Mobile Edition
Print
Get the Mag
Weekly UpdatesAbstract: The Canadian Neurological Scale (CNS), a validated stroke assessment tool, was implemented for the neurological assessment of patients with stroke. The purpose of this study was to explore nurses' values and perceptions of best-practice guidelines (BPGs) and the CNS assessment, to evaluate the effect of a workshop and implementation process on nurses' self-efficacy for CNS use, to determine whether the workshop and implementation process met the needs of the nurses, and to evaluate the accuracy and appropriateness of CNS assessment documentation. Nurses reported moderate-to-strong awareness and use of BPGs and expressed the belief that BPGs were valuable; however, they had some difficulty accessing BPGs. At 3 months after the workshop, nurses reported using the CNS assessment in practice but said that it was not easy to use and that it was not useful as a patient status communication tool or for documenting neurological changes. Nurses were moderately confident while performing the CNS assessment before the workshop. Confidence increased immediately afterward (p < .0001), and then decreased slightly at 3 months. The majority of nurses said the workshop met their learning needs. A chart audit demonstrated that only 69% of patients appropriate for the CNS assessment were assessed with this tool. Although nurses are aware of BPGs, translating these changes into practice takes time and may require BPG modification to best fit the needs of the areas in which they will be used. When choosing a validated stroke assessment tool, clinicians must consider how often the tool will be used for assessments, particularly in the acute phase.
**********
The Canadian Stroke Strategy (Heart and Stroke Foundation of Ontario, 2003) and the Registered Nurses Association of Ontario (2005b) have published best-practice guidelines (BPGs) for stroke assessment and care. Both guidelines recommend that neurological assessment of patients with stroke include the use of a validated tool for stroke. A recent survey of 9 regional stroke centers in Ontario found that only 67% of centers were using a validated stroke assessment tool and that 66% of centers had recently implemented the use of a validated stroke scale to facilitate neurological nursing assessment (Gocan & Fisher, 2005).
The interdisciplinary stroke team at University Hospital in London, Ontario, Canada, held a retreat in Spring 2005. Participants included staff nurses, allied health personnel, nurse practitioners, nurse educators, stroke neurologists, and administrators. BPGs for stroke care were highlighted at this meeting, and a committee was formed to implement the use of a validated tool for neurological assessment of stroke patients as the standard of care. The Registered Nurses Association of Ontario Toolkit (2002) and Educator's Resource (2005a) helped to guide the implementation. The committee considered the Canadian Neurological Scale (CNS; Cote et al., 1989; Fig 1), a validated stroke assessment tool, to be the most applicable for frequent bedside nursing assessment. This choice was verified by feedback elicited from staff nurses who considered the CNS assessment easier and faster to use than the National Institutes of Health Stroke Scale (NIHSS), which has more components to the assessment. A workshop was developed to educate staff; the CNS was implemented on the acute-care neuroscience unit at University Hospital in June 2006 to assess alert or drowsy patients admitted with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Patients whose level of consciousness was less-than-drowsy were assessed using the Glasgow Coma Scale (GCS). The initial purpose of this project was to evaluate the effectiveness of the workshop and the subsequent accuracy of CNS documentation. During the development of the workshop, the purpose expanded to include the assessment of nurses' perceptions of BPGs and their confidence in performing the CNS assessment.
Review of the Literature
The CNS was designed as a simple clinical tool to evaluate the neurological status of acute-stroke patients (Cote, Hachinski, Shurvell, Norris, & Wolfson, 1986). The tool was further tested and found to be valid and reliable and a predictor of outcome (Cote et al., 1989); however, this study included few patients with a comprehensive language deficit, which limited the analysis of this assessment component. Further studies have found the CNS to be a useful retrospective assessment of stroke severity (Bushnell, Johnston, & Goldstein, 2001). No studies were found that prospectively examined the CNS assessment as a continuous monitoring tool (e.g., to evaluate its ability to detect clinically significant changes in patients requiring assessments multiple times daily).
