Jan Foster, PhD, APRN, CNS
Sonya Flanders, MSN, RN, ACNS-BC, CCRN
Clinical nurse specialists (CNSs) are well-positioned to participate in the transformation of healthcare as outlined by the Institute of Medicine and called upon by the Patient Protection and Affordable Care Act of 2010. CNSs exercise their expertise through population-based care across three spheres of influence (patient/family, nurses/other professionals, systems). However, challenges during the educational process as well as implementation in practice can be barriers to optimization of the role, denying the public full benefit from the potential of CNSs. This article highlights some of the issues and provides solutions for mitigating these difficulties.
Citation: Foster, J., Flanders, S., (May 31, 2014) "Challenges in CNS Practice and Education" OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 2, Manuscript 1.
Key words: clinical nurse specialists, clinical nurse specialist practice, clinical nurse specialist education, clinical nurse specialist challenges, clinical nurse specialists in healthcare
CNSs employ seven core competencies in their practice: direct care, consultation, systems leadership, collaboration, coaching, research, and ethical decision-making. Clinical nurse specialists (CNSs) are advanced practice nurses that bring specialized knowledge to the practice setting. As they work across three spheres of influence, CNSs facilitate quality outcomes for individual patients and patient populations, support and mentor nurses, and spearhead innovative changes that advance the healthcare system in meeting the needs of patients, families, populations, and communities. CNSs employ seven core competencies in their practice: direct care, consultation, systems leadership, collaboration, coaching, research, and ethical decision-making (NACNS, 2010). The complexity of the role itself creates challenges in the educational preparation of CNSs. Finding room in the curriculum to address all seven competencies, application to the three spheres of influence, and addressing complex diseases and other health issues can be problematic. Furthermore, lack of standardization in educational preparation, regulation, and even advanced practice recognition across states has challenged CNS educators and development and sustainability of CNS education programs. Additional concerns include adequacy of faculty, clinical preceptors, clinical practicum settings, physical resources, and funding sources for students. A number of recent initiatives lend potential for solutions to some of these issues; however, they may also create a new set of problems. This article will address the Consensus Model for APRN Regulation, IOM Report, and Guidelines for CNS Education.
Consensus Model for APRN Regulation
The LACE Model defines advanced practice nursing(APRN) and delineates four roles: clinical nurse specialist (CNS), certified nurse practitioner (CNP), certified registered nurse anesthetist (CRNA), and certified nurse midwife (CNM). The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (LACE Model), is a product of the APRN Consensus Work Group and the National Council of State Boards of Nursing (2008), and was finalized and released in 2008, with a goal of full implementation by 2015. The LACE Model defines advanced practice nursing (APRN) and delineates four roles: clinical nurse specialist (CNS), certified nurse practitioner (CNP), certified registered nurse anesthetist (CRNA), and certified nurse midwife (CNM). Each of the roles is educated in at least one patient population focus: family/individual across lifespan, adult-gerontology, neonatal, pediatrics, women’s health/gender-related, and psychiatric-mental health across the lifespan (APRN Consensus Work Group/National Council of State Boards of Nursing APRN Advisory Committee, 2008).
Advanced education builds on the pre-licensure preparation for RNs and occurs at the role and population level, which then prepares the individual for initial certification. The LACE Model specifies educational program requirements and the program is accredited accordingly. APRNs may achieve specialization; however, licensure cannot be exclusively within a specialty focus. The CNS is educated and certified to practice across the range of wellness to acute care. Specialty education, recognition, and regulation will be the responsibility of the professional specialty organizations (APRN Consensus Work Group/National Council of State Boards of Nursing APRN Advisory Committee, 2008).
Another tenet of the LACE Model is the population designated as adult-gerontology. This includes the young adult to the older adult, as well as the frail elderly. These three changes (population focus, specialty focus post-certification, wellness-acute care scope) are most dramatic for CNSs, who, obviously by the title, have always practiced with a specialty focus sometimes defined as what is now a population. For example, a critical care CNS for adults would include little practice in “wellness,” and may not have preparation in elderly care. Both CNS education programs and certification exams have had to undergo profound revision as a result in order to add gerontology content and disband specialty content. The American Association of Critical Care Nurses, for example, has changed the name of the adult CCNS exam to ACCNS-AG and added items that cover wellness to acute care and items that address care of the elderly (American Association of Critical Care Nurses, 2013). For institutions that have offered only specialized CNS programs such as palliative care or gerontology, these changes can go so far as to terminate the program.
