1. Fulton, Janet S. PhD, RN, ACNS-BC, FAAN

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The United States is on the road to health care reform. There is a plan, the Affordable Health Care Reform Act, which became law on March 23, 2010. Recently the Institute of Medicine released the Future of Nursing.1 This report, a call to action for nursing, is intended to ensure the public has access to nursing services as we proceed on the road to health care reform. Available at, the report is required reading for every clinical nurse specialist. Additional information about the report can be found at


Based on the Institute of Medicine report, I recommend adding to our clinical nurse specialist (CNS) to-do list some actions for clearly articulating CNS practice to the public. Consider a typical within nursing explanation of the CNS role and practice, which tends to go something like this:


Nursing has 4 recognized advanced practice roles, and each is composed of practice competencies. Graduate education prepares nurses to function in the role. Clinical nurse specialist practice competencies are organized in 3 domains-patient/client, nurses and nursing practice, and organizations/systems. Clinical nurse specialists provide innovative, cost-effective, high-quality care to patients and families; provide clinical leadership at the bedside to ensure evidence-based best practices are delivered by the nursing staff; and remove system barriers to advance nursing practices and improve patient outcomes. We have knowledge and skills in consultation, collaboration, mentoring, coaching, teaching, and research among others. We apply theory to practice, provide holistic care, promote self-management, support family caregiving, and evaluate patient outcomes. We are clinical nursing experts in problems related to complex chronic disease management and specialize in specific diseases, clinical problems, or setting-specific care.


Now picture yourself at a meeting of retired persons or parents of children with cancer and giving this explanation. I don't think it would be very helpful in increasing the public's understanding of CNSs.


For patients, chronic disease is "what it is that I have, don't want, didn't ask for, and can't get rid of" (adapted from "What It Is That I Have, Don't Want, Didn't Ask for, Can't Give Back, and How I Feel About It," a booklet developed and published by the Ohio Cancer Information Service, Nancy Kesselring Brand, MA, director; produced under NCI contract N01-CN-85398 [year unknown]). Clinical nurse specialists help patients and families deal with the problems of living with "what it is." We manage symptoms, which in patient terms means we help them feel better. Sometimes we help by prescribing or adjusting medications, and sometimes we recommend other interventions, such as a cool cloth across the forehead or music for distraction. We promote optimal functioning and preserve functional status, which means helping patients to do what is important to them and to do it as independently as possible. Our interventions could include daily exercises to improve balance or a comfortable chair that is easy to get into and out of without help. We pay attention to how medical therapies designed to manage a disease also have adverse effects that can interfere with feeling well and functioning independently. People are defined largely by what they do, and CNSs help patients feel good and do what is important while living with "what it is." We help patients stay home with their families and come to a hospital only when necessary and then for the shortest time possible. We use self-management theories and research findings to guide our interventions, but to patients find ways to explain, motivate, and build confidence as they struggle to incorporate "what it is" into their lives. Our work is guided by theories of caregiving and social support, but to families we explain things and show them what to do. We listen to spouses, children, and friends who are all concerned about the patient, and we offer suggestions for how each can help the patient in his/her own way. We confer with patients and families, because over time they become experts in managing "what it is," and they need us to engage them as partners, not recipients. We walk the "what it is" journey with patients and families, and we take that privilege very seriously.


We keep the patient's and family's best interests in mind thorough all aspects of our work, including our work behind the scenes. We assist nurses in our individual specialties to practice to the highest standard. We teach and mentor new nurses. We promote quality and safety by implementing procedures to eliminate mistakes and minimize complications. We work with hospital administrators to address problems and improve the hospital system.


The time is now to tell the public what CNSs do. To that end, I put some thoughts into a table, a sort of translation from nursing language to public interpretation. It's a start, so please share your ideas for additions. As health care reform continues its rollout, let's make sure CNSs are always guided by nursing's social mandate to meet the public need for nursing services. A new CNS recently asked me if she thought a particular procedure should be done by CNSs in the acute care setting. I asked her: Is there a need for CNSs to do the procedure? How will nursing be serving the public by doing the procedure? Consideration of our social mandate trumps all other questions we can ask. We need science and theory to guide our practice, and we need education, regulation, accreditation, certification, and a host of other professional parameters to facilitate our practice, but we need to continuously articulate and refine our relevance to the public need for nursing services, or all else is for naught. Put explaining CNS practice to the public on your to-do list, please.




1. The Future of Nursing: Leading Change, Advancing Health. Accessed March 15, 2011. [Context Link]