Member Feature: Humeira Dhanji, CNS (Part 2)

Curious about Clinical Nurse Specialists (CNS)? The article What is a Clinical Nurse Specialist Anyway? raises awareness about the CNS role in Alberta. Upon interviewing Humeira Dhanji for the Member Spotlight, it became evident that she was an exemplar CNS. We are lucky to have Humeira as a UNA 115 member working at Foothills Medical Centre. In this interview, Humeira describes what it means to be a CNS working for the Acute Pain Service.

Q:​Many​ ​nurses​ ​are​ ​not​ ​aware​ ​of​ ​what​ ​a​ ​Clinical​ ​Nurse​ ​Specialist​ ​is.​ ​Could​ ​you​ ​give​ ​us some​ ​examples​ ​of​ ​how​ ​you​ ​apply​ ​the​​ Canadian​ ​Nurses​ ​Association​ ​(CNA)​​ ​competencies:​ ​clinical​ ​care,​ ​systems leadership,​ ​advancement​ ​of​ ​nursing​ ​practice,​ ​and​ ​evaluation​ ​and​ ​research? 

A:​ ​The​​ ​CNA defines​ ​the​ ​CNS as​ ​a​ ​registered​ ​nurse​ ​who​ ​holds​ ​a​ ​Master’s​ ​or​ ​Doctoral​ ​degree​ ​in​ ​nursing​ ​with expertise​ ​in​ ​a​ ​clinical​ ​nursing​ ​specialty;​ ​uses​ ​in-depth​ ​knowledge​ ​and​ ​skills, advanced​ ​judgement​ ​and​ ​clinical​ ​experience​ ​in​ ​a​ ​nursing​ ​specialty​ ​to​ ​assist​ ​in providing​ ​solutions​ ​for​ ​complex​ ​health-care​ ​issues.

The​ ​role​ ​of​ ​the​ ​CNS​ ​is​ ​diverse​ ​and​ ​comprises​ ​5​ ​key​ ​components:

