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Skills and competencies of Clinical Nurse Specialists

A Clinical Nurse Specialist (CNS) is an Advanced Practice Registered Nurse who has an advanced experience on nursing issues. Their involvement in advanced practice is a valuable approach that moves evidence into justifiable practice and improves excellence through the utilization of a multidisciplinary approach (Gabbard et al., 2021). They are certified in a particular field such as those mentioned above, where they possess advanced clinical skills and advanced knowledge. Clinical Nurse Specialist (CNS) act as outcome managers, educators, researchers, clinical nurses and consultants. They collaborate in a multidisciplinary healthcare team which includes physicians, social workers (Liu et al., 2018); as well as pharmacists, advanced practice nurses, social workers and physical therapists. Their role is also recognised in providing support and guidance to patients and their families and significant others while navigating the complicated system of healthcare delivery (Gabbard et al., 2021). The CNS can practice authority in many of the same areas as nurse practitioners including those that they do not have authority in. A CNS is capable of facilitating quality advice according to their experiences during critical situations.  For a Clinical Nurse Specialist to be registered by the Australian Health Practitioner Regulation Agency (AHPRA, 2019), the registered nurse must obtain the formal education of a masters in nursing science or a Doctor Of Nursing Practice (DNP) in a speciality practice area (Australian Health Practitioner Regulation Agency, 2019). A CNS specializing in operation theatre is the only nursing professional who is competent to perform asepsis, management of biological specimens, instrumentation, control of infection and complications during a surgical process (Liu et al., 2018). The following paper will critically analyse the function of a CNS in the health care setting, particularly their role in operation theatre, The paper will also explore the challenges faced by these nursing professionals.

A team of Operation Theatre comprises of several different professionals with specific expertise (Gabbard et al., 2021). Clinical Nurse Specialists manage the treatment of crucial, often complicated cases, the emergency issues that occur in a hospital setting as well as the maintenance of matters of hygiene and health concerns. The CNS is referred medical cases that require special attention, they take over the proceedings of such cases and process the diagnosis for the disorder and appropriate treatment for the patient (Edmonds, Cashin & Heartfield, 2016). Clinical Nurse Specialists improve various practices and play a role in the provision of cost-effective treatments to the recipients of care. In addition, they are also responsible for providing non-pharmacological as well as pharmacological treatments (Vogelsang et al., 2020). The scope of practice of clinical nurse specialists is varied. They treat the patients, order tests, from time to time prescribe medications, in addition to examining and diagnosing the disorders. In addition, they are also tasked with developing policies that reflect their knowledge of the latest evidence-based care, they might participate in the research for this practice (Gabbard et al., 2021).

The combination of abilities, skills and attitudes that are required for a clinical nurse specialist to perform their duty make up their professional clinical competency (Blomberg, Lindwall & Bisholt, 2019). The core competencies of a health care practitioner are collaboration in multidisciplinary team, person-centred care, evidence-based practice, safe care, informatics and quality improvement (Vogelsang et al., 2020). Person-centred care identifies the patient as a whole person instead of considering just their illness. The clinical nurse specialist ensures that the patients in an operating theatre are respected, and their preferences, differences are acknowledged. Since operation theatre nurses often meet patients foremost in the OT, they must rely on data from patient charts and establish relationships with patients in a brief time before the patient is sedated or anesthetized. Operation theatre nurses attempt to generate a calm, friendly and relaxed atmosphere when greeting patients in the operating room (Arakelian et al., 2017). In addition, the CNS provides the necessary information and maintains open conversation in a simple language that does not complicate the medical procedures. The operation theatre specialist nurse prepares sterile apparatuses and equipment before the patient enters the operation theatre to hide potentially alarming items. Communication among staff is minimized while the patient is still awake. If preoperative visits are possible, operation theatre nurses will be more motivated to customize patient care (Blomberg et al., 2015). The clinical specialist thus, enables the patient to make informed decisions about their care’s different aspects that allows the timely management of their condition, thereby decreasing any stress that they experience. The role of a multidisciplinary team in an operation theatre has been recognised for several years before a clinical nurse specialist was introduced in the heath care setting. The diversification of the postgraduate nursing education in the early twentieth century allowed the development of competency standards for speciality in Australia (Edmonds, Cashin & Heartfield, 2016). The clinical specialist nurse ensures that the team members are aware of their roles and possess the knowledge necessary for their practice. The specialist contributes to the team, through integrating their advanced knowledge and experience in the coordination, communication and collaboration for the optimization of care (Vogelsang et al., 2020). Moreover, this competency of participating in a multidisciplinary team allows the specialist nurse to deal with the progressing complexities and manage the demands of care. Moreover, according to the standard of care of the Nursing and Midwifery Board of Australia for Registered Nurses necessitates that the nursing specialist must utilize evidence-based practice to analyse their nursing practice (Nursing and Midwifery Board of Australia, 2017). Moreover, the participation of the clinical specialist nurse in a multidisciplinary team in the operation theatre also upholds the second standard of the NMBA standards for practice of engaging in therapeutic, collaborative practice for the improvement of the patient’s condition (Nursing and Midwifery Board of Australia, 2017). Nonverbal communication is common in experienced surgical teams. For example, careful hand movements by a surgeon can convey the demands of a particular instrument (Sandelin & Gustafsson, 2015). The reduction of inefficiency and preventable errors that harm patients, require constant efforts from nursing specialists to measure and understand the value of the provisioned care. The clinical nurse specialist assesses the ongoing practice and identifies the opportunities for improving these aspects of care. The operation theatre CNS documents the patient records that enables the patients to participate in their care (Westra & Peterson, 2016). It is necessary skill of the CNS to have appropriate knowledge on the minimization of risks that can harm the patients and the other professionals. Lastly, the skill of making decisions using electronic data from external and internal sources allows the clinical nurse specialist to understand and address the legal and ethical issues that may arise during procedure in the operation theatre. This particular skill enhances the education and access to reliable and accurate information that allows the agreement with regulatory necessities for confidentiality and privacy of the patients (Vogelsang et al., 2020). According to the first standard of the Nursing and Midwifery Board of Australia’s standards for practice, a nursing professional must comply with the regulations, legislation, guidelines and policies that are required for practice (Nursing and Midwifery Board of Australia, 2017).

