Bridging the Research-to-Practice Gap: The Role of the Nurse Scientist

The role of healthcare leaders in implementing equitable clinical academic pathways for nurses: An integrative review

AIM

To identify and synthesize empirical evidence on the role of healthcare leaders in the development of equitable clinical academic pathways for nurses.

DESIGN

Integrative literature review.

DATA SOURCES

Literature was searched using CINAHL, PubMed, ProQuest and Google Scholar databases.

REVIEW METHODS

A total of 114 eligible articles published between 2010 and2022 were screened, 16 papers were selected.

RESULTS

Results highlighted the need for consistent national, regional, and organizational policy approaches to developing clinical academic careers for nurses. Government health departments and National Health boards must focus on increasing engagement in research and evidence-based nursing practice for high-quality patient care. Discriminatory practices and attitudes were identified as barriers. Discrimination due to gender was evident, while the impact of race, ethnicity, and other social categories of identity are under-researched. Educational leaders must unravel misconceptions about research, highlighting its relevance to patient care and bedside nurses' work. Academic leaders together with executive nurses, research funders and professional nursing bodies must create appropriately remunerated career structures. Transformative approaches are required to develop the clinical academic nurse role and understand its value in clinical practice.

CONCLUSION

Multiple elements exist within complex systems that healthcare leaders can navigate collaboratively to develop and implement clinical nurse academic roles. This requires vision, acknowledgement of the value of nursing research and the importance of evidence-based research infrastructures.

IMPACT

Findings highlight the collaborative role of healthcare leaders as critical to the success of critical academic careers for nurses. This review can inform those still to formalize this innovative role for nurses.

REPORTING METHOD

The review complies with the PRISMA guidelines for reporting systematic reviews. This paper contributes evidence about the healthcare leader's role in developing clinical academic pathways for nurses to the wider global clinical community.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was included in this review.

Student-led Doctor of Nursing Practice projects in the clinical environment: Viewpoint from hospital-based nurse scientists and leaders

BACKGROUND

Exponential increases in Doctor of Nursing Practice (DNP) program enrollment have come with a rapid rise in the number of capstone projects conducted in clinical environments. However, misaligned priorities between students, faculty, and clinician leaders have created significant challenges.

PURPOSE

Identify opportunities to strengthen collaboration between academic and clinical stakeholders to better support DNP projects and education.

METHODS

Experienced hospital-based nurse leaders engaged in scholarly discourse supplemented by policy and research in DNP education.

FINDINGS

Facilitating a DNP project requires significant investment of time, resources, and funds from the healthcare institution. Discord has arisen due to unclear responsibilities or decision-making ability for clinical stakeholders, ethical dilemmas for students who are also employees of the clinical site, and mismatched priorities between clinical need and student/academic project desires. Clinical leaders have raised significant concerns about DNP project proposals that are research-focused, diverge from healthcare institution goals, and lack a sustainability plan.

DISCUSSION

Fortification of academic-practice partnerships and clarification of roles in the DNP student project are necessary to ensure that the project is of educational value to the student, a demonstration of learning for faculty, and of sustained clinical value to the healthcare system.

Exploring the Roles, Functions, and Work Experiences of Nurse Scientists in the Veterans Health Administration

OBJECTIVE

The aim of this project was to describe nurse scientists' roles, functions, and work experiences in the Veterans Health Administration (VHA).

BACKGROUND

Nurse scientists play a critical role in shaping the culture of clinical inquiry and closing the gap between knowledge and practice.

METHODS

A cross-sectional survey was used to collect information on sociodemographics, workload, research, clinical practice, education, and time/effort. Data were examined using descriptive statistics and χ2 analyses.

RESULTS

One hundred forty-four nurse scientists completed the survey. These nurse scientists serve dynamic and critical roles in conducting research, implementing evidence-based practice, and reforming policy. Research effort was limited due to workload and infrastructure constraints. Better research infrastructure was associated with higher research productivity and funding.

CONCLUSIONS

This survey highlights the needs and challenges nurse scientists experience in conducting research and advancing VHA's mission. Given the national shortage of PhD-prepared nurses, long-term strategies are needed to attract, hire, and retain nurse scientists in healthcare systems.

