PainLink Presents

Hot off the Press

August 2000

Wheeler, E. (2000). "The CNS's impact on process and outcome of patients with total knee replacement." Clinical Nurse Specialist 14: 159-169.

STUDY SUMMARY

This study was done to determine whether the presence of a clinical nurse specialist (CNS) on an orthopedic unit influenced the interventions used by staff nurses and selected outcomes experienced by patients. A comparative, correlational design based on retrospective chart review was used.

Setting
Orthopedic units in 4 different hospitals were used. Two units were staffed with master's-prepared CNSs, certified in orthopedic nursing, and two did not have CNSs. All four units were similar with regard to nurse-patient ratio and pattern of care delivery.

Sample
Charts of patients who were older than 18, had undergone TKR and had been discharged no more than a year before study data were collected were randomly selected from computer generated lists at each hospital. There were 64 patients selected from CNS-staffed units and 64 from those units without CNSs. There were statistically significant differences between the two groups on two demographic: age and type of anesthesia.

Data Collection
Investigator developed instruments based on orthopedic nursing care standards were used to collect information on acute pain process and high risks for disuse syndrome.

Results
Age and type of anesthesia were used as co-variates in the analyses. There were statistically significant differences on the acute pain management (APPI) and risks for disuse (HRDSPI) instruments, suggesting that patients on units with CNSs received more nursing interventions more frequently than on those units without CNSs. Patients on units without CNSs had longer total lengths of stay {LOS}(acute care and acute rehabilitation stays) than did those units with CNSs (6.84 vs. 4.87 days)-- a difference that was statistically significant. There were 17 preventable complications on units without CNSs compared with 6 complications on units with CNSs (statistical significance not reported). A significant, positive correlation was observed between acute pain management and LOS. There was a significant negative correlation between the HRDSPI and total length of stay.

COMMENTARY

When I finished reading this study, the first thing that occurred to me was that it provides support for the old saw, "If it wasn't documented, it wasn't done". Some other aspects of the study that impressed me were the extent to which the chart review instruments were based on clinical standards of care for orthopedic nursing and the fact that the author focused on process and outcomes. The author used Donabedian's structure-process-outcome framework, the conceptual framework that has been a significant influence in the CQI field and informed the development of AHRQ (formerly AHCPR) guidelines.

Why would be PainLinkers be interested in the study? First, the attempt to link clinical standards of nursing care to CQI offers an interesting model for anyone who wants to translate clinical standards into a chart audit tool that examines process and outcome. Secondly, the results suggest that for any standard to be implemented, one needs a knowledge broker, an opinion leader, in this case the CNS, to help staff implement appropriate standards of care. PainLinkers might also be interested in how acute pain management and its outcome were evaluated (Appendix C). Also, the author looked at total length of stay-not just the stay on the orthopedic unit. She found no differences in the acute care stay, but when acute LOS was combined with the rehab LOS, the difference was statistically significant, suggesting the importance of examining outcomes across systems. While the study has limitations acknowledged by the author, the design as well as the specific pain management findings are interesting and warrant further investigation.

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Last Updated: August 25, 2000