Gocan and Fisher (2005) conducted a survey of the 9 regional stroke centers in Ontario and interviewed one clinical nursing expert at each stroke center to discuss several aspects of stroke care. Participants who had been involved with implementing a stroke assessment tool at their center were asked to describe their implementation strategies and related challenges. The primary challenges identified were the consistency of the assessment and accommodating hospital staff who already were overwhelmed with their work demands. Although this study identified the strategies used to implement the stroke tool (including staff involvement with decision making, integrating the tool into daily practice and documentation, and educational workshops), it did not evaluate these strategies, nor did it address bedside nurses' perceptions of implementing this BPG.
Richardson, Murray, House, and Lowenkopf(2006) published a presurvey and a postsurvey to evaluate the implementation of the NIHSS on a stroke unit. The NIHSS was performed on admission and every 8 hours afterward on all stroke patients. The implementation plan included NIHSS instruction via in-services and videotapes during mandatory education days, distribution of NIHSS resource booklets and pocket cards at every bedside, encouragement to obtain NIHSS certification, and daily patient rounds with review of NIHSS scores. Forty-six nurses completed surveys before implementation, and 34 nurses completed surveys 9 months after implementation. Nurses were required to complete the surveys at mandatory meetings; they were encouraged, but not required, to write their names on the surveys. The percentage of nurses who reported feeling more comfortable performing the NIHSS increased from 30% preimplementation to 85% postimplementation. The percentage of nurses who said the tool was concise, comprehensive, and helpful in communicating a patient's neurological status to others also increased after implementation. The percentage of nurses who reported that they did not know how to use the NIHSS dropped from 50% preimplementation to 9% postimplementation; however, reports that the NIHSS took too much time to use remained similar before and after implementation, at 24% and 21%, respectively. Use of the NIHSS by nurses increased from 12% preimplementation to 69% postimplementation.
Bandura's Self-Efficacy Theory (1997) was used to guide this evaluation because self-efficacy (perceived confidence) has been shown to be an accurate predictor of future behavior. Self-efficacy expectations are developed from four principal sources: performance attainment, vicarious experience, physiological state, and verbal persuasion. Bandura (1997) hypothesized that self-efficacy plays an important mediating role between knowledge and behavior. More recently, self-efficacy has been useful in evaluating educational programs for nurses (DiIorio & Price, 2001; O'Farrell, Ford-Gilboe, & Wong, 2000). Ngo and Murphy (2005) studied the effect of an educational program to manage patients with a peripherally inserted central catheter (PICC). Aider implementing the program, nurses' mean ranking for self-efficacy increased by 34% (p < .0001), and the number of PICC occlusions decreased from 44 to 12 (p = .000).
Purpose
The CNS workshop was created for several purposes, the first of which was to explore nurses' values and perceptions of BPGs and the CNS assessment and to evaluate the effect of the workshop and implementation process on nurses' self-efficacy while using the CNS assessment. The second purpose was to determine whether the workshop and implementation process met nurses' needs and to evaluate the accuracy and appropriateness of CNS assessment documentation.
Method
Questionnaires administered before, immediately after, and 3 months after the workshop were used to examine the effect of a CNS assessment workshop on nurses' values and perceptions of BPGs and the CNS assessment, and their confidence in performing the assessment. The questionnaire given immediately after the workshop also sought participants' perceptions of the content and format of the workshop. Following implementation, a patient chart audit was performed to evaluate the appropriateness and accuracy of documentation of the bedside CNS tool.
All statistical analyses were performed using Statistical Analysis Software v. 9.1 (SAS Institute Inc., Cary, NC). Demographic characteristics of the participants were analyzed by descriptive methods. The impact of the intervention was assessed by comparing the before- and after-training outcomes using the t test. All statistical tests were two-tailed and performed at the .05 level of significance.
The Canadian Neurological Scale Workshop
A committee comprising neuroscience frontline staff nurses, an acute care neurology nurse practitioner, a neuroscience nurse educator, and a neurology nurse coordinator was formed to implement the CNS assessment on the acute-care neuroscience unit. The committee developed a 3-hour workshop for all staff nurses working on the acute-care neuroscience unit at University Hospital. The workshop consisted of a presentation of the CNS assessment, a video demonstration of a CNS assessment of 3 patients with stroke, and a laboratory session. In the laboratory, the nurses role-played, performed, and documented the CNS assessment using four case studies. The mandatory workshop was offered four times within a 2-week period just before implementing the CNS assessment on the neuroscience unit.
FEED