Characteristics and duties of clinical research nurses: a scoping review

Introduction

The characteristics and duties of clinical research nurses (CRNs) are constantly developing and changing with the progress of medical technology and increasing needs in patient care. With the continuous deepening and standardization of clinical trials, the importance and status of CRNs during the whole process of clinical trials are also increasingly valued.

Methods

A scoping review of studies related to the characteristics and duties of CRNs was conducted to clarify relevant roles and concepts. An electronic search was conducted on three English databases (PubMed, Web of Science, Embase) and two Chinese databases (CNKI and Wanfang database) in December 2023. Two authors independently screened the literature, extracted information from the included literature, and summarized and reported the findings.

Results

A total of 26 articles published between 1991 and 2023 were analyzed, and four characteristics of CRNs were identified as participants and managers of clinical trials, caregivers and protectors of subjects, coordinators of research teams, and educators. Basic knowledge, skills and literacy, communication and coordination ability, and advanced research ability are the competencies required for CRNs.

Conclusion

Further studies should focus on the importance of various characteristics of CRNs, so as to improve the quality of clinical trials and promote clinical evidence-based practice.

Maximizing Nurse Scientist Role Potential in Health Care Organizations

Before Magnet designation, nurse scientists functioned primarily in academia. The Magnet model's emphasis on new knowledge required that health care organizations demonstrate knowledge generation to achieve and sustain designation. The nurse scientist role definition and function within health care organizations continues to evolve, which contributes to a lack of clarity about who and how nurses generate new knowledge. The purpose of this scoping review was to (1) identify nurse scientist role components in the context of 2 theoretical models (Thompson's Knowledge Brokering Model and Edward's Research Appreciation, Accessibility, and Application Model), (2) explore the strengths and barriers associated with existing nurse scientist practice models in US health care organizations, and (3) describe a unique, expanded practice model applied within Stanford Health Care's Office of Research and its implications for building new knowledge and innovation capacity with recommendations for ongoing role development.

Nurses' preparedness to respond to COVID-19 and associated factors after the outbreak in China

AIM

Nurses are key staff in the response to the COVID-19 epidemic. The aim of present study was to assess Chinese clinical nurses' preparedness levels for COVID-19 after the outbreak, as well as the associated demographic factors.

DESIGN

The design was a cross-sectional survey.

METHODS

We distributed an online questionnaire to nurses from five eastern coastal area hospitals. The questionnaire collected demographic information, and included the nurses' preparedness to respond to COVID-19 questionnaire (NPR COVID-19).

RESULTS

The total mean NPR COVID-19 score was 200.99 (standard deviation = 33.60), and the psychological approaches subscale had the lowest mean score. Education and training were positively associated with the NPR COVID-19 score. Nurses' characteristics, such as seniority, job category and educational level, were entered into the NPR COVID-19 regression model, and seniority (≤5 years) showed the strongest negative association with NPR COVID-19 scores (standard coefficient = -0.20).

CONCLUSIONS

Chinese nurse's preparedness to respond to COVID-19 was adequate. Nurses with less than 5 years of work experience, nursing researchers and diploma-educated nurses reported feeling a low preparedness to respond to COVID-19. These nurses should receive specific training.

A scoping review on the nurse scientist role within healthcare systems

BACKGROUND

The role of the nurse scientist in the clinical setting is not well defined, which contributes to variability in role implementation, scope, administration, funding, and affiliation across healthcare sites.

AIMS

The aim of this scoping review was to identify attributes of the clinical nurse scientist role and its operationalization in the clinical setting through available evidence.

METHODS

A comprehensive, computerized search of the literature in PubMed, Medline, and CINAHL was conducted in early May 2020 by a medical research librarian and repeated in July 2021 and April 2022. The 5-step framework described by Arskey and O'Malley guided the review methodology. Two reviewers conducted an independent screen of all articles, followed by a full-text review of eligible articles by two independent reviewers each using a standardized data extraction template. Themes were then organized and synthesized using descriptive content analysis from the included articles.

RESULTS

A final sample of 55 full-text articles were included in the review. Overall, the findings suggest that the nurse scientist role in a clinical setting can be challenging to implement in complex healthcare environments. Successful models include the nurse scientist in a leadership role, alignment of research with institutional priorities, and strong support from senior leadership.

