The Clinical Nurse Specialist

Chapter 14


The Clinical Nurse Specialist




Chapter Contents



Overview and Definitions of the Clinical Nurse Specialist,


Clinical Nurse Specialist Practice: Spheres of Influence and Advanced Practice Nursing Competencies



Current Marketplace Forces and Concerns



Future Directions


Conclusion



Overview and Definitions of the Clinical Nurse Specialist


The clinical nurse specialist (CNS) role was created for the following reasons: (1) to provide direct care to patients with complex diseases or conditions; (2) to improve patient care by developing the clinical skills and judgment of staff nurses; and (3) to retain nurses who are experts in clinical practice (Cooper, Sparacino, & Minarik, 1990; Hamric & Spross, 1989). Expert clinical practice is the essence, the core value, of the CNS role. Historically, the role has been versatile, evolving, flexing, responsive, and adaptable to patient populations and health care environments, notably the same characteristics that have led to concerns regarding role confusion and ambiguity because of variability in implementation. However, the core strength of the CNS in providing complex specialty care while improving the quality of care delivery has remained central to the understanding of this advanced practice nurse (APN) role. Currently, the CNS is defined as an APN who practices in three substantive areas, as articulated by Lewandowski and Adamle (2009), to manage the care of complex and vulnerable populations, educate and support nursing and interdisciplinary staff, and facilitate change and innovation in health care systems. Lewandowski and Adamle developed these concepts of the three substantive areas of CNS practice in the context of the evolving health care environment by conducting an extensive literature review, based on the foundational work delineated by the National Association of Clinical Nurse Specialists (NACNS). In their 2004 document, Statement on Clinical Nurse Specialist Practice and Education, NACNS described CNSs as practicing in the three interrelated spheres of client direct care, nurses and nursing practice, and organizations and systems. As noted earlier in this text, direct care of patients is the primary distinguishing feature of CNS practice (see Chapter 7) and interventions in the other two spheres are intended ultimately to affect the care of patients. Examples include interventions such as guiding and educating staff nurses in the nurses and nursing practice sphere and leading quality improvement projects and redesigning the delivery of care in the organizations and systems sphere. In the NACNS model, therefore, the client direct care sphere encompasses the interventions of the other two spheres to depict the centrality of the patient care focus. NACNS has been currently revising their statement at the time of this writing. In this chapter, we will use the NACNS spheres of influence and the further refined substantive areas of practice from Lewandowski and Adamle (2009) to illustrate the unique contributions of the role of the CNS and how the CNS role differs from other APN roles.


Exemplar 14-1 describes a typical day in the life of a pediatric clinical nurse specialist.



imageExemplar 14-1   A Day in the Life of a Clinical Nurse Specialist


PM, a pediatric CNS in the department of neurosurgery, started his day by checking the list of patients on the service. After reviewing their charts, he noted that a new brain tumor patient, an 11-year-old boy, was admitted during the night after a seizure. After looking at the head CT scan, checking his vital signs and nurses’ notes, he noted that the patient had a Glasgow Coma Scale (GCS) score of 15 and was stable. PM checked to make sure that the patient had been started on appropriate doses of dexamethasone and ranitidine and that he had a brain magnetic resonance imaging (MRI) scan ordered for this morning. PM was mentoring a CNS graduate student and she joined him just before rounds. He reviewed the patients with her, including the 11-year-old boy’s head computed tomography (CT) scan, explaining that the seizure was caused by the location of the tumor. He also explained the importance of steroids in treating edema in brain tumor patients.


PM, his CNS student, and the pediatric neurosurgeon made rounds together on the patients, formulating a plan of care for each one for the day. Because the neurosurgeon would be in the operating room most of the day, PM planned to keep him updated on any changes in patient conditions. PM included the staff nurses caring for each patient in rounds so they could contribute to developing the patient’s plan for the day.


After documenting daily progress notes on each patient, PM then led a meeting with a group of staff nurses and CNSs from medical-surgical units and the medical-surgical intensive care unit to address issues related to the care of neurosurgical patients throughout the hospital. PM had noticed inconsistencies across units in patient neurologic assessments, documentation of those assessments, and lack of implementation of current guidelines in the care of this population and had formed the group to discuss these concerns. PM had led the group in reviewing the latest evidence in neurosurgical patient care, identifying gaps in the electronic health care record to facilitate accurate documentation and care planning, and performing a learning needs assessment of the staff caring for these patients. The group had identified next steps to take in improving the quality of care and was continuing to meet under PM’s leadership to implement identified strategies and assess the effectiveness of these interventions.


