Internationally the concept of specialized expert or advanced nursing is not new and can be identified as early as the 19th century in the United States Civil War. (Hamric et al., 2005; Jacobs 2007). Advanced nursing practice, however, became definitively established in the USA in the 1970’s through advances in educational preparation and clinical practice roles for both the CNS and NP (Harmic et al.). The present-day CNS role is also established in Australia, Taiwan, China, Japan, New Zealand and the United Kingdom (Chen, 2009; Hamric et al.). In each country the definition and scope of practice of the CNS are influenced by factors such as the national economy, culture, education, practice standards and models of health care delivery (Chen; Hamric et al.).
The Nurse Practitioner/NP is currently the most obvious example of the advanced practice nurse in the US, and there has been a lot written about the role of the NP and its contribution to health care. (Dunn, 1997; Gardner et al., 2004). The role of the Clinical Nurse Specialist or CNS, however, has been much less looked at in the US. Based on internationally and nationally accepted definitions the CNS role falls under the canopy of advanced nursing practice. The International Council of Nurses states: A nurse practitioner/advanced practice nurse is a registered nurse who has the expert Knowledge base, complex decision making skills and clinical competencies for expanded Practice, the characteristics of which are shaped by the context and/or country in which She/he is credentialed to practice. A master’s degree is recommended for entry level (ICN, 2005, p. 5).
The nursing council of New Zealand defined advanced practice as that which “reflects a range of highly developed clinical skills and judgments acquired through a combination of nursing experience and education.” (ICN. 2005, p.4). In Canada a CNS is defined as a Registered Nurse (RN) who, through both practice and masters level education, has become an expert in a clinical area of nursing (Sparacinc, 2005). The American Nurses Association (1996) defines the CNS as an “expert clinician and client advocate in a particular specialty or subspecialty of nursing practice.” (p.3). In the Literature there appears to be a lot of similarities about what constitutes ‘expert’. The qualities most often referred to are: expert delivery of care; facilitating change and quality improvements; education of self (post graduate) and in the workplace to colleagues and patients; active involvement in research; functioning as a leader; and cultural and ethical influence (Borbasi, 1999; Caslledine, 1999; National nursing organization in the US 2005.).
The most important quality is considered to be the delivery of expert care (Benner, 1984; Pallerson 1987). More recently it appears the importance is shifting from the delivery of care to the multitude of roles the expert is also expected to fulfill, such as leader, researcher, teacher, change agent, police writer and professional spokesperson (Casiledine; National nursing organizations in the US). Hamric et al. (2005) describes several competencies important to the CNS role. These include clinical practice, coaching and guidance, consultation, research, leadership, collaboration and ethical decision making. There is emphasis on the direct patient care component of the definition, as clinical practice, skills, knowledge and clinical know-how are explained to be the role of CNS practice (Sparacino, 2005). There has been considerable discussion about integration of the NP and CNS roles (Elson, Happel & Manis, 2006; Gardner et al., 2004) because they share similar aspects such as research, education and consulting (Henderson, 2004.). Research, however, explains vital differences in the roles; NPs are, “responsible for diagnosing and managing” while the CNSs care for patients with, “already identified health problems” (Gardner et al., p. 11). Dunn (1997) suggests, in the American setting, a NP provides more comprehensive care than a CNS but this could be due to the difference in the patient population. Clinical Nurse Specialists commonly care for patients in acute hospital settings and NPs are likely to be in Primary Health. In New Zealand this is not the case; NPs are registered to work in both acute hospital settings and in primary health and, according to Harris (2007), it appears more are working in acute hospital settings. In Australia the title CNS referrers to a promotional position on a clinical career pathway. The establishment of the CNS role was focused on by the industrial process and associated with financial progression to “enable nurses to progress professionally without having to leave the bedside to take up positions in education or administration” (Elsom et al., 2006, p. 57). Although there have been many definitions of the CNS nationally and internationally, the disproportionate amount of indirect care contradicts their defined role. Both Duffield et al. and Scott (1999) show role confusion is still an issue for the CNS across the board. LaSala, Connors, Pedro, and Phipps (2007) surveyed RNs and CNSs to determine how CNSs are utilized at a large US teaching hospital.
