Introducing a Clinical Nurse Educator (CNE) Role in Long-Term Residential Care Facility: A PEPPA Framework Proposal

This proposal suggests introducing a Clinical Nurse Educator (CNE) role in a Long-Term Residential Care Facility using the PEPPA Framework. The proposal includes steps to define patient population, identify stakeholders, determine need for a new model of care, identify priority problems and goals, define the new model of care and CNE role, and plan implementation strategies. The CNE role will help improve staff competency, orientation of new staff, and ensure patient safety and care.

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ACCOUNTABILITY LEADERSHIP
Executive Summary
The Clinical Nurse Educator (CNE) is a complex and dynamic profession. The core role of a
CNE includes creating, implementing and evaluating continuous clinical teaching programs,
updating policies and procedures, and ensuring staff competency, orientation of new staff to
the facility (Dempsey, 2007, p.1). The CNE also act as preceptor/mentor to all staff.
It is crucial to introduce a CNE in the Long-Term Residential Care Facility. Dempsey in his
article stated that nursing continuing education will improve nursing activity by developing
their knowledge, skills and attitude, and this will improve the healthcare system. On the
contrary, if the continuing education and training program is not implemented properly, it
affects the patient safety and care (Henderson & Eaton, 2013, p. 1980. For instance, it is a
challenging to deliver end-of-life care in aged care facilities. There are only 20% of the
population that die in this setting. The commonly reported reasons include limited access to
medical care, inadequate clinical training and leadership, and poor communication between
nursing home and medical professions (Henderson & Eaton, 2013, p. 200).Henderson and
Eaton argued that continuing training and education program for aged care providers is
suggested as the most important way of overcoming these barriers.
This proposal aim to introduce a CNE role into a Long-Term Residential Care Facility by
using PEPPA Framework. PEPPA Framework is used to assist in developing, implementing
and evaluating Advance Practice Nursing (APN) role. It is a participatory, evidence-based,
patient-centred process (Henderson & Eaton, 2013, p. 201). This framework was generated
and upgraded from other existing frameworks, in order to conquer the barriers when
implementing the roles of APN through knowledge and understanding of APN roles and
environment. In this process, the relationships and interactions between patients, care

workers, organisations and other stakeholders have been emphasised. It is a complex and
dynamic process to introduce an advanced nursing role into a workplace.
Step 1: Define patient population and describe current model of care
The identified priority patient population in this proposal should be ageing population, as
Mohamed in his article stated that the world’s population is ageing (Mohamed, 2016, p. 1).
There are an increasing number of elder people who live and die in an Aged Care Facilities.
In order to provide best care for elderly, staff needs to gain updated education from an
expertise.
Model of Care means the way health services are delivered. It is a multifaceted concept, it
outlines the best practice care and services delivered to a patient or patient cohort through the
application of a set of services and principles. It aims to ensure patient get the right care, at
the right time, by the right team and in the right place (Oermann, 2016, p. 2).
The current model of care in the Aged Care Facilities the writer worked in, is the Resident
(patient)-centred care but lack of evidence hampered research to some extent. The care
provider generated a specific care plan according to each individual client Such as what the
Registered Nurse did with the client, their family, Local Medical Officer (LMO), and other
health professional (e.g. Physiotherapist, podiatrist, etc.). When considering to introduce a
CNE role into the facility, the benefit should not be limited to the clients alone as they can get
best care from well trained staff. The benefits should also be extended to protect care
providers by continuous training to avoid unaware of updated regulations and standards.
Step 2: Identify stakeholders and recruit participants
The stakeholders can be divided into internal and external to the organisation (PEPPA). The
internal stakeholders include residents and families, nurses, Advanced nurses, managers,
physicians and other healthcare providers, etc. The external stakeholders include professional