Despite the difficulties the LACE Model may generate, one of the primary benefits is that it provides for standardization in educational and certification requirements with APRN recognition in all states. Of all the APRN roles, this is especially valuable to CNSs because in many states, graduate education is not a requirement and CNSs do not enjoy advanced practice recognition. The LACE Model will help move along process changes in these states, which will be good for CNS education and practice.
The IOM Report
...CNSs can “seamlessly” move from a master’s level of preparation into a DNP program, as sanctioned by the IOM report. Another influential document is “The IOM Report”. The Institute of Medicine in partnership with the Robert Wood Johnson Foundation first released a report brief in 2010 entitled The Future of Nursing: Leading Change, Advancing Health, followed by a full publication in 2011 describing the barriers to nursing practice that impede the ability to fulfill the objectives of the 2010 Patient Protection and Affordable Care Act and the changes within nursing that must happen to meet the nation’s health care needs (IOM, 2011). Four key messages surfaced with eight corresponding recommendations. One of the messages relevant to CNS education was nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression (IOM, 2011). This goes hand in hand with the standardization of educational programs as set forth by the APRN Consensus Model, which at this time requires a minimum of a master’s degree. However, the American Association of Colleges of Nursing (AACN) released a document in 2004, proposing the doctorate of nursing practice (DNP) as entry level preparation for CNSs and other APRNs, effective 2015 (AACN, 2004). Because the Consensus Model for APRN curricula requires a course in advanced pathophysiology, advanced physical assessment, and advanced pharmacotherapeutics (“the Three Ps”) and the majority of DNP programs thus far are post-master’s, CNSs can “seamlessly” move from a master’s level of preparation into a DNP program, as sanctioned by the IOM report.
For nurses to achieve higher levels of education, be it master’s or DNP, more nursing faculty is required. With a looming faculty shortage likely to worsen as seasoned faculty retire, having adequate numbers of faculty is a problem for all of nursing education, not just CNS programs. In 2012, the AACN reported results of a Special Survey on Vacant Faculty Positions; of the 662 nursing schools responding (78.9%), there were 1,181 vacancies, most of which required or preferred a doctorate degree (7.6% vacancy rate). The top two reasons identified were 1) limited pool of doctoral prepared nurses (32.9% of respondents) and 2) poorly competitive salaries (27.6%) (AACN, 2012). Recommendation 5 of the IOM Report advocates for doubling the number of nurses with doctorate degrees by 2020 (IOM, 2011, p. 281). The report goes on to say that private funding agencies and federal monies should be used to expand programs and offer accelerated curricula to reach this goal. Because salaries in the service sector (hospitals) are typically higher than those paid in academia, offering competitive benefit packages to recruit and retain faculty will help to build a cadre of qualified faculty. This allows for educating nurses to become CNSs as well as attracting CNSs into faculty positions.
An example of an APRN fellowship is NET SMART, the Neurovascular Education and Training in Stroke Management and Acute Reperfusion Therapy program... Recommendation 3 of the IOM Report promotes nurse residency programs for nurses after completing prelicensure and advanced degree programs when transitioning into a new clinical practice area (IOM, 2011, p 280). Some take issue with the term residency for preparing advanced practice RNs, believing the term fellowship is more appropriate, which somewhat parallels the medical education process: completion of medical school (nursing school) – residency (graduate school with at least 500 post-baccalaureate clinical hours) – fellowship. Putting semantics aside, academic programs are designed to prepare CNSs to perform at a novice advanced practice level; an opportunity to proceed through a residency/fellowship program for development as an expert clinician meets with one of the fundamental competencies of CNS practice which is Direct Care (National CNS Competency Task Force, 2010). The major intent of the IOM for this recommendation is to improve nurse retention rates and improve patient outcomes; retention rates is relative to baccalaureate prepared/newly licensed nurses, however, improving patient outcomes under CNS leadership is consistent with fundamental CNS practice. An example of an APRN fellowship is NET SMART, the Neurovascular Education and Training in Stroke Management and Acute Reperfusion Therapy program, which is a post-graduate APRN fellowship designed to teach recognition and management of acute stroke (Alexandrov, et al., 2009). The program is comprehensive, consisting of 14 modules using an on-line platform with 24/7 availability covering epidemiology, pathophysiology, neuro-imaging, management including reperfusion and concomitant therapy, complications, and emergency systems, stroke centers and stroke units. In addition to didatic content, fellows are required to contract with a local physician, preferably a neurologist for clinical training and education. Competency validation occurs at the conclusion of each module before advancing to the next; following completion of the 14 modules, fellows fulfill 80 hours of on-site supervised clinical time with the program faculty and stroke team (Alexandrov, et al., 2009). Besides complying with the IOM recommendations, this program satisfies the APRN Consensus Model by providing post-graduate specialty education. In addition to increased knowledge of stroke gained by participants, early patient related outcomes of the NET SMART program included a 7% increase in thrombolytic administration and stroke unit certification (Alexandrov, et al., 2009), fulfilling a key principle of IOM recommendation 3, creating opportunities for improving patient outcomes.