Clinical Nurse Specialists in operation theatre

Being an operation theatre nurse takes more than just proper data of the patient's, psychological, ethical, physiological and spiritual demands, which are referred to as nontechnical abilities. It also necessitates formal technical understanding of surgical department devices, instruments, and sterilising methods, as well as to avoid hurting the patient, safety considerations (Crafoord & Fagerdahl, 2017). Perioperative nursing knowledge of technical skills, nontechnical skills, and training in complex practical presentations and processes are all part of the operation theatre nurse's job description. It goes without saying that this complicated occupational job necessitates in-depth education in order to practise the occupation in a patient-safe method. To get a grasp of the full human being in the perioperative situation, a postgraduate diploma in specialised operation theatre is required (Gillespie et al., 2018). This has been backed by registered nurses who participated in research and found that both non-technical and technical skills are required for the operation theatre nurse to enhance the safety of the patient in the operation theatre. From the perspective of skilled operation theatre nurses, improving patient safety in the operating room is a never-ending effort to manage risks and prevent patient injury. It involves being aware of the individual's fragility in the OT by being observant to the individual at all times, making eye contact with the patient, and understanding how the patient loses all control while anaesthetized or sedated and is thus completely reliant on the OT personnel (Sandelin & Gustafsson, 2015). It also necessitates the OTN guiding the individual through the perioperative process as securely as possible through meticulous planning, the use of protocols and checklists, and taking precautions to avoid problems and damage. It also entails improving work conditions in the OT to contribute to a safety culture (Ingvarsdottir & Halldorsdottir, 2017).  Fundamentals for intraoperative safe teamwork and nursing care, from the perspective of operating theatre nurses, include a preoperative discussion among associates of the clinical team for cordial collaboration, obtaining a dependable preoperative total picture based on satisfactory data transfer, and the sustenance of a devoted first-line administrator (Sandelin, Kalman & Gustafsson, 2019). While there is little concrete evidence that these roles are useful, a number of areas where a nurse professional role could help were identified, as well as avoiding serious events in the operation theatre and improving patient experiences and outcomes (Griffiths et al., 2014).

