith: I think the thing that is probably the most work, to keep moving, as I'm sure anyone listening to this that's tried to tackle it has encountered. We've done a lot of work in our organization around reducing alarm fatigue. It's well supported in the literature for many, many years. The alarm fatigue in healthcare is a pervasive issue that really can result in poor patient outcomes. If we're so inundated by alarms that we tune them out, then when we need to respond, we're not going to hear them.

And so, I decided to tackle it as part of my DNP project because I knew that I would be working on it for three years, and I knew there was plenty to work on in the course of three years, and I wouldn't run out of things to do. So, we have an alarm fatigue task force at our organization that started about three years ago, around the time I started my CNS coursework. And it has two physician leads and two nursing leads, and I'm one of the nursing leads on that task force. And we did a lot of work that I'm really proud of, but I think the parts that I'm most impressed with is our ability to really collaborate across disciplines, to move changes forward as we looked at-- let's look at better monitor parameters for our patients so that these monitors don't go off so often. And when they do go off, they mean something. So, that required really getting buy-in from a lot of key stakeholders that initially had a lot of concerns about it.

So, we did pilots. We did real estate analysis to see what does it currently look like, how many alarms are we having, how are we managing our alarms, and how can we make it better. And really took all of that data along with qualitative surveys of how much alarm fatigue do you have in your day back to the key stakeholders to show kind of the breadth of the issue and why we needed to move forward with the changes we were suggesting. So, everyone on my team did a lot of work, but I think I'm really proud that we all worked together with our individual pieces of the puzzle to make it move forward.

And in December of this last year, we got a lot of good changes implemented that we're now evaluating implementation science. We have to see if what we did, did the thing we thought it was going to do. So now, we're evaluating to see how well it worked and what areas we need to bolster up or work on from here.

Host 2: That's a great example. Deb, do you have any others?

Deb Echtencamp: I think our team works with the new nurse residents as they come in and we help mentor them through their evidence-based practice projects. And so, it's been really nice to see the breadth of the projects that come out of that program. And also, a lot of those projects we have continued. It's been more than just a learning objective for the nurse resident. It is actually translated into changes within their units. As a new nurse, they get very excited about, "I did this, I helped bring this forward." And we also work with them then to create a poster. Some of them have presented their work at national conferences, and they're doing that at the start of their career instead of waiting as I did in my career. Oh, it happened mid-career or later in my career that I did some of those things. They're learning that upfront, and that's only going to continue, and they could potentially have a body of work that they have and the impact that they're making as a new nurse. And so, I think the fact that we have hands on that, and we're helping to mentor them and bolster them and help improve their practice, that's one of the things that I take away that I really love that our team does.

Host 1: That's pretty amazing to see how CNSs impact our organization and how it goes beyond these walls as well. All right. Is there anything else that we have not covered today that you all maybe were thinking about before we got together to talk today?

Christina Smith: I think the only other thing I would say is if you're interested in the CNS role, I know there's the national CNS website, we get people that reach out and ask just for more information and what it looks like both inside our organization and outside.

I think all of us are really happy to talk to anyone that's considering it. Because had I maybe had that conversation a little bit earlier in my career, I could have been doing the thing I love sooner. While I loved what I did before, I wish I had more information sooner. So if that's you and you would like to get more information or talk to us or just connect with someone else to see what's involved, I would encourage you to do so. We're all happy to talk.

Host 1: All right. Well, it's time to wrap up Nurses Connect. Thank you both so much for joining us today.

Deb Echtencamp: Thank you for having us.

Host 2: If you want to know more about nursing at Children's Health, we encourage you to visit childrens.com/nursingannualreport. Here you'll find information that summarizes a variety of our nursing initiatives. Thank you to our listeners for joining us today. We'll talk to you next time on Nurses Connect.