Another recommendation of the IOM report is to “expand opportunities for nurses to lead and diffuse collaborative improvement efforts” (IOM, 2011, p 279). Systems Leadership is a core competency for CNSs and as such is integral to CNS education. Thompson and Nelson-Martin (2011) describe a process for teaching leadership in a CNS program at the University of Colorado through development and implementation of a change project that incorporates another core competency, (using) research. Over a series of three courses, students identify a problem/issue, search and appraise the literature, and using a theoretical approach, design educational materials, measurement instruments, screening tools, and the like. At the conclusion of the CNS program, students deliver a poster presentation highlighting results achieved under their leadership of the project (Thompson & Nelson-Martin 2011). Not all CNS programs entail implementation of a project, however; the degree requirement may be merely to propose an idea. Merely proposing a project can be a disservice to the CNS student following graduation because during their clinical preceptorship, students may spend more time “following” than “leading.” Bringing a project full circle, on the other hand, provides opportunities for CNS students to see the impact of their projects while preparing them to be competent in systems leadership.
Guidelines for Clinical Nurse Specialist Education
With the growth of online master’s programs, attaining preceptors for CNS students can become very competitive as “local” and “distant” students seek out a limited number of individuals. In 2004, Guidelines for Clinical Nurse Specialist Education was released (NACNS, 2004a). Recommendations pertinent to the organization/administration, curriculum, clinical resources, and program evaluation were included in the publication. Seven items compose the organization/administration portion of the document addressing accreditation, program definition, and faculty qualifications. The curriculum requirements put forth in the guidelines are the most prescriptive, mandating inclusion of CNS-specific didactic content and a minimum of 500 clinical hours. The guidelines advise that clinical resources for CNS education include 1:6 or 8 faculty: student ratio and 1:1 or 2 preceptor: student ratio, preceptor qualifications, and clinical experiences that ensure students achieve the competencies as outlined in the NACNS Statement on Practice and Education (NACNS, 2004b). This aspect of the guidelines can carry the greatest challenge. Few practicing CNSs may be available to students and/or may practice in institutions that are limited in clinical services, with little opportunity for CNS students to encounter a multiplicity in specialty services or even challenging patients. Due to variety in understanding and utilization of the role across practice settings, CNSs who are available may function as hospital educators vs. systems leaders applying solid clinical expertise and improving outcomes with application of research findings. This role confusion is further exacerbated by the ...assets that strengthen CNS education and development of core competencies include simulation classrooms, information technology support, and library resources... proliferation of nurse practitioners whose role too may be poorly understood and hospital administrators require them to do “CNS work”. With the growth of online master’s programs, attaining preceptors for CNS students can become very competitive as “local” and “distant” students seek out a limited number of individuals.
Other assets that strengthen CNS education and development of core competencies include simulation classrooms, information technology support, and library resources, to name a few. Variability among universities in these resources can hamper CNS students’ growth and integration of core competencies.
Preparing a solid workforce of CNSs carries many challenges. Diverse role competencies, faculty shortages, changing educational requirements, and scarce resources are some of the issues. Thoughtful solutions have been put forth to meet some of these challenges; continued work by CNS educators, policy makers, legislators, and regulators will be necessary to provide for preparation of CNSs in order to meet the growing healthcare needs of Americans.