The survey aimed to describe the role and its impact on patient outcomes. They found that the CNSs role at the hospitals they studied consisted of expert critical care, and teaching and coaching staff, but, they also described ways the roles directly impacted patient outcome. In this study they determined that the role of the CNS may end up being a “dispensable luxury” if the nurses in these positions continue to be unable to showcase their specific role and the unique influence they have on the reduction of health care costs and positive patient outcomes (LaSala et al.). In the United Kingdom Bousfield (1997) described the CNS are very similar to the CNSs of the US, as, “advancing knowledge, expertise and leadership skills” (pg. 245). However Bousfield found the CNSs potential was not being utilized due to the fact that many of the in roles describe organizational road-blocks restricting their ability to practice independently as well as feelings of burnout, isolation, and role conflict. The National PDRP working partly to report to the National Nursing Organizations of New Zealand (2005) recommends national role titles. These include advanced clinical titles such as “Nurse Specialist”. Since this report, the district health boards/NZNO Nursing and Midwifery multi-employer collective agreement (MECA) (NZNO, 2007) has expanded the role designation and national titles CNS is included and loosely defines having a focus on patient care delivery providing specialist care and expert supporting nursing staff to provide expert care, and having a role in research and policy and procedure development (NZNO). With the plethora of definitions and explanations of the CNSs scope of practice it seems as if this role is now and will continue to make a name for the role while positively affecting the health care system as a whole with contributions to better and safer patient outcomes. Today more than ever, the role of the clinical nurse specialist is a vital part to insuring the
establishment of quality patient care; it is also critical to improving staff development along with liking professional practice to evidence-based outcomes. As a member of the leadership team, the clinical nurse specialist is able to directly affect patient care by responding to the needs of the patient, staff nurses, and physicians. My purpose is to describe the evolving role of the clinical nurse specialist in hospitals and the effects this role has on patient outcomes and evidence based practice. In the acute setting, the clinical nurse specialist impacts quality initiatives at the bedside, on a unit-based level, and hospital wide. The expertise of the clinical nurse specialist is sought to assist, implement, and evaluate hospital-wide quality initiatives and cost-effective patient care practices. The impact of the clinical nurse specialist enhances patient care and professional nursing practice. The clinical nurse specialist’s presence is evident throughout a large urban teaching hospital. In this hospital there are more than 50 clinical nurse specialists in the institution, making a strong statement of organizational support and commitment to the role. The clinical nurse specialist is considered a leadership position in which individuals are empowered to act as leaders, role models, practice experts, and supporters and participants of research in their particular area of expertise. (LaSala et al.). At a meeting of clinical nurse specialists, the group was given a questionnaire that asked the number of years of nursing experience each person had; the total collective years of experience in nursing was 848 years. The questionnaire results also showed the participation in 33 different professional organizations with more than 30 certifications and credentials held by the collective group.
Bereavement, ethics, qualitative and quantitative research, stroke education, and wound care were a few of the areas of expertise characterized by the group. The main focus of the clinical nurse specialist is to influence practice on the unit and throughout the organization through direct care in both acute impatient settings and outpatient areas. (LaSala et al.). The clinical nurse specialists ask nurses to rate and report frequency of common patient problems they encounter in daily practice, nursing diagnoses or problems that occur on their units, and their perceived preparedness to manage each problem or diagnosis. The common nursing problems are looked at and validated by the clinical nurse specialists who in turn develop programs and interventions to remedy these problems to improve patient safety and patient satisfaction. (LaSala et al.). Examples of some of these programs include the development of wound care programs and unit based information to assist the staff in preventing skin breakdown. The stroke program with unit based information and certifications that aid in the identification of new onset stroke symptoms and the prevention of CVA’s with patient focused education on risk factors. In these instances the clinical nurse specialists who are unit-based wound and stroke specialists are recognized and consulted by members of the interdisciplinary team. Programs have also been developed regarding airway management, risk for injury, confusion, fall prevention, and end-of-life issues.
Programs like these have had a very positive influence on the nurse’s ability to care for critically ill patients safer due to evidence-based practice. Staff is better prepared to address the needs of these patients as well as anticipate what the patients’ needs may be. Positive outcomes like this have and will lead to staff satisfaction and also staff retention with overall improve positive patient outcomes. The general medical-surgical units have their own set of specific learning opportunities and challenges. These units are where many new graduating nurses find initial employment and begin to build their own level of confidence and competence. This is the foundation that will follow them throughout their careers impacting continuing professional development. In these medical-surgical environments the clinical nurse specialist is able to impact care and positive outcomes by influences these new nurses to be proactive in their patients care. Boyle (1996) identified patient-focused instruction as the primary characteristic that distinguishes the clinical nurse specialist in the educator role compared with nurses functioning as educators in staff development. Teaching may be formal or informal, occurring in the classroom or at the bedside. Collaborative patient care planning and learning are optimized through collective discussion of the patient’s problems, patient specific assessment, and shared decision making. (Boyle, 1996). As a role model, the clinical nurse specialist assists in situations that allow staff to get involved independently in the future.