The clinical nurse specialist faces several challenges in the operation theatre that affect their willingness to work and influences their intention of staying in the role (Qiang & Sun, 2017). It was reported that understanding of the CNS role in an operation theatre by the employer, certification of speciality, working in a public catchment area have a positive influence on the tea dynamics with the CNS; whereas, the permanent employment was shown to have a negative effect on the CNS’ team dynamics. Moreover, the responsibility to a non-nurse supervisor has a negative impact on the dimension of education (Kilpatrick et al., 2016). The major challenges that were reported by clinical nurse specialists were lack of resources and support by their managers, role strain, ambiguity in role, lack of confidence, incompetent educators, leaders in the workplace (Campbell & Profetto-McGrath, 2013). In addition, the possible risk of exposure to infectious agents (flu germs), cold, the operation theatre is usually kept at low temperatures of 23 degrees Celsius to 26 degrees Celsius to maintain normothermia for individuals under anaesthesia which is reported to be uncomfortable for the operation theatre members such as the clinical nurse specialist (Bindu, Bindra & Rath, 2017). In addition, the clinical nurse specialists have also been victims of bullying in their workplace, pressure from senior team members in the operation theatre. All these environmental, physical, mental challenges that these professionals face increase their distress and results in burnout of the specialist which is a common occurrence for them. Furthermore, they suffer from mental health issues that are usually preventable (Russell et al., 2018). A widespread problem defined by a decrease in nurses' energy, which emerges as emotional tiredness, a lack of desire, and emotions of irritation, and may lead to work efficacy reductions. Emotional tiredness has been reported to increase the work-associated infections, errors in medication (despite it being a rare role for operation theatre nurse), poor relations between the operation theatre clinical nurse and the patient, as well as with the professional team members. The emotional tiredness also results in poor personal accomplishments and heightened dissatisfaction with their job (Poku, Donkor & Naab, 2020). Exhaustion is associated with tension, yet it has distinct features. Burnout is frequently caused by stress; an employee may be pressured in their job, and the longer they are stressed, the more likely they are to become burned out (Dall’Ora et al., 2020). Over-engagement with one’s job is a symptom of work pressure. Workplace burnout is different, marked by apathy and detachment. OTN burnout is crucial to comprehend for a number of reasons. The primary reason is that thousands of clinical nurse specialists are disappointed and detached at work, which is damaging to their mental health and overall well-being. Burnout among nurses also has serious consequences for patients. When nurses are burned out, patients are more likely to be displeased with their care and have inferior health outcomes (Dall’Ora et al., 2020). Stressed out nurses are more likely to overlook changes in their patients' wellbeing, miss an emergency and be unfocused from their task. When nurses are burned out, their mental and physical well-being, as well as the well-being of others, is jeopardised. Apart from the challenges at the workplace, clinical nurse specialists face challenges during their transition due to the challenges in educational process that hinders the implementation in practice and the optimization of their role. This in turn, distresses their capability to offer high quality care to the individuals (Foster & Flanders, 2014).

Multidisciplinary team approach in operation theatre

The health system must prioritise an assurance and devotion of tools to build and endure a multidisciplinary and interprofessional method for modification in order to reduce exhaustion, recover resilience, and eventually progress patient outcomes. Individual-focused, structural or organisational, and combined interventions were the three types of interventions. Regulation of emotion was found to be a substantial mental factor related to burnout and emotional tiredness (Zhang et al., 2020). The nurses’ burnout was reduced by means of emotion management or self-regulatory techniques such as mindfulness. Stress management skills, Self-care workshops and communication skills training were included in the individual-focused interventions. Mindfulness, yoga, meditation, and therapeutic massage were among the other methods mentioned (Zhang et al., 2020).  

Conclusion

A CNS is an Advanced Practice Registered Nurse who has an advanced experience on nursing issues. Their involvement in advanced practice is a valuable approach that improves quality through the utilization of a multidisciplinary approach. They are certified in a particular field such as those mentioned above, where they possess advanced clinical skills and advanced knowledge. Clinical Nurse Specialist (CNS) act as outcome managers, educators, researchers, clinical nurses and consultants. A CNS specializing in operation theatre is the only nursing professional who is competent to perform asepsis, management of biological specimens, instrumentation, control of infection and complications during a surgical process.  Clinical Nurse Specialists manage the treatment of crucial, often complicated cases, the emergency issues that occur in a hospital setting as well as the maintenance of matters of hygiene and health concerns. The CNS is referred medical cases that require special attention, they take over the proceedings of such cases and process the diagnosis for the disorder and appropriate treatment for the patient.  The combination of abilities, skills and attitudes that are required for a clinical nurse specialist to perform their duty make up their professional clinical competency. The clinical specialist thus, enables the patient to make informed decisions about their care’s different aspects that allows the timely management of their condition, thereby decreasing any stress that they experience. The clinical nurse specialist faces several challenges in the operation theatre that affect their willingness to work and influences their intention of staying in the role.

References

AHPRA. (2022). Australian Health Practitioner Regulation Agency. health.gov.au. Retrieved from https://www.health.gov.au/contacts/australian-health-practitioner-regulation-agency.

Arakelian, E. , Swenne, C. L. , Lindberg, S. , Rudolfsson, G. , & von Vogelsang, A. C. (2017). The meaning of person?centred care in the perioperative nursing context from the patient’s perspective – an integrative review. Journal of Clinical Nursing, 26(17–18), 2527–2544. https://doi.org/10.1111/jocn.13639  

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Blomberg, A. C. , Bisholt, B. , Nilsson, J. , & Lindwall, L. (2015). Making the invisible visible–?operating theatre nurses’ perceptions of caring in perioperative practice. Scandinavian Journal of Caring Sciences, 29(2), 361–368. https://doi.org/10.1111/scs.12172   

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Person-centred care and communication

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