Challenges in Clinical Nurse Specialist Practice
CNSs working in clinical practice settings have opportunities to influence quality patient care using both direct and indirect tactics... CNSs working in clinical practice settings have opportunities to influence quality patient care using both direct and indirect tactics: providing direct care, acting as mentors for frontline nurses and other healthcare professionals, during CNS leadership activities, and in many other ways. The variety in services CNSs can provide, however, may be the very reason challenges in practice arise. While different healthcare settings likely present unique problems for CNSs, shared problems include CNS role-definition, moving evidence into practice, effective change management, prioritization and time management, and demonstrating benefits to the organization. A review of these challenges along with suggestions for mitigating each is discussed.
One challenge CNSs may face is lack of clear-cut role definition. Within and outside the healthcare arena, some people are unfamiliar with the title clinical nurse specialist. If one were to ask a layperson, physician, or even a registered nurse (RN) what a nurse practitioner, certified nurse midwife, or certified registered nurse anesthetist is, a fairly accurate response is likely. Of the four types of APRNs, the CNS seems to be the least familiar to others, despite having over 75,000 CNSs in the United States with the education and credentials to practice as such (National Association of Clinical Nurse Specialists, n.d.). How is it that such a large group has such an identity problem?
CNSs have an array of skills and knowledge and are able to adapt to a variety of professional roles... One possibility is role diffusion stemming from the chameleon-like abilities of CNSs. CNSs have an array of skills and knowledge and are able to adapt to a variety of professional roles including direct patient care providers, educators, case managers, researchers, clinical improvement project leaders, and more. This flexibility can lead to blurred lines rather than clear role parameters and cause others to assume the CNS has a job title typically associated with these types of activities. For instance, a CNS who spends a great deal of time providing direct patient care in a chronic disease clinic may be mistakenly referred to as a nurse practitioner, while another who focuses on nursing education may be labeled an educator.
Role challenges can be frustrating to CNSs in clinical practice because others’ perceptions may lead to limitations in job responsibilities and underutilization of the advanced knowledge and skills CNSs possess. For example, a CNS may face barriers to the credentialing and privileging process necessary for providing medical care to patients and billing for services, even when the CNS has met all appropriate requirements and such practice is permitted by the respective state board of nursing. Other frustrations may be a perceived lack of respect for the CNS’s breadth and depth of knowledge, salaries not commensurate with other categories of APRNs, or a diminished sense of leadership responsibilities.
CNSs in clinical practice need to be able to articulate their roles in clear, concise, and meaningful ways. CNSs in clinical practice need to be able to articulate their roles in clear, concise, and meaningful ways. One way to do so is to prepare a brief verbal statement that can be delivered in 30 seconds or less when describing one’s own CNS role to others. This is informally referred to as an ‘elevator speech.’ When developing this description, a CNS might reflect upon the primary role(s) in which he or she functions, then state associated activities and outcomes in concrete terms. The National CNS Competency Taskforce (2010) published CNS Core Competencies, which includes behavioral statements and could be used to generate ideas for developing this description (National CNS Competency Taskforce, 2010). Additionally, the NACNS website has a frequently asked question (FAQ) page on which the CNS role is explained (NACNS, 2013). This explanation offers a starting point for the CNS looking to develop a personalized role description in terms of specialty, population served, and outcomes achieved. An example of an elevator speech is shown in Box A.
Box A: Sample “Elevator Speech” to Describe CNS Role
“I have a master’s degree as a clinical nurse specialist and am certified in Adult Health. I use advanced nursing knowledge and skills to make changes in clinical practice and improve patient outcomes in the critical care unit at County Hospital. Some of the things I’ve done have helped eliminate healthcare acquired infections in our unit and decreased the amount of time patients spend on ventilators. I work directly with patients, families, nurses, physicians, and other healthcare team members to make sure our practice is based on the best available evidence.”
In addition to verbal communication, CNSs can develop handouts, brochures or business cards listing key role features to share with colleagues or patients. For organizations with intranets, CNSs can request a webpage to house information about APRNs, including photographs, role descriptions and contact information.
