Role of the clinical nurse specialist: an integrative review of the literature

Clinical Nurse Specialist Transition to Practice

PURPOSE

A quality improvement/evidence-based practice project identified the critical components of clinical nurse specialist (CNS) transition-to-practice (TTP) needs based on the experiences and perceptions of entry-level CNSs (n = 4), experienced CNSs (n = 7), and directors of nursing (n = 6) employed in a tertiary healthcare center. Structured 60- to 90-minute face-to-face discussions were conducted.

DESCRIPTION

As knowledge workers, CNSs are critical to investigating, solving, and transforming some of the most challenging current and future healthcare problems. Lack of standardized CNS TTP may result in variable levels of practice, knowledge, skill attainment, and ability to attain interdisciplinary practice competencies.

OUTCOMES

Findings included identification of entry-level CNS TTP key components: 16 categories with 8 critical categories identified as imminent needs. Challenges identified included stakeholders' lack of knowledge/understanding of the CNS role and scope; enormous TTP expectations of entry-level CNSs; transdisciplinary relationships and collaboration; leadership culture and collaboration; organizational culture; deliberate practice; and lack of support, resources, and basic needs.

CONCLUSION

Critical components for advanced deliberate practice within a CNS TTP program include an organizational culture and subculture that understands and values the CNS, along with tiered sustainable support from preceptors, mentors, and support CNSs across the setting and system.

Reporting relationships of clinical nurse specialists in acute care

Reporting relationships between clinical nurse specialists (CNSs) and administrators (ADMs) can facilitate or constrain CNS practice and affect patient outcomes. Limited information is available comparing reporting relationships and perspectives of CNSs and ADMs.

PURPOSE

The purpose of the present study was to describe CNS and ADM reporting relationships and compare their perspectives about the activities and outcomes of CNS practice in acute care settings.

DESIGN

The present study uses a descriptive survey.

SETTING

Four healthcare organizations in the midwestern United States.

SAMPLE

Clinical nurse specialist participants (n = 30) were master's degree prepared and employed in an acute care setting. Administrator participants (n = 7) were responsible for supervision and evaluation of CNSs in their organization.

METHODS

Questionnaires were developed from literature and content review by experts. The CNS and ADM questionnaires contained separate sections for CNS and organization information with parallel construction of questions about CNS activities and outcomes.

FINDINGS

There was variability across organizations related to reporting relationships and structure of CNS work. No significant differences were found when comparing CNS and ADM perspectives of work activity proportions and the importance of 10 activities and 7 outcomes. The most important CNS activities included developing clinical protocols and guidelines, quality improvement, and coordination of care. The most important outcomes included evidence-based nursing care and skilled and competent nursing staff.

CONCLUSION

Comparing perspectives of work activity time, priority activities, and outcomes provides a basis for collaboration between CNSs and ADMs in reporting relationships.

IMPLICATIONS

Clinical nurse specialists should develop positive interactions and shared understanding with ADMs to improve effectiveness and enhance patient outcomes.

The clinical nurse specialist in chronic diseases

BACKGROUND/RATIONALE

The number of individuals with chronic illness is growing at an astonishing rate because of the rapid aging of the population and the increased longevity of persons with chronic conditions. Nurses in clinical nurse specialist (CNS) roles are well positioned and ideally suited to meet the needs of a growing population with chronic diseases; yet, to date, there has been no critical review of the CNS in chronic diseases.

PURPOSE/OBJECTIVES

This article provides a critical review of the literature in order to better define and understand the CNS related to patients living with chronic illnesses (cardiovascular and oncology).

DESCRIPTION OF THE PROJECT/INNOVATION

Using the guidelines of DiCenso et al (2005) for evaluating health services interventions, the literature was appraised in order to identify the characteristics of CNS roles, and the strengths and limitations of research about the effectiveness of CNS in chronic disease management.

IMPLICATIONS

Clinical nurse specialists with master's-level preparation provided high-quality and cost-effective care to patients with chronic diseases. The CNSs had a positive impact on patient, family, and healthcare team outcomes. Further evaluation of the CNS role in the research domain of practice is recommended.

Clinical nurse specialist education: actualizing the systems leadership competency

PURPOSE

The purpose of this article was to show how sequenced educational strategies aid in the acquisition of systems leadership and change agent skills, as well as other essential skills for professional clinical nurse specialist (CNS) practice.