LINKING EVIDENCE TO ACTION

Findings suggest that standardized guidelines are lacking to govern the implementation of the nurse scientist role in the clinical setting. To succeed, the nurse scientist role must be valued and supported by organizational leaders. Further, access to resources to build infrastructure must be provided. The magnitude and scope of individual organizational support can be tailored based on the resources of the institution; however, the foundation of having institutional leadership support is critical to role success of the clinical nurse researcher.

Nurses and the doctorate: A mixed study in French health care organizations

AIM

This research aims to understand the place and role of nurses holding a PhD or PhD students (nurse doctor [ND]/nurse doctoral students [NDS]) in health care organizations in France.

CONTEXT

Worldwide, many nurses are undertaking doctoral studies. France is no exception. However, in France, there is no doctorate dedicated to nursing. The question of ND/NDS integration into health organizations is thus raised in a specific manner.

METHODS

We used a two-stage mixed methodology. The first stage used data from questionnaires that were sent to 165 ND/NDS in France. To contextualize issues raised by these data, we used qualitative methods which comprised 45 semi-structured interviews with nurses, 10 interviews with health managers and chief nurses and 27 h of in situ observations with research coordinators.

RESULTS

Seventy-nine participants (47.9% response rate) completed questionnaires. The data showed that work organization in some departments-intensive care units (ICUs), oncology and psychiatry-favoured the development of scientific expertise among nurses. Favourable elements promoting the professional and academic development of ND/NDS included the potential for medical teaching in healthcare services, participation in research projects and, most importantly, medical proximity. Conversely, our data also identified poor visibility and recognition of nursing doctoral courses in French health organizations: A lack of task missions, a lack of suitable posts and poor integration into the nursing profession. Currently, French nurses define their profession as providing direct care to patients and their families-yet this definition fails to consider other important professional elements, such as research.

CONCLUSIONS

Our study identified how proper ND/NDS integration is important to health care organizations. We identified key organization factors facilitating the integration of ND/NDS, such as participating in research teams and providing research support management.

IMPLICATIONS FOR NURSING MANAGEMENT

In recent years, the nursing profession has significantly evolved. We are interested in the impact of these changes in work organizations following the development of new scientific skills. Our study investigates all aspects of the nursing profession (teaching, practice, research and organizations). Our study advocates managerial roles, among others, to improve ND and NDS integration into work organizations. We directly observed work organizations that helped develop nursing research. Our study is also aimed at managers who have roles as decision-makers in promoting and facilitating research and nurse researchers.

A scoping review of outcomes of operational success for nurse scientists in clinical practice settings

BACKGROUND

The nurse scientist in the clinical setting is a role that has evolved over recent decades to encompass the concomitant development of personal research programs and the facilitation of staff and advanced practice nurse research in health care settings. However, the definition, operationalization, and measures of success are extremely variable.

PURPOSE

To identify the defining features and characteristics of the nurse scientist role in clinical practice settings as represented in the existing literature.

METHODS

We conducted a scoping review using PubMed and CINAHL databases. We initially identified a total of 3345 references from 1976 to June 2020, 217 of which were published from 2005-2020. We used the Joanna Briggs Institute (JBI) framework to explore the state of the science of the role of nurse scientists in practice settings.

DISCUSSION

Approximately 100 articles met the criteria for full-text analysis, and the final review consisted of 20 descriptive analytic studies addressing the nurse scientist role definition, operationalization, and outcome measures.

CONCLUSION

Findings suggest that nurse scientist roles serve to promote health system success through a host of research-focused activities that conceivably contribute to improved patient care outcomes. Work is needed to support the cost of requisite resources and infrastructure and to increase acceptance of the role as part of a tenure-earning track in academic settings that also stand to benefit.

Modified ABCDEF-Bundles for Critically Ill Pediatric Patients - What Could They Look Like?