Other ways CNSs can explain their roles is to write or revise CNS job descriptions that accurately reflect the role, and to create performance goals based on CNS functions and desired outcomes. A well-written CNS job description can clarify and legitimize the role of the CNS within a particular organization. This set of expectations can be taken a step further by integrating role and competency related questions into the CNS interview process. CNSs in one organization developed a structured behavioral peer interview process centered on the CNS competencies (Lampe, Geddie, Aguirre, & Sole, 2013). Such an interview process is an excellent opportunity for CNSs to refine role definition within a particular organization so expectations can be clear to all involved. CNSs seeking employment might consider using a similar approach to pose questions to the interviewers about how the CNS role is viewed and operationalized. This could aid in identifying whether or not an employer is a good fit for the job-seeking CNS. Table 1 lists several tools CNSs can use as vehicles to communicate the role to others.
Table 1: Tools to Communicate CNS Roles
- Short, prepared verbal description (Elevator speech)
- Business card
- Single page handout
- Webpage on organization’s intranet
- Job descriptions
- Structured interview questions
The CNS and Evidence-Based Practice (EBP)
A key activity of CNSs in clinical settings is to drive changes in practice based upon best available evidence; however, various barriers to adoption and implementation of EBP exist. Impediments to change come from different angles including bedside nurses or nurse leaders and other healthcare professionals reluctant to change, workflow processes, financial constraints, and a host of other factors.
A recent study by Campbell and Profetto-McGrath (2013) examined factors around CNS promotion of EBP. The top five challenges to implementing EBP identified by CNSs in this study were multiple CNS roles, heavy workload, time constraints for bedside clinical nurses, time constraints for CNSs, and lack of resources. All respondents in the study indicated dedicated time, and almost 96% believed assistance/support from others, influenced their abilities to disseminate evidence. The authors concluded CNSs needed individual and organizational support to facilitate EBP (Campbell, & Profetto-McGrath, 2013). Similarly, an integrative review of the literature examining barriers and facilitators to EBP reported that organizational barriers included time, higher prioritized goals for leaders, lack of resources and heavy workloads (Solomons & Spross, 2011). Cultural barriers to EBP were resistance to change, lack of interest, recognition for EBP, and lack of authority to create change.
Individual CNSs’ lack of knowledge and comfort in accessing and evaluating evidence can be barriers to EBP (Solomons & Spross, 2011). Concerns can range from how to search for evidence to how to evaluate statistical analyses and conclusions of a research study. Although CNSs are prepared through education and experience to do these things, not everyone has the same comfort level while engaging in these activities.
Facilitators to EBP within organizations have also been identified. These include linking EBP to job descriptions and promotions, having nurse representation on organizational committees, discussing EBP in orientation, and giving nurses dedicated time for literature review and participation in practice changes (Solomons & Spross, 2011). Some hospitals have EBP committees and/or journal clubs, which allow nurses to develop their own skills, then pass this on to others through mentoring and guidance (Solomons & Spross, 2011). Another approach is using existing groups as opportunities to facilitate EBP activities, such as requesting time on the agenda at staff meetings or other council meeting for dialogue about the importance of EBP (Dogherty, Harrison, & Graham, 2010).
Outside of formal committee structures, CNSs can shift culture by embracing informal opportunities to teach EBP and the benefits to patients, nurses and the organization. CNSs can teach data-base searching skills and critical appraisal methods. The CNS can connect the medical librarian with the staff and introduce internet-based resources such as PubMed, Google Scholar, or websites of professional nursing organizations with access to evidence-based resources. Fostering a personal connection helps in translating research into practice. Patient-focused case examples illustrating negative outcomes of eluding EBP and positive outcomes from using EBP can be an effective strategy used to aid in adoption of EBP. Sustaining a culture of EBP requires mentoring and supporting staff champions, translating research into user-friendly language, and providing frequent feedback on project progress and outcomes.
CNS as Change Agent
With growing disparity in the US population, sicker patients, increasing regulatory requirements, and shrinking reimbursement, balancing the demands to survive requires organizations to respond quickly, with never-ending change a consequence. While clinical practice reforms have always been a cornerstone of CNS practice, CNSs may be called upon to lead transformation beyond the bedside to address these challenges. Acquiring new products or capital equipment, remodeling a nursing unit, developing a model for APRN practice, or working on a team to map workflow and design in an electronic health record are some examples where CNSs may assume a leadership role.