After the meeting, PM was called to the preanesthesia testing unit to do a history and physical examination on a 3-year-old boy who was to undergo surgery the next day to release his tethered cord. After examining the child, he answered the mother’s many questions about what to expect after surgery, such as activity, pain control, and wound care. PM also arranged for the child life specialist to visit with the child about what to expect because his mother was concerned about his understanding of the hospital stay.


PM received a page from the emergency department (ED) to see a 5-year-old patient with spina bifida who presented with a 1-day history of fever and vomiting. Because he also had a ventriculoperitoneal shunt, the ED physician wanted neurosurgery to evaluate him for shunt malfunction. PM went to the ED, assessed the patient, and ordered a head CT and shunt series x-ray, explaining to his CNS student that although there are many causes of fever and vomiting in a child with spina bifida, he wanted to rule out shunt malfunction. PM also asked the ED physician to order a urinalysis and culture because the patient’s mother said that his urine had started to look cloudy. The CT and shunt series were within normal limits for this patient but the urinalysis showed that he had a urinary tract infection, which the ED physician treated with antibiotics.


After grabbing a quick lunch at his desk and writing postoperative orders, PM remembered that he needed to follow up with one of the patient’s mothers. He called the nurse caring for the 11-year-old brain tumor patient to see if his mother was available. On hearing that she was, PM and his CNS student went to talk with her in a private conference room about her concerns for surgery to remove his tumor. His mother was insistent that she did not want her son to know about the surgery until the day before because he was such a “worrier.” She was upset that so many of the staff kept coming in his room and talking over him like he wasn’t there and mentioning all sorts of scary procedures. After letting her verbalize her concerns, PM assured her that because she knew her son the best and could determine the best time to talk with him about surgery, the team would support her decision to discuss his condition outside of his room. PM communicated this with his primary team, neurosurgery team, and staff nurse caring for him.


PM then left the floor to give a lecture to staff nurses on a medical-surgical unit on how to perform neurologic assessments. He had developed this lecture as one of the interventions identified from the earlier quality improvement group to improve the care and outcomes for the neurologic population.


As PM was returning to the neurologic unit after the lecture, one of the staff nurses stopped him and said she was worried that the 3-year-old with a recurrent brain tumor was less responsive and not drinking as well as yesterday. PM and his CNS student stopped by the patient’s room to assess her. After determining that she was responsive but not as alert as yesterday, he ordered a head CT stat to check for hydrocephalus and restarted her IV fluids. He called the neurosurgeon to report his assessment findings and interventions and that the head CT showed an improvement. The neurosurgeon wanted to increase her dexamethasone and obtain an MRI scan of the brain in the morning, so PM placed those orders. He thanked the staff nurse for being alert to the patient’s decline and explained the CT scan to her, comparing it with her previous one. He said he would call back in an hour to check on her.


Shortly thereafter, PM received a page from a new staff nurse to come to a patient’s room because the patient’s ventriculostomy tubing had come apart. The nurse had noted the disconnection right away and clamped the tube so only a minimum amount of cerebrospinal fluid (CSF) drained onto the floor. PM praised the nurse for her quick action and demonstrated how to reattach a new system using sterile technique. Because the nurse was new, PM also took this opportunity to explore and review with her knowledge related to the purpose of a ventriculostomy. He asked about her understanding of the risks and benefits of this treatment, answered other questions for her, and reviewed the plan of care for this patient with this intervention.


Back in his office, PM had time to return phone calls from anxious parents and answer questions his CNS student had about the day. He called the nurse caring for the 3-year-old and was gratified to learn that she had improved. The neurosurgeon was out of surgery at this time, so PM reviewed the patients with him before leaving for the day.


In spite of a core understanding of the nuances of the CNS role, the activities of CNSs are as varied as their individual specialty practices. The diversity of CNS specialties, differences in their individual practices, and practice differences seen among CNSs in the same institution has created confusion about what CNSs do. Unlike other APNs, whose primary role is to deliver direct patient care, the multifaceted CNS delivers direct patient care specifically to complex and vulnerable populations, educates and supports nurses and interdisciplinary staff, provides leadership to specialty practice program development, and facilitates change and innovation in health care systems (Lewandowski & Adamle, 2009). This variability in CNS practice, even within the same institution, has characterized the role since its creation. The definition of the CNS role has remained deliberately broad so that CNSs can respond to changing clinical environments. For example, a unit- or population-based critical care CNS with an experienced, certified specialty staff may balance his or her time equally among direct patient care activities, educating interdisciplinary staff, and system-wide improvements. Conversely, if a preventive cardiology CNS works in an outpatient clinic in the same institution and sees a panel of patients as a provider of expert specialty care, that CNS practice may focus more on direct patient care and less on education and system-wide improvements. Several clinical, staff, and system variables must be weighed when planning for CNS positions and implementing the role, including the number, type, and background of nurses and other clinical staff, clinical, educational, or institutional resources, and patient population, acuity, and outcomes.