BACKGROUND AND SIGNIFICANCE

Advances in pediatric intensive care have led to markedly improved survival rates in critically ill children. Approximately 70% of those children survive with varying forms of complex chronic diseases or impairment/disabilities. Length of stay, length of mechanical ventilation and number of interventions per patient are increasing with rising complexity of underlying diseases, leading to increasing pain, agitation, withdrawal symptoms, delirium, immobility, and sleep disruption. The ICU-Liberation Collaborative of the Society of Critical Care Medicine has developed a number of preventative measures for prevention, early detection, or treatment of physical and psychiatric/psychological sequelae of oftentimes traumatic intensive care medicine. These so called ABCDEF-Bundles consist of elements for (A) assessment, prevention and management of pain, (B) spontaneous awakening and breathing trials (SAT/SBT), (C) choice of analgesia and sedation, (D) assessment, prevention and management of delirium, (E) early mobility and exercise and (F) family engagement and empowerment. For adult patients in critical care medicine, research shows significant effects of bundle-implementation on survival, mechanical ventilation, coma, delirium and post-ICU discharge disposition. Research regarding PICS in children and possible preventative or therapeutic intervention is insufficient as yet. This narrative review provides available information for modification and further research on the ABCDEF-Bundles for use in critically ill children.

MATERIAL AND METHODS

A narrative review of existing literature was used.

RESULTS

One obvious distinction to adult patients is the wide range of different developmental stages of children and the even closer relationship between patient and family. Evidence for pediatric ABCDEF-Bundles is insufficient and input can only be collected from literature regarding different subsections and topics.

CONCLUSION

In addition to efforts to improve analgesia, sedation and weaning protocols with the aim of prevention, early detection and effective treatment of withdrawal symptoms or delirium, efforts are focused on adjusting ABCDEF bundle for the entire pediatric age group and on strengthening families' decision-making power, understanding parents as a resource for their child and involving them early in the care of their children.

Paediatric oral sensorimotor interventions for chewing dysfunction: A scoping review

BACKGROUND

Chewing dysfunction can have adverse effects on growth, development and quality of life. There is a lack of evidence-based consensus guidelines for sensorimotor intervention. To address this, we need to understand the current state of the science in clinical sensorimotor interventions for paediatric chewing dysfunction and systematically plan a research agenda and priorities for the field.

AIMS

The purpose of this scoping review was to examine the extent, range and nature of evidence for oral sensorimotor interventions for paediatric chewing dysfunction.

METHODS & PROCEDURES

This scoping review entailed five phases that included: identification of the research question; identification of relevant studies; study selection; data charting; and collation, summarization and report of the results. Treatment studies that were peer-reviewed and written in English were included. All studies involved a paediatric population and included an oral sensorimotor and/or chewing intervention. Information regarding study design, population, intervention, comparator, outcome measures and findings were extracted.

MAIN CONTRIBUTION

Of the 21 studies included in this scoping review, 53% were specific to children with cerebral palsy. All interventions were multi-component in nature and the treatment studies included a range of study designs, but few were controlled trials with comparators. A wide variety of outcomes measures were used within and across studies to determine treatment effectiveness.

CONCLUSIONS & IMPLICATIONS

The findings suggest that in a small number of studies, sensorimotor interventions provide preliminary evidence for effectiveness in specific populations. These and other treatment protocols must be trialled in additional clinical populations and settings to improve the evidence base for sensorimotor treatment of paediatric chewing dysfunction. This review also serves to help prioritize research agendas and further motivates the need for consensus-based clinical guidelines for paediatric chewing treatment.

WHAT THIS PAPER ADDS

What is already known on the subject Paediatric feeding disorders are highly prevalent and children often have chewing dysfunction that results in significant negative consequences. We lack evidence-based sensorimotor treatment approaches for chewing dysfunction, which directly impacts the care clinicians can provide children. What this study adds to existing knowledge This scoping review is the first step in examining the literature to understand the current state of the science for oral sensorimotor interventions for paediatric chewing dysfunction. Few randomized controlled studies were identified and a majority included children with cerebral palsy. Most of the interventions were multi-component and included a variety of treatment approaches. What are the potential or actual clinical implications of this work? The results of this scoping review can be used as an initial reference for clinicians selecting treatment approaches for chewing dysfunction. It also serves to help prioritize research agendas and further motivates the need for consensus-based clinical guidelines for paediatric chewing treatment.

Who Advances Nursing Science in Practice Settings and How?

Nurse scientist (NS) roles in clinical practice settings are key components of The Future of Nursing and ANCC Magnet® recognition. Despite increased opportunities for NS roles, leveraging these roles to advance nursing science remains at an early stage. We describe opportunities and challenges for NSs in clinical practice settings, highlighting the value of a strong partnership with chief nurse officers as critical for the success of NSs and outcomes associated with these roles.