No matter what the change, hurdles are likely. Erwin (2009) identified three main challenges to success when studying change in hospitals. The first challenge focused on a cluster of gaps in the skills of people within the organization to plan and implement change. The second involved beliefs about financial performance in conflict with quality patient care. The third was a gap in maintenance of energy, commitment and patience to sustain performance. Recommendations were to provide leadership development, to make thinking about financial measures part of the organizational culture and a value for all members, and to recognize the need to invest time coupled with patience and courage to accept change (Erwin, 2009). Related considerations for the CNS are to continuously improve as a change manager by learning to apply different approaches, demonstrate the financial impact of change alongside quality outcomes, and to persist in worthwhile change projects, even when they move slowly or setbacks are encountered.
CNSs will need to employ collaboration competencies to facilitate change because just as healthcare delivery requires a multidisciplinary team, change is a team activity. CNSs can contribute to change management by participating on, facilitating, or leading improvement teams, and involving staff nurses and other stakeholders in implementing change. Leaders in an organization’s quality department can be good resources for CNSs seeking information about preferred organizational approaches for process improvements and change management.
CNSs must become experts in time management and priority setting... Insufficient time for self- or organization-defined accomplishments and responsibilities has been identified as a barrier for CNSs’ effectiveness (Campbell, & Profetto-McGrath, 2013; Dogherty, Harrison, Graham, 2010). Given the reality of much work to be done and a finite amount of time, CNSs must become experts in time management and priority setting to maximize desired results and decrease feelings of being chronically overworked.
Ellis and Abbott (2011) provide several suggestions for time management aimed at nurse managers, but equally pertinent to CNSs. One is to maintain focus, have a vision, and leverage a team to achieve that vision. CNSs can apply these principles by working with teams of other CNSs, nurses, managers, educators, and/or other stakeholders to maximize efforts of all toward achieving desired outcomes. CNSs need to prioritize work and focus on what is determined to be most important: activities that bring value to the organization, to the patient population, to the nursing staff, or sometimes to the CNS. Creating a list then evaluating each item in terms of time-sensitivity and value can help clarify which activities take priority. In the face of competing agenda items with no clear top priority, the CNS may want to seek input from administrative leaders to ensure focus on priorities for the organization.
Other time management tactics described by Ellis and Abbott (2011) are setting aside time each day to work on key initiatives, saying no to non-productive activities, prioritizing meetings and/or sending a designee, and setting daily goals. Using technology such as sharing web-based work sites can decrease the number of meetings and make better use of time. CNSs should remember to include at least some activities that offer professional gratification each week in order to maintain a sense of purpose and self-care.
Value to the Organization
Another reality in the healthcare arena is the need to demonstrate the value CNSs bring to an organization. Another reality in the healthcare arena is the need to demonstrate the value CNSs bring to an organization. Terms such as “indirect caregivers” and “non-productive time” are used in budgets, and, to the less informed, can suggest employees in such roles are wasteful overhead. CNS positions may fall into these categories because they are not typically included in direct patient care staffing. CNS positions may be at risk when budgets are tight and cutbacks are necessary. CNSs need to be clear about how they contribute to the organization in concrete ways nurse and non-nurse leaders can appreciate.
Ideally the value a CNS brings can be quantified financially. An EBP project to reduce catheter-associated urinary tract infections (CAUTI), for instance, has financial implications because of reimbursement changes from the Centers for Medicare and Medicaid Services (CMS) that took effect in 2008 (Department of Health and Human Services, Centers for Medicare and Medicaid Services, 2012). A CNS who participates in this type of work needs to work with the quality, infection control, supply management and hospital finance departments to analyze the financial benefits of EBP changes. Pre- and post-implementation data can be used to compare cost of care before and after the project to demonstrate the impact of a CNS-influenced initiative.