The clinical nurse specialist also mentors staff by creating an environment that encourages them to develop to their full potential and to envision mistakes as opportunities for learning, developing, critical-thinking skills, and growing professionally. (Boyle, 1996). As a mentor, the clinical nurse specialist listens attentively, acknowledges the mentee’s insight, and affirms that it makes a difference. To function effectively as a consultant, the clinical nurse specialist must be readily available, be nonjudgmental, possess excellent interpersonal communication skills, and be sensitive to boundary and territorial issues. In the mentoring role, the clinical nurse specialist focuses on the individualized needs of the mentee, promoting a caring, supportive relationship. (Boyle, 1996). The clinical nurse specialist teaches in ways that motivate others to learn. As clinical expert, collaborator, consultant, and educator, the clinical nurse specialist has a unique opportunity to positively influence patient care outcomes, continuity of care, and the professional development of staff through role modeling, mentoring, coaching, and direct care activities. The clinical nurse specialist promotes a sense of clinical inquiry and critical thinking through research use and evidence-based practice. (LaSala et al.).
The presence of clinical nurse specialists is one of the forces that preserve stability in the often chaotic environment of the modern American hospital. The statistics show that patients are now sicker and move through the health care system more quickly, does not adequately describe the actual experience of the patient, family, and clinical staff in this setting. (LaSala et al.). Patients and families come as strangers to the clinical unit, often after spending hours in the emergency department or the recovery room after surgery. They are frightened, tired, in pain, and, if they have been delayed for a long time they are frustrated and angry. The nurse is the first member of the healthcare team to greet the patient when he or she arrives on the unit. In the brief period of time after the patient arrives, the nurse needs to assess the patient and get to know him or her well enough to monitor stability and be cautious for potential unwanted changes. In this first encounter, the nurse forms the foundation of a connection that establishes a safe and healing place for the patient and his or her family. It is the environment of the clinical unit and the clinical comfort that allows this connection to occur. (LaSala et al.). There are many areas in healthcare that will have increasing needs for the expertise of the Clinical Nurse Specialist to be as close as possible to direct patient care.
Especially with all the advances in technology that require skilled understanding of the latest developments with equipment, patient care, and advanced assessment. (Henderson, 2004). As the patient population changes there will be a much greater need for quality initiatives and the adoption of more evidence-based practice initiatives. An example of this is the ever increasing percentage of the elderly that will need the development of innovative approaches in geriatric care. Other areas of concern include disease prevention and the close monitoring of patients with chronic diseases and the nursing care of the poor and uninsured. The Clinical Nurse Specialist, trained as the expert practitioner will play an important role in preparing healthcare systems for the future. (Henderson, 2004)
The expanding body of research on Clinical Nurse Specialist outcomes show a strong connation between interventions and safe, cost effective patient care. The Clinical Nurse Specialist practices have been directly linked to reducing hospital costs, reducing length of hospital stay, improved pain management, increased patient satisfaction, and decreased visits to the emergency room and less complications to admitted patients. Because of this strong connection to patient safety, the AACN urges hospitals to utilize the use of the Clinical Nurse Specialist. (Henderson, 2004) A clinical nursing unit is a community. The existence of a strong leadership team between the nurse director and the clinical nurse specialist will define the nature of the community. Support is provided in difficult situations, clinical knowledge is shared, expectations of those caring for patients are clearly defined, and staff behaviors that leave less than to be desired is addressed and monitored. The Clinical Nurse Specialist is available to identify and support the learning needs of the nursing staff, assess the care of patients, monitor quality control and develop innovative approaches to care for the patients on the nursing units. The health of our nation relies on having an adequate supply of highly qualified nurses available to provide care in many different capacities. Nurses are needed both at the point of care and in advanced practice roles to deliver care that is growing ever more complicated. It is essential that the nursing staff be mixed with Clinical Nurse Specialists whose roles help provide quality, safe and cost-effective specialty care across the board.
References
Elsom, S., Happell, B., Manias, E. (2006). The clinical nurse specialist and nurse practitioner
Roles: Room for both or take your pick? Australian Journal of Advanced Nursing, Pages
56-59.
Gardner, G., Carryer, J., Dunn, S., & Gardner, A. (2004). Report to Australian Nursing and
Midwifery Council: Nurse Practitioner standards project. Dickson, Australian
Nursing and Midwifery Council.
Hamric, A., Spross, J., & Manis, C. (2005) Advanced Practice nursing: An integrative approach
(3rd ed.). St.Louis, MD: Elsevier Saunders.
Henderson, Sharon (2004). The Role of the Clinical Nurse Specialist in Medical-Surgical
Nursing. Medsurg Nursing, Pages 38-41.
International Council of Nurses. (2005). Regulation terminology. Geneva: Author. Retrieved
from http://www.icn.ch/Regulation-Terminology.pdf
LaSala, C., Connors, P., Pedro, J., & Phipps, M., (2007). The Role of the Clinical Nurse Specialist in Promoting Evidence-Based Practice and Effecting Positive Patient Outcomes. The Journal of Continuing Education in Nursing, Pages 262-270.
Roberts, J., Floyd, S., & Thompson, S. (2011). The Clinical Nurse Specialist: How is the Role Defined? Nursing Praxis in New Zealand. Pages 24-34.
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