Promoting cardiovascular nursing practice and research: A model for a university joint appointment

BACKGROUND

University joint appointments promote continuity of academic leadership and the acceleration of nurses' impact on improved outcomes and health service delivery. The role of university-appointed and hospital-located nurse scientists is of growing interest in the academic and clinical settings, and within the nursing profession. There is a pressing need to describe and study models of appointments, responsibilities and contributions to strengthen the integration of this boundary-crossing role across the continuum of the nursing profession.

AIMS AND OBJECTIVES

We report on the implementation of the inaugural St. Paul's Hospital and Heart & Stroke Professorship in Cardiovascular Nursing at the University of British Columbia, Vancouver Canada.

DISCUSSION

This model was based on recommendations provided by nursing to provincial government policy-makers, co-created and co-funded by academic and practice partners. Appointed by the university, the role is primarily located in the hospital, with the target of contributing 75% of time and focus on clinical research and leadership. The position is facilitated by its academic affiliation and the provision of university research and teaching infrastructure. In clinical practice, the role benefits from integration and visibility in the cardiac programme and leadership team, collaboration with advanced practice and multidisciplinary research groups, and access to office and human resources located on the clinical unit. Deliverables centre on achieving adjusted indicators of university performance to support academic promotion, and delivery of a practice-close research programme that prioritises improved patient outcomes, multidisciplinary practice and improved outcomes.

RELEVANCE TO CLINICAL PRACTICE

The dual appointment aims to provide tangible benefits to both the university and the hospital that match each organisation's needs; this requires sustained senior leadership engagement and support, and modification of conventional indicators of impact and success. Its ongoing evaluation will elucidate required modifications and future strategies required to strengthen nurses' academic and clinical leadership.

Kangaroo Care for Hospitalized Infants with Congenital Heart Disease

BACKGROUND

Kangaroo care (KC), or skin-to-skin care, occurs when an infant is dressed in a diaper and held to a parent's bare chest. This form of holding has been shown to have many benefits for hospitalized infants and has been shown to be a safe and feasible intervention to support infants with congenital heart disease. Despite known benefits, KC was not implemented routinely and consistently in our cardiac center for infants with congenital heart disease. The purpose of this project was to support use of KC as a nursing intervention for hospitalized infants with congenital heart disease and their parents.

METHODS

A KC quality improvement committee formed to develop strategies to increase frequency of KC, including the creation of a new nursing policy and procedure on KC for infants, adaptation of the electronic health record to facilitate KC documentation, education, and supporting translation of KC into practice through the cardiac center's first Kangaroo-A-Thon.

RESULTS

Twenty-six nurses initiated KC 43 times with 14 patients over the 8-week period for the Kangaroo-A-Thon. No adverse events were reported as a result of infants being held by their parents in KC.

CONCLUSION

Our local initiative provided preliminary evidence that KC can be safely integrated into standard care for hospitalized infants with congenital heart disease. Formal standards and procedures, along with creative initiatives such as a Kangaroo-A-Thon, can be a first step toward fostering the translation of KC into practice.

Understanding the Broker Role of Clinician-Scientists: A Realist Review on How They Link Research and Practice

PURPOSE

Clinician-scientists are said to be well placed to connect research and practice, but their broker role has been underexplored. This review sought to gain an understanding of the broker role of clinician-scientists.

METHOD

The authors conducted a realist review to describe context-mechanism-outcome (CMO) configurations associated with the broker role of clinician-scientists. CINAHL, PubMed, PsycINFO, Web of Science, and Embase were searched between May and August 2017. Data were analyzed qualitatively; data synthesis focused on assembling CMO configurations.

RESULTS

Of an initial 2,241 articles, 9 were included in the final review. Included papers show that clinician-scientists, in their broker role, achieve 2 organizational-level outcomes: an increased volume of clinically relevant, research, and increased evidence application to improve care. They also achieve the individual-level outcome of professional development as a researcher, clinician, and broker. Multidimensional skills and management support are necessary context factors. Mechanisms that contribute to outcomes include balancing economic and scientific interests and performing boundary-crossing activities. Four CMO configurations by which clinician-scientists achieve outcomes in brokering a connection between research and practice were identified. Useful program theories for explaining these are boundary crossing, social network, communities of practice, and diffusion of innovation theory.