BACKGROUND

Clinical nurse specialist education offers the graduate student both didactic and clinical experiences to help the student transition into the CNS role. Clinical nurse specialist faculty have a responsibility to prepare students for the realities of advanced practice. Systems leadership is an integral competency of CNS practice.

IMPLICATIONS

The contemporary CNS is to be a leader in the translation of evidence into practice. To assist students to acquire this competency, all CNS students are expected to use research and other sources of evidence to identify, design, implement, and evaluate a specific practice change. Anecdotal comments from students completing the projects are offered. Student projects have been focused in acute and critical care, palliative care, and adult/gerontologic health clinical settings; community outreach has been the focus of a few change projects. Examples of student projects related to the systems leadership competency and correlated to the spheres of influence impacted are presented.

Clinical nurse specialist practice patterns

PURPOSE

The study purpose was to describe clinical nurse specialist (CNS) practice patterns (activities, outcomes, and practice barriers).

DESIGN

A cross-sectional survey design was used for this research study.

SETTING AND SAMPLE

California Board of Registered Nursing certified CNSs (N = 1,523).

METHOD

Surveys were mailed to CNSs and included the CNS Activity Questionnaire, the Clinical Nurse Specialist Outcomes and Barriers Analysis Survey, and a demographic survey. Descriptive (means, percentages) and inferential (t tests and one-way analyses of variance) statistics were used to analyze the data.

CONCLUSIONS

Practicing CNSs (n = 947) demonstrated a role preference for expert clinical practice. Practice patterns (activities, outcomes, and barriers) differed in terms of CNS specialty, years of experience, number of units covered, and CNS reporting structure. Clinical nurse specialists are spending time in the 5 broad role components expert (clinical practice, consultation, education, clinical leadership, and research) utilized by the California Board of Registered Nursing as an organizing framework for practice; however, CNS practice patterns from this study reflect more discrete and functional activities that may be better encompassed under the CNS spheres of influence practice model. A number of barriers to practice exist, the most commonly reported being reporting structure. Years of experience in the role result in differences in both practice patterns and perceptions of barriers. Recommendations for CNSs and organizations include evaluating CNS reporting structures, developing advanced practice outcome-based job descriptions and competencies, and designing performance evaluations that recognize differences between inexperienced and experienced CNSs.

The role of the clinical nurse specialist in promoting evidence-based practice and effecting positive patient outcomes

Clinical nurse specialists (CNSs) are vital members of the healthcare delivery leadership team. The knowledge and expertise of the CNS is germane to the quality of care a patient receives. More than 50 CNSs practice at Massachusetts General Hospital (the state's first Magnet hospital), where they share their clinical skills, mentor staff through difficult situations, identify learning needs, and implement innovative approaches to patient care. This article presents a brief history of the CNS role and describes how the CNS role is operationalized at Massachusetts General Hospital and its impact on unit-based and organizational outcomes. In addition, several programs and interventions identified by the CNSs in response to results of the Staff Perception of the Professional Practice Environment Survey are discussed. How the CNS influences the professional development of staff and potential implications for the future role of the CNS are described. An exemplar is included depicting a typical work day of a CNS on an acute adult medical unit.

Perioperative Clinical Nurse Specialist Role Delineation: A Systematic Review

A CLEARLY DEFINED ROLE for the perioperative clinical nurse specialist (CNS) has not been identified or established. USING ROLE THEORY as a framework, a systematic review of the literature was conducted to provide recommendations for a delineated CNS role and to compare this role with other nursing roles. SEVERAL FACTORS CONTRIBUTE to CNS role confusion, including the versatility of the position, lack of certification examinations, and variance of state recognition. FUTURE RESEARCH should investigate merging of CNS and nurse practitioner titles, perioperative CNS functions, spheres of influence, and patient outcomes.