There are several other ways CNS activities can produce positive financial outcomes. CNSs may contribute to improvements in nurse retention by mentoring others or developing an innovative program to reduce the number of hours newly hired nurses spend in orientation. CNSs who manage a specific population of patients, such as those with heart failure, may be able to demonstrate reduced lengths of stay or recidivism rates. CNSs who bill for services can report their contribution to a facility’s reimbursement income. CNSs should look for opportunities to translate CNS activities into financial benefits. Demonstrating the value a CNS brings not only helps justify the individual CNS’s position, but raises awareness of the role’s value and contributes to the financial security of the institution.
There are various ways CNSs can demonstrate value to the organization (Table 2). One approach is developing a portfolio to showcase a variety of professional activities and associated outcomes (Shirey, 2009; Hespenheide, Cottingham, & Mueller, 2011). Another is creating a spreadsheet or dashboard listing key activities of the CNS with specific outcomes. Benefits of a dashboard include the ability to succinctly record information that can be used to monitor progress so timely adjustments can be made if needed (Harrington, et al, 2005). Another approach is to ensure annual performance goals include measurable outcomes a CNS can use as evidence of contributions to the organization. CNSs who do not already contribute to development of their own performance goals may want to consult with their superiors to discuss ways to do so. This collaborative approach can be mutually beneficial: articulating annual goals can assist the CNS in setting priorities and focus on activities most likely to achieve desired results for both the individual and the organization.
Table 2: Ways to Communicate Annual Contributions to an Organization
- Professional portfolio
- Performance goals
CNSs are well qualified to respond with expertise in advanced nursing practice, knowledge of patient and family concerns, and systems thinking. CNSs in clinical practice face various challenges. Depending on the situation, there are opportunities to use effective ways to untangle complex, organizational issues, or to experiment with novel approaches. CNSs are well qualified to respond with expertise in advanced nursing practice, knowledge of patient and family concerns, and systems thinking. Educators must consider these realities when developing didactic content, clinical practica, and other learning opportunities in order to adequately prepare CNSs for the complexities of a chaotic, ever changing healthcare system.
Jan Foster, PhD, APRN, CNS
Jan Foster is an associate professor at Texas Woman’s University. She has been a CNS since the late 1980s and has been manager of the CNS track and faculty for all CNS role course content at Texas Woman’s University. She is founder and president of Nursing Inquiry and Intervention, Inc., which provides opportunities to exercise the CNS Consultation and Research/EBP competencies by assisting hospitals with implementation of research into practice.
Sonya Flanders, MSN, RN, ACNS-BC, CCRN
Sonya Flanders is a Clinical Nurse Specialist with the Baylor Scott & White Health. She has experience as a CNS in acute clinical care and has been actively engaged in a multitude of CNS activities to implement evidence-based practice and measure associated outcomes at the unit, service line, and organizational levels.
Alexandrov, A. W. W., Brethouer, M., Cudlip, F., Swatzell, V., Biby, S., Reiner, D., …Yang, J. (2009). Postgraduate fellowship education and training for nurses: The NETSMART experience. Critical Care Nursing Clinics of North America, 21(4), 435-449.doi:10.1016/j.ccell.2009.09.001
American Association of Colleges of Nursing. (2004). AACN position statement on the practice doctorate in nursing. Retrieved from www.aacn.nche.edu/publications/position/DNPpositionstatement.pdf
American Association of Colleges of Nursing. (2012). Special survey on vacant faculty positions. Retrieved from www.aacn.nche.edu/leading-initiatives/research-data/vacancy12.pdf
American Association of Critical Care Nurses. (2013). ACCNS-AG certification for adult-gerontology clinical nurse specialists. Retrieved from www.aacn.org/wd/certifications/content/accns-ag-landing.pcms?menu=certification
APRN Consensus Work Group/National Council of State Boards of Nursing APRN Advisory Committee. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from www.aacn.nche.edu/education-resources/APRNReport.pdf
Campbell, T. D., & Profetto-McGrath, J. (2013). Skills and attributes required by clinical nurse specialists to promote evidence-based practice. Clinical Nurse Specialist, 27(5): 245-254. doi: 10.1097/NUR.0b013e3182a0ba68
Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2012, October). Hospital acquired conditions (HAC) in acute inpatient prospective payment system(IPPS) hospitals, fact sheet. Retrieved from www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/downloads/hacfactsheet.pdf
Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2013, March). Hospital value-based purchasing program. Retrieved from www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf
Dogherty, E.J., Harrison, M. B., Graham, I. D. (2010). Facilitation as a role and process in achieving evidence-based practice in nursing: A focused review of concept and meaning. Worldviews on Evidence-based Nursing. 7(2),76-89. doi 10.1111/j.1741-6787.2010.00186.x
Ellis, P., & Abbott, J. (2011). Smarter working: Strategies and tactics for renal managers. Journal of Renal Nursing, 3(6), 296–298.