  1. Clinician​:​ ​I​ ​have​ ​advanced​ ​knowledge​ ​in​ ​acute​ ​pain​ ​management​ ​nursing​ ​and work​ ​with​ ​Anesthesiologists​ ​in​ ​managing​ ​acute​ ​pain​ ​for​ ​surgical,​ ​trauma,​ ​cancer pain​ ​&​ ​some​ ​complex​ ​medical​ ​patients​ ​(e.g.​ ​sickle​ ​cell​ ​crises,​ ​burn​ ​patients,​ ​etc). As​ ​a​ ​team,​ ​we​ ​follow​ ​all​ ​patients​ ​with​ ​non-obstetrical​ ​epidural​ ​infusions, intrathecal​ ​morphine,​ ​single​ ​shot​ ​peripheral​ ​nerve​ ​block patients,​ ​continuous​ ​peripheral​ ​nerve​ ​block​ ​infusions,​ ​implantable​ ​intrathecal ports​ ​inserted​ ​for palliative​ ​patients​ ​and​ ​other​ ​patients​ ​with​ ​complex​ ​pain​ ​issues that​ ​are​ ​challenging​ ​to​ ​treat.
  2. Educator​:​ ​I’m​ ​always​ ​trying​ ​to​ ​promote​ ​a​ ​learning​ ​environment​ ​for​ ​patients, nurses,​ ​students​ ​and​ ​other​ ​healthcare​ ​professionals.​ ​Some​ ​of​ ​the​ ​topics​ ​I​ ​teach include:​ ​Pain​ ​Talk​ ​among​ ​nursing​ ​students;​ ​Basic​ ​Pain​ ​Workshop​ ​which​ ​certifies nurses​ ​to​ ​manage​ ​patients​ ​with​ ​regional​ ​anesthesia;​ ​Pain​ ​Lecture​ ​to​ ​medical students​ ​about​ ​the​ ​different​ ​types​ ​of​ ​pain,​ ​assessment​ ​of​ ​pain​ ​and​ ​the​ ​various treatment​ ​options​ ​available​ ​to​ ​the​ ​patient;​ ​Low​ ​Dose​ ​Ketamine​ ​Intravenous Infusion​ ​certification​ ​for​ ​analgesia;​ ​Lidocaine​ ​Intravenous​ ​Infusion​ ​certification for​ ​analgesia;​ ​Intravenous​ ​Patient​ ​Controlled​ ​Analgesia​ ​Train-the-Trainer program​ ​to​ ​Clinical​ ​Nurse​ ​Educators.​ ​I​ ​have​ ​also​ ​delivered​ ​lectures​ ​at conferences​ ​regarding​ ​the​ ​Pathophysiology​ ​of​ ​pain,​ ​neuropathic​ ​pain,​ and ​basic​ ​pain principles.
  3. Consultant​:​ ​As​ ​an​ ​expert​ ​in​ ​acute​ ​pain​ ​management,​ ​I​ ​get​ ​asked​ ​to​ ​see​ ​patients whose​ ​pain​ ​trajectory​ ​does​ ​not​ ​follow​ ​a​ ​typical​ ​course​. In​ ​collaboration​ ​with​ ​the​ ​anesthesiologist,​ ​I​ ​discuss​ ​the​ ​various​ ​options​ ​for​ ​the patient.​ ​This​ ​may​ ​include​ ​equianalgesic​ ​conversions​ ​of​ ​the​ ​patient’s​ ​opioid medication,​ ​commencement​ ​of​ ​adjuvant​ ​medications,​ ​initiating​ ​ketamine​ ​/ lidocaine​ ​ ​infusions​ ​&​ ​considering​ ​the patient’s​ ​eligibility​ ​for​ ​regional​ ​analgesia​ ​if​ ​applicable.  
  4. Researcher​:​ ​I​ ​use​ ​evidence-based​ ​practice​ ​to​ ​guide​ ​my​ ​role​ ​as​ ​a​ ​CNS​ ​&​ ​acute​ ​pain expert.​ ​Whenever​ ​there​ ​is​ ​a​ ​procedure​ ​change​ ​or​ ​introduction​ ​of​ ​a​ ​new​ ​practice, I​ ​am​ ​guided​ ​by​ ​research.​ ​I​ ​go​ ​through​ ​the​ ​current​ ​literature​ ​to​ ​determine​ ​the most​ ​specific​ ​application​ ​of​ ​a​ ​particular​ ​practice. An​ ​upcoming​ ​project​ ​I​ ​am​ ​collaborating​ ​on​ ​with​ ​anesthesiologists​ ​and​ other CNSs​ ​is​ ​an​ ​opioid​ ​tapering​ ​brochure​ ​for​ ​patients.​ ​Healthcare and​ ​our​ ​population​ has​ ​changed​ ​markedly​ ​over​ ​the​ ​last​ ​20​ ​years​ ​that​ ​I​ ​have​ ​been in​ ​the​ ​nursing​ ​profession.​ ​Surgical​ ​procedures​ ​are​ ​being​ ​done​ ​for​ ​ailments​ ​we never​ ​thought​ ​would​ ​be​ ​possible.​ ​Many​ ​patients​ ​have​ ​a​ ​history​ ​of​ ​chronic​ ​pain pre-operatively​ ​and​ ​are​ ​on​ ​opioid​ ​analgesics​ ​and​ ​therefore​ ​opioid​ ​tolerant. Post-operatively,​ ​these​ ​patients​ ​have​ ​acute​-on​-​chronic​ ​pain​ ​and​ ​end​ ​up​ ​on​ ​higher doses​ ​of​ ​opioid​ ​analgesia.​ ​Several​ ​patients​ ​end​ ​up​ ​being​ ​discharged​ ​home​ ​on opioid​ ​doses​ ​significantly​ ​higher​ ​than​ ​what​ ​they​ ​were​ ​admitted​ ​into​ ​the​ ​hospital with.​ ​A​ ​lot​ ​of​ ​these​ ​patients​ ​do​ ​not​ ​have​ ​a​ ​family​ ​physician​ ​that​ ​can​ ​assist​ ​them with​ ​tapering​ ​their​ ​opioid​ ​dose,​ ​thus​ ​putting​ ​them​ ​at​ ​risk​ ​for​ ​opioid​ ​dependency. Our​ ​goal​ ​is​ ​to​ ​develop​ ​a​ ​brochure​ ​that​ ​will​ ​facilitate​ ​a​ ​self-weaning​ ​process among​ ​patients.
  5. Leader​:​ ​I​ ​consider​ ​myself​ ​to​ ​be​ ​a​ ​change​ ​agent,​ ​as​ ​I​ ​am​ ​always​ ​looking​ ​for​ ​ways​ ​to advance​ ​nursing​ ​practice.​ ​Not​ ​only​ ​my​ ​own​ ​practice,​ ​but​ ​the​ ​profession​ ​of nursing​ ​in​ ​general.​ ​This​ ​in​ ​turn​ ​will​ ​increase​ ​the​ ​quality​ ​of​ ​healthcare​ ​available​ ​to individuals.  Examples​ ​of​ ​how​ ​I​ ​have​ ​led​ ​a​ ​change​ ​in​ ​practice​ ​include:  (a)After​ ​a​ ​critical​ ​incident​ ​involving​ ​a​ ​patient’s​ ​Methadone​ ​regimen,​ ​I collaborated​ ​with​ ​Anesthesiologists​ ​and​ ​nurse​ ​practitioners​ ​and​ ​launched​ ​the development​ ​of​ ​Methadone​ ​Guidelines​ ​for​ ​the​ ​Calgary​ ​Zone.​ ​It​ ​outlines​ ​a​ ​safe approach​ ​in​ ​continuing​ ​/​ ​replacing​ ​a​ ​hospitalized​ ​patient’s​ ​Methadone treatment. (b)Pain​ ​management​ ​can​ ​be​ ​challenging​ ​among​ ​some​ ​patients​ ​due​ ​to​ ​opioid tolerance​ ​or​ ​opioid​ ​refractory​ ​pain.​ ​This​ ​requires​ ​using​ ​adjuvants​ ​for analgesic​ ​therapy.​ ​An​ ​adjuvant​ ​analgesia​ ​that​ ​Acute​ ​Pain​ ​Service​ ​in​ ​the Calgary​ ​Zone​ ​has​ ​introduced​ ​last​ ​year​ ​is​ ​Lidocaine​ ​Intravenous​ ​Infusion​ ​for Analgesia.​ ​Working​ ​with​ ​my​ ​APS​ ​nursing​ ​colleagues​ ​and​ ​Anesthesiologists,​ ​I led​ ​the​ ​development​ ​of​ ​the​ ​Protocol​ ​and​ ​Learning​ ​Module​ ​for​ ​Lidocaine Intravenous​ ​Infusion​ ​for​ ​Analgesia.​ ​It​ ​is​ ​being​ ​used​ ​on​ ​patients​ ​whose​ ​pain​ ​is not​ ​managed​ ​well​ ​due​ ​to​ ​opioid​ ​tolerance,​ ​neuropathic​ ​pain​ ​or​ ​opioid sensitivity.
Pictured above: Calgary APS at the 5th annual Pain Awareness Education Day. (From Left to Right) Candace Krause, Gordon Jones, Rosa Reyes, Lynn Acheson, Janice Rae, Humeira Dhanji, Kayla Denness, Sumeeta Kapoor, and Roberta DeJong.