Advanced Practice Nursing: Unification Through a Common Identity

Despite the wide variety of advanced practice roles in nursing and the well-documented differences among them [Hamric, A. (2000). A definition of advanced nursing practice. In A. Hamric, J. Spross, & C. Hanson (Eds.), Advanced nursing practice: An integrative approach (pp. 53-73). Philadelphia, PA: W. B. Saunders], the authors suggest that nurses in these roles should adopt a common identity, that of an "advanced practice nurse" (APN). The authors outline the development of advanced practice nursing in Canada and the United States, tracking historical influences and highlighting current issues facing APNs. The authors explore elements that constitute the definable and describable core of advanced practice nursing-knowledge, education, scope of practice, regulatory issues, and outcomes. They conclude that adoption of a common identity for all advanced practice nursing roles may clarify role confusion (which is currently experienced within and outside the profession), reinforce links between knowledge development and nursing practice, and ensure that advanced nursing practice is responsive to the needs of society.

Observing the Work of the Clinical Nurse Specialist

The Clinical Nurse Specialist (CNS) is an advanced practice nurse (APN) with graduate preparation as a clinical expert within a specialty area of nursing practice. There is a need for information about the work of the CNS in order to link CNS activities to outcomes and costs of care.

PURPOSE

To describe the work of the CNS in the acute care setting using the National Association of Clinical Nurse Specialists (NACNS) model as an organizing framework.

DESIGN

Descriptive pilot study of the work of the CNS in acute care.

SETTING

A 500-bed academic medical center located in the Midwestern United States.

SAMPLE

Five masters-prepared APNs in a unit-based CNS role.

METHODS

Direct observation and time study were used to record activities and time for 4 hours with each CNS (n = 5) for a total of 20 hours of observation.

FINDINGS

CNS activity and time within each practice domain included patient/client (30%), nursing (44%), organization/system (10%), and other activities (16%). Specific activities observed were linked to possible outcomes in the NACNS framework.

CONCLUSIONS

The NACNS model provided a useful framework for developing a data collection tool that can be used in a larger study that analyzes the work of the acute care CNS.

IMPLICATIONS

Describing the work of the CNS is an important preliminary step to measuring outcomes and costs of care.

Capturing Reimbursement for Advanced Practice Nurse Services in Acute and Critical Care

Advanced practice nurses (APNs) have been affected positively and negatively by recent changes in the way hospitals are financed. Among these changes are the shift from cost-based reimbursement to a prospective payment system and increased opportunities for billing APN services under the physician payment system. Positive effects include the need for hospitals to decrease the length of stay of hospitalized patients, leading to jobs for APNs who make the hospital course and discharge more efficient. Negative effects include budget shortfalls that lead to layoffs. This article explains the current financial landscape, including phenomena that are impeding the billing of APN services, and recommends adjustments so that the APN role will be on firm financial footing.

Dare to be different: transformational leadership may hold the key to reducing the nursing shortage

Health care leadership continues to run under a transactional style that may be causing nurses to leave the system. Nurses no longer wish to stay in the profession perhaps because they struggle ideologically with the system in which they work. However, nurses may hold the key to transforming health care and dragging it into the 21st century in terms of work practices and reform. This is because nurses are visionary, creative, involved in decision making at patient level and have gender based qualities, and communication strategies that the health care sector needs. In contrast to transaction leadership, transformational leadership and team development has a positive affect on communication and team building. The later style is ideologically suited to nurses and may ensure the future of nurses and nursing in the health care sector. The case study described in this paper was an actual working environment and one that I came across all too often as a registered nurse and clinical educator.

The role of the clinical nurse specialist in creating a healthy work environment

The clinical nurse specialist (CNS) contributes to a healthy work environment through partnerships with the nursing staff, nurse manager, physicians, and other colleagues across the health system. Examples of these partnerships are described in this article, highlighting how the work of the CNS influences the care that patients and families receive, shapes the practice environment, and fosters collegial and respectful relationships among caregivers. The CNS is a pivotal figure in creating an environment where nurses can provide the care that is needed and feel valued for their work. Partnership with a variety of clinicians enables the CNS to influence critical care nursing practice, the intensive care unit team, and the environment in which care is provided.

Measuring advanced practice nursing outcomes

The measurement of outcomes has become an important component of evaluating health care. Although it is clear that measuring outcomes is necessary to establish the effectiveness of advanced practicing nursing, which outcome measures to use and how to conduct an effective outcomes assessment remain unclear. The purpose of this article is to present an overview of advanced practice nursing outcomes research, review outcome measures important to advanced practice nurses (APNs), and discuss sources of outcome measures and instruments that can be used by APNs to establish the effectiveness of the role.