This versatility in CNS practice has continued to challenge the CNS role definition and understanding of the impact of CNSs on clinical outcomes and costs of care. Role confusion and variability, regulatory drivers, and fiscal retrenchment in the last 20 years have resulted in the loss of CNS positions in many parts of the country to save hospitals money without jeopardizing direct care registered nurse (RN) positions. The CNS role is the only APN role to decrease in numbers in the most recent national RN survey (see Chapter 3). CNS clinical practices are shaped by many factors, such as health care agency needs, community needs, payor and other regulatory agency mandates, statutory limitations, supervisor requests, and individual CNS interests. Over the past few decades, CNSs have been able to change their practices in response to these influential forces.


Clarifying the work and core competencies of all CNSs, regardless of specialty, has been complicated historically because specialty organizations have established varying educational, competency, and practice standards for CNSs (e.g., critical care, oncology, neuroscience specialties). NACNS was not established until 1995 (see Chapter 1). The NACNS itself has acknowledged that advanced practice organizations for the other three APN roles had a significant head start in defining competencies and influencing health policies related to advanced practice nursing (NACNS, 2004b). The American Nurses Association (ANA), many specialty organizations, and APN leaders have worked hard to define CNS practice, define standards and competencies, and develop CNS curricula (see Chapters 1 and 2). More work, however, is required to educate colleagues, administrators, and the public about the role of the CNS. For reasons outlined later in this chapter, and discussed in Chapter 21, we believe that CNSs and the nursing profession are at a critical juncture for the survival of the role of the CNS. For the purposes of clinical practice and licensure, accreditation, credentialing, and education (LACE), the work and contributions of CNSs as APNs must be made unambiguously clear.


The ANA has defined APNs as nurses who “practice from both expanded and specialized knowledge and skills” (ANA, 2003, p. 9). An expanded knowledge base and skill set refers to the “acquisition of new practice knowledge and skills, including the knowledge and skills that authorize role autonomy within areas of practice that may overlap traditional boundaries of medical practice” (ANA, 2003, p. 9; see Chapter 3). Specialized knowledge and skills are defined as “concentrating or delimiting one’s focus to part of the whole field of professional nursing” (ANA, 2003, p. 9). According to the National Council of State Boards of Nursing (NCSBN) Consensus Model for advanced practice registered nurse (APRN) regulation, a defining factor for all APNs is that a significant component of the education and practice be focused on direct care of individuals (NCSBN, 2012b). If CNSs want to be recognized nationally, statewide, or locally as APNs, they must have a significant component of direct care of individuals in their role. If the focus is mainly on educating nursing and/or interdisciplinary staff or process improvement without direct care of individuals, the clinician is not practicing in the role of a CNS (Cronenwett, 2012).


New opportunities for expanded CNS practices have presented themselves with the introduction of the Patient Protection and Affordable Care Act (PPACA; U.S. Department of Health and Human Services [HHS], 2011). Successful CNSs have consistently delivered direct and indirect care that improves patient care quality and outcomes, patient safety, and nursing practice and that ensures efficient use of resources, cost efficiency, cost savings, and revenue generation (NACNS, 1998, 2004b; Newhouse, Stanik-Hutt, White et al., 2011; see Chapter 23). CNSs’ clinical acumen and expertise are not limited to their patients’ physiologic and psychological needs. Their clinical expertise permeates the other elements of their multifaceted responsibilities—education, evidence-based practice (EBP), health policy, organizational factors, and political change—and they are highly qualified to lead interdisciplinary teams in health care reform. The purpose of this chapter is to describe the core competencies, current marketplace challenges, and future directions for CNSs.