associations, volunteers, government, funders, insurance companies and healthcare suppliers
(Sayers, Salamonson, DiGiacomo, & Davidson, 2015, p. 4). Those stakeholders need to be
involved and provide support for planned change even if they may have different roles, goals
and responsibilities.
After the stakeholders have been identified, organisation need to consider how to recruit them
and let them to participate in the process (Henderson & Eaton, 2013, p. 198). Henderson and
Eaton suggested that participants should represent different kinds of stakeholders in order to
have a more comprehensive interaction with the new model of care and to introduce a CNE
role (Henderson & Eaton, 2013, p. 198). However, it is very difficult to ensure correct
balance in composition and numbers of participants. In order to overcome this problem,
Henderson and Eaton provides a set of strategies to assist recruit residents, their families and
advocacy groups (Henderson & Eaton, 2013, p. 199). An example is distributing press
releases, posters, clinic flyers, letters or phone calls; attending current resident education
events or resident meeting which can help to explore resident’s need, experiences and gaps in
the current model of care; gathering residents feedback by filling a suggestion or complaints
for evaluation of current services provided; involving residents and their families to have a
regular family conference to discuss face to face about their concern in order to meet their
needs.
Meaningful resident involvement in healthcare planning is important as they are the experts
in their needs. It is crucial to ensure cooperation with them so as to develop the new model of
care. Therefore, relevant education related to organisation systems and their individual health
condition are irreplaceable (Christenbery, 2012, p. 33). In addition, PEPPA also support that
argument of involving the residents in the teaching process since they can be positively
effective in shifting the power balance between healthcare providers and service users.

Hence, introducing a CNE role in an aged care facility can boost education in participants so
that they can fit within a new model of care.
Step 3: Determine need for a new model of care
In order to find out the strengths and limitations of current model of care, a needs assessment
should be conducted to a variety of stakeholders. From this needs assessment, healthcare
provider can collect and/or generate information about the extent, severity, and importance of
unmet resident health needs and how healthcare organisation can improve and meet these
needs.
Unmet needs for residents include practical, emotional, physical and existential domains.
According to resident’s preference, some of the unmet health needs may overweight others
(Christenbery, 2012, p. 34). Therefore, the unmet needs should be prioritised. On the
contrary, a similar process is used to ensure retention of the strengths of current model of
care.
Step 4: Identify priority problems and goals
After finding out the unmet healthcare needs for resident, health providers need to identify
the priority problems and set outcome-based goals to improve the model of care delivery and
resident health.
Priority problems is a challenging decision making process, it is all about how finite
healthcare resources will be distributed and utilised after completion of a needs assessment.
Effective priority setting not only improve stakeholders understanding and acceptance of the
priority problems and goals, but also improve their satisfaction by involving them into the
decision making process (Christenbery, 2012, p. 35). In order to achieve maximum
improvement in the model of care, keep consensus decision of the stakeholders is important.
Henderson and Eaton in their article also introduce several assistant tools such as Delphi

method, Nominal Group Process, Avoiding Group Think and Decision-Making Matrix to
assist stakeholders achieve consensus decision (Henderson & Eaton, 2013, p. 198).
To set outcome-based goals, they further suggested establishing a SMART (Specific,
Measurable, Appropriate, Reasonable and Timed) goal.
Examples of measurable CNE role outcomes are shown in Table 1(REF).
Table 1. resident and
their family
Health
providers
Organisation
and healthcare
system
Quality of Care Satisfaction
with care,
resident safety,
Knowledge
about disease
and treatment.
Updated
knowledge and
skills of specific
disease and
treatment,
job satisfaction,
recruitment and
retention of
staff, reduction
in injuries
Complication
rates, update of
best practices,
achievement of
standardised
benchmarks
Step 5: Define the new model of care and CNE role
In this step, detailed strategies and solutions need be identified after establishing the
outcome-based goal. In order to implement the new model of care, it is important for
participants to learn more about the purpose of the new CNE roles. Such as why the
organisation needs to establish a CNE role rather than other nursing or health provider roles,

