This domain encompasses the key principles of the Clinical Nurse Specialist’s role in providing expert advice and promoting wellbeing to patients experiencing a particularly illness, or requiring a specific service, as a member of a multidisciplinary healthcare team. This may involve health promotion, counseling and patient education, diagnosis of ill health, minimizing adverse effects of illness/ill health, expert care provision, supported transfer within health contexts and discharge planning, including establishing appropriate therapeutic and interpersonal relationships to maximize the delivery of safe care to patients, families, the wider community and society.
Patient Centered Care
Provides skilled safe, holistic, culturally competent, person-centered expert nursing care to patients, families, community and society, in collaboration with the multidisciplinary team irrespective of healthcare settings, to promote wellbeing.
Performance criteria
- Undertakes a comprehensive, holistic systematic assessment involving the patient, family and other healthcare providers, as appropriate, in order to determine the needs, concerns, problems, issues, and/or diagnosis that serve as a basis for care planning.
- Performs and documents a comprehensive medical/nursing history, physical, psychosocial emotional, ethnic, cultural and spiritual assessment of the patient’s health status.
- Formulates differential diagnoses through the integration of the patient/family health information and evidence-informed practice.
- Initiates appropriate referrals to other members of the health care team based on assessment and referral guidelines.
- Develops or contributes to the long term care plan in collaboration with the patient/family and the health care team, and documents as part of an interdisciplinary plan of care.
- Provides direct, specialized, comprehensive care, emphasizing health promotion, patient advocacy, disease prevention and collaborative management strategies to positively affect health outcomes.
- Communicates with patients and families about health assessment findings.
- Implement aspects of care
- Identify and implements creative strategies for managing complex health-care situations within the selected clinical specialty.
- Participates in the coordination of complex discharge planning.
- Provide education and counseling regarding diagnoses, prognoses, disorders, conditions, risk factors, medication (use, side effects, risk factors, interactions) and therapeutic interventions – ensuring patients can make informed choices about their treatment and lifestyle.
- Acts as the Contact Person/key worker for selected patient populations.
- Assesses, evaluates and revises the interdisciplinary care plan.
- Evaluates and revises the interdisciplinary plan of care in collaboration with the patient/family and the health care team to ensure patient needs are being met.
Communication and teamwork
Uses advanced communication skills to ensure that other members of the health care team, the patient and their family are, and remain, fully informed.
Performance Criteria:
- Reinforces, clarifies and elaborates upon medical staff communications of diagnosis, treatment options and lifestyle implications for his / her client group in order to promote patient autonomy and well-being.
- Provides consultation to nurses and the health care team regarding clinical complex situations (within area of expertise).
- Works with all disciplines to achieve the best health outcomes for patients and families.
- Consults with and/or refers clients to other health-care providers at any point in the care continuum when the patient’s condition is not within the CNS scope of practice or the individual CNS competence.
- Acts as a consultant to, and/or refers and accepts referrals from, health-care providers, community agencies and allied non-healthcare professionals.
- Applies advanced knowledge and skills in communication, negotiation, coalition building, change management and conflict-resolution, including the ability to analyze, manage and negotiate conflict to support and facilitate relationships with peers, members of the healthcare team, physicians, patients and families, both internal and external to the organization.
- Provides informal/formal consultation to the Executive team, the hospital and other organizations.
- Provides consultation to external partners and/or the community to collaboratively develop standards, policies and procedures to ensure seamless care for patients and families.
- Initiates, develops and terminates therapeutic relationship with individuals, families and groups through the use of appropriate communication and interpersonal skills.
- Demonstrates cultural competence across patient groups.
- Consistently communicates relevant, accurate and comprehensive information in verbal, written and electronic forms in a timely manner to ensure the delivery of safe, competent and ethical care.
- Works with others to affect change and produce positive outcomes through the sharing of knowledge of the individual and/or the situation.
- Participates in building consensus or resolving conflict in the context of patient care.
- Demonstrates the ability to work as a team member by engaging in teamwork and the team-building processes.
- Works in collaboration with other members of the wider multidisciplinary team across patient pathways.
- Collaborates with other disciplines in teaching, consultation, management, and research activities to improve outcomes in nursing practice and enhance the healthcare environments.
- Uses coaching and advanced communication skills to facilitate the development of effective clinical teams.