CONCLUSIONS

The mechanisms found may provide insight for interventions aiming to support clinician-scientists in their broker role. The authors expect that if more attention is paid to learning multidimensional skills and management support for the broker role is strengthened, stronger links between research and practice could be forged.

Research translation and the evolving PhD and DNP practice roles: A collaborative call for nurse practitioners

Doctoral prepared nurse practitioners (NPs) are uniquely positioned for responsible leadership as essential members of the health care system and have a professional responsibility to contribute to research and clinical inquiry initiatives that advance health care delivery and improve outcomes. Academic preparation of the Doctor of Philosophy (PhD) and Doctor of Nursing Practice (DNP), although different in focus, offers opportunities for effective collaborations that transcend and integrate the scientific and practice roles of generating data and translating evidence. As health care organizations evolve in managing complexities of providing high-quality care, roles for the PhD as research scientist and DNP as research translation specialist will also evolve to keep pace. Despite this professional calling and global opportunity for research and evidence-based practice (EBP), future NPs and nurses will be challenged with an imminent lack of experts who have the skills needed for data and research generation and evidence translation. This commentary introduces and discusses emerging roles and organizational models for doctoral prepared NPs in research, EBP, quality assurance, and quality improvement projects, offers suggestions for NPs interested in research and clinical inquiry, and seeks to ignite excitement for scientific discovery in NP-driven initiatives. Nurse practitioners are encouraged to take advantage of the many opportunities to shape and expand their careers by engaging in knowledge generation for improving health care outcomes.

A Global Perspective on Publishing in Oncology

OBJECTIVES

To describe the discordance in contributions to the literature between developed and low- and middle-income countries (LMICs); identify global challenges in accessing the literature, publishing, and conducting research; and describe successful collaborative publishing models.

DATA SOURCES

Published literature; survey data; personal experience.

CONCLUSION

There is a scarcity of literature written by nurse authors in LMICs. Limited support for nursing research, inconsistent internet access, workforce shortages, and language barriers are significant barriers to publishing success.

IMPLICATIONS FOR NURSING PRACTICE

Nurses from developed countries can build relationships with global partners from LMICs to increase dissemination capacity. Mentorship programs and academic partnerships are two possible solutions for increasing publications from nurses in LMICs.

Description of Nurse Scientists in a Large Health Care System

Replicating a research study that described the work of nurse scientists in children's hospitals, the purpose of the study was to describe the role, activities, and outcomes of nurse scientists employed in a national health care organization. The characteristics of nurses filling the nurse scientist role in clinical settings and outcomes associated with the role have not been extensively described. The setting of this study is ideal since the organization includes facilities of various sizes located in rural, urban, and suburban areas in 18 states. Names and contact information of nurse scientists were obtained from nurse executives at each of the 110 affiliated organizations. Nurse scientists completed an anonymous survey. The primary role of the nurse scientists is to facilitate the work of others. Recommendations to strengthen the research infrastructure are provided.

Clinical Nurse Specialist Roles in Conducting Research: Changes Over 3 Years

PURPOSE

The aim of this study is to describe clinical nurse specialists' characteristics, interest, confidence, motivators, and barriers in conducting research.

DESIGN

This study was a descriptive, multicohort design.

METHODS

Clinical nurse specialists were recruited electronically through national and local organizations to complete anonymous surveys 3 times, over 3 years. Comparative analyses included χ and Kruskal-Wallis tests.

RESULTS

Of 2052 responders (initial, n = 629; 18 months, n = 465; and 3 years, n = 958), mean (SD) participant age was 50.3 (9.3) years. Overall, 41.7% of participants were involved as principal or coinvestigators in research. Interest in conducting nursing research (on a 0-100 scale) was 61.1 (38.4) and was lowest among the 18-month time point participant group (score, 39.1 [32.2]) and highest at the 3-year time point (68.3, [30.7]; P < .001). Confidence in conducting research, discussion of statistics, and perceptions of motivators and barriers to conducting research did not differ across time period groups. Access to literature and mentors and research knowledge were the most prevalent barriers to conducting research.

CONCLUSIONS

Less than 42% of clinical nurse specialists conducted research and the rate did not change between different time groups. Access and knowledge barriers to conducting research were prominent. Workplace leaders need to consider resources and support of academic educational opportunities to increase research conduct by clinical nurse specialists.