Clinical Nurse Specialist Practice: Spheres of Influence and Advanced Practice Nursing Competencies


Although other models of CNS practice have been described (see Chapter 2), the NACNS’s three spheres of influence and Hamric’s seven competencies (see Chapter 3 and Chapters 7 through 13) will primarily be used to organize and explain CNS practice in this chapter. CNS students are encouraged to familiarize themselves with the NACNS Statement on Clinical Nurse Specialist Practice and Education (2004b) and with specialty-specific standards (e.g., the Emergency Nurses Association [2011] competencies for clinical nurse specialists) to understand the discussion of spheres and competencies better. In addition, readers should also be aware of the substantive areas of CNS practice reported by Lewandowski and Adamle (2009) to understand a more recent articulation of CNS practice. To be successful, a CNS must understand and apply the seven competencies of advanced practice nursing across the three spheres of influence, regardless of setting or specialty (Sparacino & Cartwright, 2009). The NACNS (2010), along with other nursing organizations, has endorsed a list of comprehensive, entry-level competencies and behaviors expected of graduate programs in the preparation of CNSs (Table 14-1).



Advanced practice competencies are categories of proficient performance and include specific knowledge and skill sets. The direct care of patients and families is the central competency in Hamric’s model (see Fig. 2-4) and links every other competency. According to the NACNS model, the impact and influence of CNSs are felt within three spheres of influence—direct care of patients or clients,* nurses and nursing practice, and organizations and systems (NACNS, 2004b; see Fig. 2-2).


Both the Hamric and NACNS models emphasize the importance of direct care; clinical expertise and direct care are basic to CNS practice. For this reason, the direct care of patients or clients sphere is the largest sphere in the NACNS model and encompasses the other two spheres. For examples of activities in this sphere, as expanded on by Lewandowski and Adamle (2009), see Box 14-1.



imageBox 14-1


Manage the Care of Complex and/or Vulnerable Populations




Adapted from Lewandowski, W., and Adamle, K. (2009). Substantive areas of clinical nurse specialist practice: A comprehensive review of the literature. Clinical Nurse Specialist, 23, 73–90.


CNSs demonstrate all seven competencies across the three spheres of influence and often execute some competencies simultaneously. They exert influence in the nurses and nursing practice sphere by caring for patients directly and by serving as coaches, guides, and role models for nursing staff and other caregivers. They provide consultation. They demonstrate EBP competencies by working with staff to develop, implement, and evaluate EBPs. They may collaborate in clinical research, an activity likely to affect all three spheres of influence. Similarly, they collaborate and facilitate team development, assess and intervene to alleviate the moral distress inherent in clinical care, and create environments that support clinicians’ ethical decision making. See Box 14-2 for examples, as described by Lewandowski and Adamle (2009). CNSs exert influence in the organizations and systems sphere by providing clinical and systems leadership in many ways, whether articulating nursing issues to team members, advocating for a patient, taking a stand on behalf of nurses, or evaluating the quality and cost-effectiveness of technologies and care processes. Box 14-3 lists activities in this sphere (Lewandowski & Adamle, 2009).



imageBox 14-2


Educate and Support Interdisciplinary Staff





Adapted from Lewandowski, W., and Adamle, K. (2009). Substantive areas of clinical nurse specialist practice: A comprehensive review of the literature. Clinical Nurse Specialist, 23, 73–90.



imageBox 14-3


Facilitate Change and Innovation Within Health Care Systems



Adapted from Lewandowski, W., and Adamle, K. (2009). Substantive areas of clinical nurse specialist practice: A comprehensive review of the literature. Clinical Nurse Specialist, 23, 73–90.


Throughout all three spheres, CNSs apply the nursing process; assessment, planning, implementation, and evaluation activities are designed to improve the care of patients, develop nurses, and improve the systems in which nurses work and care is delivered. Experienced CNSs understand that activities in each sphere of influence and their advanced practice competencies exert reciprocal influences on each other. Implementing competencies across the three spheres can result in improvements in clinical outcomes, patient safety, patient-family satisfaction, resource allocation, professional nursing staff knowledge and skills, health care team collaboration, and organizational efficiency (Murray & Goodyear-Bruch, 2007; Ryan, 2009; Vollman, 2006).


The variety of activities, the challenge of in-the-moment problem solving that characterizes clinical work, and intermediate- and long-range planning efforts to improve the care of patients attract CNSs to this work. Throughout the history of CNS practice, and despite the changes in health care, reimbursement, and credentialing that have affected advanced practice nursing, CNSs have remained focused on championing excellence in nursing practice and on improving clinical care and the systems in which the care is delivered.


Without sustained engagement in direct care (direct care of patients or clients sphere), it would be difficult, if not impossible, to continue to be effective in the other two spheres, because the effectiveness depends on the CNS’s clinical credibility. However, because CNSs provide more than just direct care, maintaining their commitment to patient care is often challenged as organizational priorities change. In the following sections, the ways in which CNSs implement the seven competencies across three spheres of influence are described.