Q:​ ​Recently,​ ​the​ ​College​ ​and​ ​Association​ ​of​ ​Registered​ ​Nurses​ ​of​ ​Alberta​ ​(CARNA) published​ ​a​ ​short​ ​​article ​​ ​on​ ​the​ ​history​ ​of​ ​ANP​ ​in​ ​Alberta​ ​where​ ​the​ ​author, Jananee​ ​Rasiah,​ ​identified​ ​common​ ​challenges​ ​facing​ ​APNs​ ​in​ ​Alberta​ ​such​ ​as role​ ​overlap,​ ​lack​ ​of​ ​awareness​ ​of​ ​scope,​ ​role​ ​confusion​ ​and​ ​lack​ ​of​ ​funding.​ ​What do​ ​you​ ​think​ ​is​ ​the​ ​biggest​ ​challenge​ ​facing​ ​Clinical​ ​Nurse​ ​Specialists​ ​today?

A:​ ​I​ ​think​ ​there​ ​are​ ​a​ ​few​ ​challenges​ ​facing​ ​Clinical​ ​Nurse​ ​Specialists​ ​today.​ ​One​ ​of the​ ​main​ ​challenges​ ​is​ ​role​ ​ambiguity.​ ​I​ ​find​ ​it​ ​beneficial​ ​to​ ​have​ ​the​ ​Canadian​ ​Nurses Association​ ​identify​ ​our​ ​role​ ​and​ ​state​ ​the​ ​5​ ​domains​ ​of​ ​our​ ​nursing​ ​practice. However,​ ​not​ ​all​ ​health​ ​care​ ​professionals​ ​have​ ​a​ ​clear​ ​understanding​ ​of​ ​the​ ​CNS title.​ ​​ ​Therefore,​ ​in​ ​job​ ​postings​ ​or​ ​even​ ​performance​ ​evaluations,​ ​we​ ​lack​ ​role clarity.​ ​There​ ​is​ ​inconsistent​ ​use​ ​of​ ​the​ ​CNS​ ​title.​ ​This​ ​impedes​ ​role​ ​implementation. Reporting​ ​structure​ ​is​ ​important.​ ​It​ ​is​ ​vital​ ​for​ ​a​ ​manager​ ​to​ ​have​ ​a​ ​clear understanding​ ​of​ ​the​ ​CNS​ ​practice​ ​domains,​ ​allowing​ ​for​ ​realistic​ ​expectations​ ​at work​ ​and​ ​appropriate​ ​work​ ​distribution.​ ​I​ ​am​ ​fortunate​ ​to​ ​work​ ​with​ ​Nurse Clinicians​ ​who​ ​have​ ​a​ ​clear​ ​understanding​ ​of​ ​my​ ​role​ ​&​ ​their​ ​own.​ ​This​ ​allows​ ​me​ ​to carry​ ​out​ ​my​ ​responsibilities​ ​as​ ​a​ ​CNS.





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