and what are the pros and cons for introducing a CNE role (Salminen et al., 2016, p. 18). In
addition, introduction of a new model of care needs confirmation about the best care, the best
healthcare providers, and how they will be involved in the new care practice and goal-related
strategies.
The reason why an organisation needs to establish a CNE role and why it is important will be
explained below. For instance, in the long-term residential care system, staffs generally have
poor knowledge of basic palliative care practice such as pain, weight loss or the use of feeling
tubes management (Salminen et al., 2016, p. 19). The reason why health providers lack
knowledge about palliative care as explained by Henderson and Eaton is that health
professionals are only trained to investigate, diagnose, and treat diseases(Henderson & Eaton,
2013, p. 197). They are meant to be curing the patient. However, in the aged care setting, it is
necessary for the staff to get more palliative care concepts training in order to take care this
unique, fragile and vulnerable group. Therefore, the provision of adequate training and
education related to palliative care for aged care healthcare providers should be a high public
health priority.
Another example in aged care facility is that the staff should show low level of awareness of
compulsory reporting. The compulsory reporting must be taken into account when abuse
(physical, psychological or emotional, financial or material, sexual) or neglect happens
between healthcare provide and resident or between resident and resident (Salminen et al.,
2016, p. 21). In other words, healthcare provider should be able to maintain consistently
identify, document and report abuse of older people in aged care system . A study showed a
positive relationship between the increase in reporting of elder abuse and the increase in
knowledge and educational training about abuse and neglect (Salminen et al., 2016, p. 22).
Such kind of education can improve their attitude toward this issue.

From these two examples there is demonstration of the importance of education among aged
care facilities. Healthcare organisations are striving to find a way to deliver efficiency,
ultimately, quality, safe, and cost-effective patient-centred care. CNEs are considered as
being crucial to assist healthcare organisation to achieve this goal (REF).Therefore, to
establish a CNE role is interconnected with alternative health provider roles.
Step 6: Plan implementation strategies
During this step, the organisation need to develop a plan that ensures the CNE role is read for
implementation which include identifying the potential barriers and facilitators that can
influence role of implementation (Button, Harrington, & Belan, 2014, p. 1320). Another
important aspect at this step is to develop an evaluation plan which includes goal-related
outcomes for each CNE role domain and other changes to the model of care, establish
timelines, and identify baseline data to be collected for role implementation and goals to be
achieved(Henderson & Eaton, 2013, p.200)
Henderson and Eaton suggested that the plan of implementation needs focus on four areas:
1. Stakeholder awareness
The role is not clear among stakeholders and this is a barrier to CNE role
implementation. Henderson and Eaton explained that as stakeholders may articulate
the role differently than it was initially envisioned which can make the role unclear, it
is important to keep in touch with key stakeholder groups in order to get regular
updates, CNE presentation and evaluation of the role.
2. Administrative supports and resources
It is challenging to implement a new advance nursing role within complex health care
system (Button, Harrington, & Belan, 2014, p. 1322. Seeking administrative support
by involving meetings with administrative supports, maintaining visibility in clinical
areas and developing in-service programs for colleagues is necessary. In addition,

administrative support ensures that practical resources are provided and supports the
CNE role to perform it (Button, Harrington, & Belan, 2014, p. 1318). Practical
resources include adequate office and clinical examination space, audio-visual
equipment, and communication and computer technology. Practical support include
assistance with clinical procedures, data management and educational opportunities
(Button, Harrington, & Belan, 2014, p. 1320). Those recourses and supports are
crucial for CNE. For instance, CNE needs to answer staff’s certain question
immediately at the point of care. This requires instant access to trusted and
authoritative information to quickly reply the clinical questions and give evidence-
based best practices directly at the bedside.
3. Regulatory mechanisms, policies and procedures
Regulation is the way a profession is controlled to ensure accountability and for
protection of the public (Moran et al., 2012, p. 2). For CNE at legislative level, the
nurse who is planning to take this role may needed to have credentials that proves an
expanded role of activities.
Facilities and providers can design their own policies and procedures, but they all
need to adhere to all the standards included in the regulations(Petit-dit-Dariel,
Wharrad, & Windle, 2014, p. 1372).The facility should support CNE role autonomy
which include authority, collaborative, independent practice and clinical decision-
making. Goodrich also argued that the role of autonomy enables full CNE role
implementation and gives the permission to the CNE to be creative, flexible and
immediately responsive to patient’s needs (Goodrich, 2014, p. 3).