Direct Clinical Practice


Specialization was the genesis of the CNS role, but expert clinical practice—and direct patient care—is its heart. The central competency of direct clinical practice is explicitly linked to the patient-client sphere of influence; the insights and outcomes of providing direct care influence the CNS’s work in the other two spheres of nursing practice and systems.


CNS practice includes advanced assessment skills and the integration of “biophysical, psychosocial, behavioral, sociopolitical, cultural, economic, and nursing science” (American Association of Colleges of Nursing [AACN], 2006b, p. 16) into specialized, expert nursing practice. Skills (clinical, advanced communication, and relational) and knowledge (theoretical, practical, and particular) are essential, but practical wisdom is a hallmark of advanced practice nursing (Oberle & Allen, 2001). Many authors have described strategies for successfully implementing the expert clinician dimension, building on the conceptual foundations of previous authors (Duffy, Dresser, & Fulton, 2009; Fulton, Lyon, & Goudreau, 2010; Zuzelo, 2010). Each strategy is highly dependent on the individual CNS and his or her practice setting and can fluctuate from year to year in relation to the prevailing health care environment. It is easy for the direct care component of the role to be overemphasized or underemphasized because of institutional priorities and competition for CNS expertise. The unique skill set of CNSs may result in them being continually pulled away from direct care to lead projects that are of high priority for the institution. Conversely, if an institution recognizes value only in the revenue generation component of direct care, the CNS may be required to focus exclusively on that component of the role. The CNS role is optimally enacted when CNSs have the opportunity to use what they have learned from direct clinical practice to improve care for individual patients, families, and patient populations, whether that occurs at the patient-CNS interface, through nursing personnel, or through organizational improvements.


Although clinical expertise is the cornerstone of CNS practice, a CNS’s success will not be measured by clinical knowledge or technical expertise alone. Providing regular and consistent direct patient care is essential for the CNS to do the following:



Direct care, or direct clinical practice, refers to CNS activities and responsibilities that occur within the patient-nurse interface (see Chapter 7). For many years, a CNS’s direct clinical practice was not clearly linked to measureable goals, such as patient outcomes or resource use. Thus, few data were available to justify the role and correlate its expense with the cost avoidance and quality improvement aspects of the role when health care institutions were restructuring their operating systems. However, most patients requiring the expertise of a CNS are sicker, more frail, and in need of specialized expert care. Clinical studies with high-risk patients, such as very-low-birth-weight (VLBW) infants, women with a high-risk pregnancy, and older adults with cardiac diagnoses, have consistently shown improved patient outcomes and reduced health care costs when CNSs and other APNs were directly involved with patient care, including assessing, teaching, counseling, and negotiating systems (Dejong & Veltman, 2004; Murray & Goodyear-Bruch, 2007; Ryan, 2009; Vollman, 2006).


A CNS is most likely to care directly for a patient whose diagnosis or care is complex, unique, or problematic. Examples of complex or problematic patients include a VLBW infant, frail older person with multiple hospital readmissions, child with complex congenital heart disease, young pregnant woman with a transplanted organ, or man diagnosed with bipolar disorder who has survived a suicide attempt but who requires prolonged physical rehabilitation. Examples of unique situations include the care of a child with a rigid external distraction device for midface advancement, evaluation and implementation of a new intervention, such as teletechnology to assess the efficacy of preventive interventions for pressure ulcers, and introduction of an experimental chemotherapeutic agent. CNSs have the advanced skills to care for these challenging patients by incorporating a holistic perspective, forming therapeutic partnerships, and using expert clinical thinking and skillful performance to optimize outcomes. The CNS has the access and ability to evaluate the latest evidence and apply it in diverse ways to manage complex cases.


Direct care also affords a CNS the opportunity to assess the quality of care for a specific patient population. This qualitative assessment enhances the interpretation of quantitative data and directs changes in care processes. For example, a CNS might notice a pattern of frequently missed clinic appointments for a heart failure patient. Through the therapeutic partnership, the CNS may determine that a lack of clinic parking results in a barrier for this patient to keep appointments. The outcome is not one of a noncompliant patient but a logistical failure that requires immediate resolution for the benefit of all clients with heart failure. When a home care nurse notes that older patients are not taking medications consistently, a CNS’s engagement with those patients can provide a more detailed and complex assessment. The result of such an assessment may be that older patients are cognitively impaired and forget to take their medications, the medication regimen may be too complex, causing a patient to miss doses, or the medication may be too expensive and not covered by supplemental insurance or Medicaid, causing a patient to halve or skip doses and let prescriptions go unfilled. The CNS’s evaluation might integrate advanced assessment skills, such as cognitive screening, into the admission assessment of all older patients, might identify therapeutic alternatives, such as a simpler or more economical medication regimen, to improve compliance, or might introduce other creative interventions to promote health and quality of life.