Erwin, D. (2009). Changing organizational performance: Examining the change process. Hospital Topics: Research and Perspectives in Healthcare, 87(3), 28-40.
Harrington, L., Hoffman, E., Allard, P. M., Adams, B. J., Hamilton, P., Wright, K., & Cargo, V. (2005). Nursing research dashboard: A tool for managing your nursing research program. Nurse Leader, 4(5), 54-57. doi:10.1016/j.mnl.2006.06.002
Hespenheide, M., Cottngham, T., & Mueller, G. (2011). Portfolio use as a tool to demonstrate professional development in advanced nursing practice. Clinical Nurse Specialist, 25(6), 312-320. doi: 10.1097/NUR.0b013e318233ea90 10.1097/NUR.0b013e318233ea90
Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. Retrieved from http://books.nap.edu/openbook.php?record_id=12956&page=R3.
Lampe, J. S., Geddie, P. I., Aguirre, L., & Sole, M. L. (2013). Finding the right fit: Implementation of a structured interviewing process for clinical nurse specialists. AACN Advanced Critical Care, 24(2),194-202. doi: 10.1097/NCI.0b013e31828a0b1f
National Association of Clinical Nurse Specialists National CNS Competency Task Force. (2010). Clinical nurse specialist core competencies. www.nacns.org/docs/CNSCoreCompetenciesBroch.pdf
National Association of Clinical Nurse Specialists (n.d.). Advanced practice registered nurses: the clinical nurse specialist. Retrieved from www.nacns.org/docs/APRN-Factsheet.pdf
National Association of Clinical Nurse Specialists (2004a). Guidelines for clinical nurse specialist education. Clinical Nurse Specialist, 18(6),285-287.
National Association of Clinical Nurse Specialists (2004b). Statement on clinical nurse specialist practice and education 2nd ed. Harrisburg, PA.
National Association of Clinical Nurse Specialists, (2013). CNS FAQs. Retrieved from www.nacns.org/html/cns-faqs.php
Shirey, M. (2009). The nursing professional portfolio: Leveraging your talents. Clinical Nurse Specialist, 23(5), 241-244. doi: 10.1097/NUR.0b013e3181b207af
Solomons, N. M., & Spross, J. A. (2011). Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: An integrative review. Journal of Nursing Management, 19(1), 109-120. doi: 10.1111/j.1365-2834.2010.01144.x
Thompson, C., & Nelson-Martin, P. (2011). Clinical nurse specialist education actualizing the systems leadership competency. Clinical Nurse Specialist, 25(3), 133-139. doi:10.1097/NUR.)b)13e318217b5c5
© 2014 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2014
- Full Practice Authority for Advanced Practice Registered Nurses is a Gender Issue
Nancy Rudner Lugo, DrPH, APRN (May 4, 2016)
- Barriers to NP Practice that Impact Healthcare Redesign
Debra Hain, PhD, ARNP, ANP-BC, GNP-BC; Laureen M. Fleck, PhD, FNP-BC, CDE, FAANP (May 31, 2014)
- Addressing Issues Impacting Advanced Nursing Practice Worldwide
Ruth Kleinpell; Andrew Scanlon; Denise Hibbert; Freda DeKeyser Ganz; Linda East; Debbie Fraser; Frances Kam Yuet Wong; Michelle Beauchesne (May 31, 2014)
- Midwifery Practice and Education: Current Challenges and Opportunities
Deborah Walker, DNSc, CNM, FACNM, FAAN; Barbara Lannen, MSN, CNM; Debra Rossie, MS, CNM (May 31, 2014)
- Education and Practice Barriers for Certified Registered Nurse Anesthetists
Debra P. Malina, CRNA, DNSc, MBA, ARNP; Janice J. Izlar, CRNA, DNAP (May 31, 2014)