4. CNE Education
Continuing Professional Development (CPD) is compulsory to renew the Nurses’
Registration according to Australian Health Practitioner Regulation Agency
(AHPRA).
They requested a minimum 20 hours CPD for Registered Nurse each year.
In order to promote patient safety, continuing evidence-based education courses is
important for CNE .Goodrich also stated that CNE has the responsibility to be
prepared well and be updated with current trends in nursing care to maintain their
effectiveness. In addition, maintaining effective communication and professional
teaching skills can contribute to CNE effectiveness as well (Williams, 2012, p. 368).
Therefore, both the organisation and providers should send CNE to study outside or
into other similar facilities regularly and let CNE to spread their knowledge to all
members. At last but not least, CNE also needs to maintain self-study such as search
books, classes and scholarly journals on the internet in order to keep themselves
updated on current issues.
Step 7: Initiate CNE role implementation plan
After the plan has been implemented in step 6, the organisation needs to hire a CNE for the
position. According to Goodrich, normally an APN role requires three to five years form
novice to a fully developed role (Goodrich, 2014, p. 2). As Goodrich stated, health care
systems always changes. Therefore, the new strategies and support for CNE role development
are needed along with those changes. The implementation plan requires a continuous process
to meet the needs of the new organisational policies and procedures (Gore & Singh, 2018,
p. 2). In addition, the organisation also needs to maintain developmental evaluation and
communication with CNE to ensure that all the required supports and resources for
development are in place (REF).

Step 8: Evaluate CNE role and new model of care
Goodrich uses The Donabedian’s structure-process-outcome evaluation for new graduation
nurses performance. In this step, the organisation can utilise this framework to evaluate the
new model of care and CNE role as a strategy to promote ongoing role development
(Weidman, 2013, p. 4). Structure representation of all the resources, working environment,
organisational staff and characteristics of CNE is essential. Process representation all services
provided by CNE, how the services are provided, and how the CNE role functions in relation
to clinical practice, education staffs and patients, evidence-based research, and leadership is
also important. Outcomes representation of delivered quality of care to patients and cost-
related outcomes. Outcomes affected by both structure and process. To identify role barriers
and facilitators is another important component in this step (Nambiar-Greenwood, 2012,
p. 2). Organisation to set SMART outcome-based goals in earlier step 4 in order to monitor
and exam the structures and processes of CNE role, then identify extra requirement for
supporting CNE role development and further expansion.
Step 9: Long-term monitoring of the CNE role and model of care
Continuous change in the health care system can affect safety, satisfaction and sustainability
of the CNE role (Booth, Emerson, Hackney, & Souter, 2016, p. 56). Therefore, both the
organisation and CNE need to maintain continuous and interactive monitoring to ensure that
current CNE role and model of care is suitable in the health care system, patient needs and
clinical practice (Booth, Emerson, Hackney, & Souter, 2016, p. 56). If current practice is out
of date, CNE has the responsibility to update knowledge for themselves and others, improve
treatment practice and keep monitoring. In addition, when implement Long-term monitoring,
each steps of the PEPPA framework should be reviewed and the CNE role and model of care
should be changed appropriately (Booth, Emerson, Hackney, & Souter, 2016, p. 57).

Conclusions
It is a complex and dynamic process to successfully implement a new advanced nursing role
in an organisation as the role itself. The PEPPA framework has clear steps and strategies that
should be adhered to in order to implement the new role into the healthcare organisations.
Involving stakeholders in the process provides the opportunity to establish a clearly-defined
CNE role. Comprehensive planning and implementation strategies support effective CNE
role development. The outcome-based goals also provides the basis for long-term evaluation
and continuing improvement of the CNE role.

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