A CNS’s clinical practice interventions may be continuous, in which the CNS carries a consistent caseload, or time-limited, regular, or episodic, in which the CNS cares for complex cases as they arise (Koetters, 1989). Examples of regular ongoing care include the following: providing care for high-risk newborns in a pediatric special care clinic; providing psychotherapy, medication management, and other specialized nursing care for patients requiring mental health care; delivering total patient care to the first patients in an innovative surgery program; or providing yearly comprehensive neurologic care for children with spina bifida in a hospital-based clinic. Episodic care helps a CNS assess and intervene in a particular problem. Examples of episodic care include planning and coordinating a patient’s complex hospital discharge, facilitating a support group for families of children with hydrocephalus, and providing total patient care (similar to a staff nurse but with a different lens) to determine the feasibility of proposed changes in patient care or other system changes. Involvement in regular or episodic care enables CNSs to identify systems problems that interfere with care and require CNS intervention. Examples include lack of staff knowledge, the need for clinical policies or procedures, and the need for conflict mediation among team members. For each clinical situation, a CNS takes a comprehensive approach, using discriminative judgment, advanced knowledge, and expert skills, including expertise in the technical, humanistic, and organizational aspects of care. In these situations, CNSs are particularly skilled at the use of surveillance, quickly identifying patient and system issues and intervening to avoid further complications. A CNS intervention may be as simple as assisting a patient and family navigate a hospital’s bureaucracy. A CNS knows how and when to break the rules and when to bypass organizational or philosophical roadblocks, thus ensuring the focus on the patient and family and a successful outcome.


If clinical skills (e.g., particularly psychomotor ones, such as administering chemotherapy and troubleshooting external ventricular drains) are not used periodically, CNSs become less proficient. Regular clinical practice helps a CNS maintain the expertise and clinical competence needed to practice and develop the skills of other nurses. In addition to maintaining and refining clinical skills, direct clinical practice is imperative at two pivotal points—during a CNS’s orientation to establish credibility and before and occasionally throughout the implementation of organizational change to assess the impact of the change on patient care. CNSs must weigh the benefits and costs of different ways to implement direct care. Advantages, such as developing credibility with staff or maintaining one’s skills, are evaluated against potential disadvantages, such as competing demands or time pressures. For example, the pediatric oncology CNS may need to prioritize responsibilities, such as talking with parents of a child newly diagnosed with neuroblastoma, performing a lumbar puncture on a 3-year-old with leukemia, teaching the pediatric chemotherapy class, and visiting the school of a child who has been treated with radiation and chemotherapy for a brain tumor and now has learning disabilities. In addition to episodic involvement with particular patients, a critical care CNS could schedule 8 hours of staff nursing per month to maintain clinical skills, assess staff needs and the quality of teamwork and communication, and identify obstacles to the delivery of care. This hands-on involvement helps a CNS understand the conditions under which nurses are expected to implement standards of care and ensure quality.


Clinical practice can also occur indirectly. For example, a CNS may delegate direct care to a staff nurse but still guide the care. A CNS’s goal is always to improve the direct care skills and knowledge of staff nurses. A CNS may select a patient population in which there are recurrent problems, poor outcomes, or recidivism and then collaborate with members of the health care team to develop and implement standards of care, clinical pathways, clinical procedures, and/or quality or performance improvement plans. Implementation of and adherence to recommended practice changes should be evaluated to assess the impact of the change on outcomes, refine algorithms or guidelines, improve clinical management, and promote consistent adherence. Algorithms and guidelines are rarely self-sustaining and require a champion who continuously facilitates their implementation, constantly evaluating new evidence that may result in the need for revisions. This role is imperative if the algorithm or guideline is to be successful and achieve its intended outcome. A CNS is often the person to fulfill the champion role.


System responsibilities for evaluating technology and its impact on patients and resources is another facet of the CNS’s indirect clinical practice. Technologic advances have accelerated changes in health care delivery. These advances, however, coupled with the pressure of cost containment, increased competition, heightened consumer expectations, and capped budgets, create conflicting demands and priorities. Technologic advances have provided the objective data necessary to make clinical judgments (e.g., medication titration based on hemodynamic indices), devices to remotely assess a patient (e.g., telemonitoring of vital signs and weights), and interventional alternatives to treat disease (e.g., fiberoptic, robotic, and virtual reality surgery). However, technology warrants close scrutiny, because with it comes responsibility to evaluate its impact on budgets, quality of care, the environment, risk-benefit ratios, staff, and patients.


Patient safety is integral to all aspects of direct and indirect clinical practice, including CNS availability to and support of novice nurses (Altmiller, 2010; Ebright, Urden, Patterson, et al., 2004). The CNS’s familiarity with National Patient Safety Goals, the Agency for Health Research and Quality (AHRQ) patient safety network, teaching strategies from Quality and Safety Education in Nursing (QSEN), and Open School at the Institute for Healthcare Improvement (IHI) are resources that can help the CNS keep abreast of patient safety issues (AHRQ, 2012; IHI, 2012; QSEN, 2012; The Joint Commission [TJC], 2012). It is this direct clinical practice that empowers a CNS to assume a leadership role in evaluating patient safety, exploring root cause analyses, and preventing adverse events. A CNS facilitates change, influences others, and builds an atmosphere of trust in situations in which adverse events are investigated.


Although providing direct care to patients is a core competency, how CNSs provide direct care varies across CNS specialties and practice settings; it is determined by population needs, influenced by the expertise of other nursing personnel, and affected by regulatory designations of CNSs as APNs and their scopes of practice. When, how, for whom, and with whom direct care is given are fluid and are negotiated and renegotiated with professional nursing staff and organizational leadership, based on patients’ needs and the knowledge and clinical skill of nursing personnel.


Exemplar 14-2 illustrates how one of the authors (CC), a pediatric CNS, uses her professional competencies to provide expert care to a specific patient population and demonstrates the importance of direct care to execution of the other CNS competencies. CC coordinates health care services for a large pediatric craniofacial population, specifically infants with craniosynostosis. The pediatric neurosurgeon with whom CC works uses a new, less invasive technique to correct craniosynostosis in young infants. To inform families and referring health care providers about craniosynostosis treatment in her hospital, CC has developed and maintains a craniosynostosis link on the institution’s website. This minimally invasive surgical treatment—and its follow-up—has drawn patients from a large geographic area.



Guidance and Coaching


One of the essential components of the CNS role is that of expert coach. This role of coach, guide, or educator is one that facilitates transition from one situation to another and depends on the interaction of technical, clinical, and interpersonal competencies and self-reflection (see Chapter 8). Its development is also influenced by scholarly inquiry and the use, interpretation, and application of relevant research. CNSs use formal and informal coaching and teaching strategies with patients and families, nurses and nursing personnel, graduate nursing students, other clinical nurse specialists, health professionals, consumer groups, and organizations or systems (see Chapter 8).



imageExemplar 14-2   Direct Clinical Practice and Core Competencies of the Clinical Nurse Specialist


I (CC) perform the preoperative history and physical examination in the clinic, order appropriate radiographs, laboratory tests, and consultations, and obtain cephalometric measurements and photographs for patients undergoing surgery for craniosynostosis. On the day of surgery, I notify the staff nurses who will be caring for the patient about pertinent findings and specific needs. Postoperatively, I assess the patient for adequate pain control, dietary needs, vital sign changes, incision status, swelling, and neurologic function. I facilitate discussions about these findings, staff nurses’ concerns, parents’ concerns and plan of care among care team members. I adapt standing orders for each patient in collaboration with the neurosurgeon.




Guidance and Coaching


The Internet can be an excellent resource for families seeking health care information about medical conditions and treatment options. To help families learn more about craniosynostosis, I created a website that describes the various types of craniosynostosis and treatment options, including a new, less invasive technique. As a result, I receive many inquiries from families seeking information about this new technique for their babies. Providing accurate information on the website is critical so that families can make informed decisions about surgery. Much of the preoperative teaching is done by telephone or in the clinic because parents and other family members have many questions.


I have educated nurses about the early recognition of craniosynostosis, surgical options, and positional plagiocephaly through professional journal articles, a book chapter, presentations at national nursing conferences, teaching at the school of nursing, and in-service education programs for the staff nurses. Mentoring graduate students has provided additional opportunities for role modeling.






Ethical Decision Making


Although this new surgical treatment for craniosynostosis results in minimal blood loss, an infant will occasionally present with a low hemoglobin level or experience excessive intraoperative blood loss. Some families refuse blood transfusions for religious reasons, requiring more intensive preoperative preparation to minimize the need for a blood transfusion. Being present for the conversations that the neurosurgeon has with the family who refuses blood transfusion assists in understanding the reasons for refusing a blood transfusion and allows the CNS to reinforce the plan of care should the child need blood during or after surgery. A protocol for preoperative erythropoietin injections can be sent to the patient’s pediatrician in an attempt to increase the hemoglobin level.


A great deal of preparation is required for a family to bring their baby to the hospital for this type of surgery. The CNS is instrumental in facilitating this process, using the core competencies and spheres of influence.



Patients and Families


A CNS’s expert coaching and guidance are pivotal in providing or influencing patient and family education. CNS coaching and teaching complement the care given to a patient and family by other nurses and health professionals. CNSs continually seek better ways to coach patients and families using combinations of cognitive, educational, and behavioral strategies to improve patient education and adherence to interventions. However, a CNS cannot teach every patient and family and so must assess whom to teach. For example, a CNS could mentor a case manager or presurgical program educator to provide routine preoperative teaching for cardiac surgical patients. A CNS could then allocate more time to coach high-risk, complex, unusual, or challenging patients, such as a teenage girl with a recurrent brain tumor who is scared that she will die if she undergoes surgery again, or a young pregnant mother whose fetal MRI scan shows that her baby has spina bifida and must prepare to give birth to a child with special needs. A CNS may demonstrate to staff nurses how to facilitate difficult conversations with patients and their families by supporting the parents of a newborn who has died, working with a patient and family on end-of-life decisions, or “translating” a physician’s technical explanation into lay terms.


As health care systems are restructured, there is increasing emphasis on patients’ accountability for their own health. This means that in addition to coaching individuals, CNSs are even more likely to be involved in educational program planning and implementation aimed at helping groups of patients manage chronic illnesses and associated symptoms. Many patients know that they need to be better informed and educated about the health risk determinants, preventive self-care, treatment options, and risks and benefits of treatments, but their health care behaviors are influenced by many personal, psychological, and sociocultural factors. Because a patient is not always able or willing to change his or her lifestyle or to adhere to health care recommendations, a CNS must determine which patient or patient population is most appropriate for the advanced coaching requiring a CNS, such as a prenatal patient with poor social support living in an economically depressed community, an African American woman at risk of contracting human immunodeficiency virus (HIV), or a teenager who engages in risky behaviors. With many consumers seeking health care from nontraditional providers (Tindle, Davis, Phillips, et al., 2005), CNSs often help patients and providers integrate conventional and integrative therapies into care plans.



Nurses and Nursing Personnel


A CNS is a role model for nurses, demonstrating the practical integration of theory and EBP. Whereas nurse practitioners (NPs) and certified nurse-midwives (CNMs) primarily coach patients and families, a CNS strives continuously to improve clinical practice and integrate new knowledge into practice, thereby influencing the further development of the proficient and expert nurse and enhancing the staff nurse’s accountability and self-sufficiency (Cronenwett, 2012). A CNS cannot be effective when she or he is or is perceived to be territorial, omnipotent, or omniscient (see Chapter 11). A CNS’s time is often better spent by teaching others the why, what, and how of common patient care interventions rather than repeatedly personally providing those same interventions. For example, a well-developed, standardized nursing care plan that details the assessment of different wound types and stages, with stage-specific interventions, will enable the nursing staff to provide consistent and evidence-based care to patients with the simpler types of wounds. The CNS is then appropriately consulted for complex wounds. Developing standards for patient education and providing resources to ensure consistency across populations are equally important CNS educational activities. As a staff nurse applies the new knowledge and skills taught by a CNS, the CNS can attend to new or more complex responsibilities. A staff nurse can become the role model for the skill mastered or the knowledge gained, and so a CNS’s influence will continue to improve patient care. This notion of extending the reach of the CNS’s expertise can be considered a defining characteristic of the coaching competency of CNS practice. The cycle of enrichment and growth is never complete. Whenever major staff turnover occurs or a CNS enters a new practice setting, the cycle must begin anew.

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Related posts:

  1. Role Development of the Advanced Practice Nurse
  2. The Acute Care Nurse Practitioner
  3. Leadership
  4. Evidence-Based Practice

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Oct 19, 2016 | Posted by in NURSING | Comments Off on The Clinical Nurse Specialist

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