1. Beglinger, Joan Ellis MSN, MBA, RN, FACHE, FAAN

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Healthcare reform is unfolding and promises to be the most significant practice transition of most nurses' professional lives. Although most of the details have yet to emerge, now is the time for clinical nurse specialists (CNSs) to step up and lead. The future will bring greater emphasis on population health and outcomes managed at the point of care. Nursing's role is critical, and for CNSs as leaders, mentors and coaches, the need has never been greater.


A number of forces are converging for dramatic change. The Affordable Care Act,1 with its goals of expanding access to insurance, improving clinical outcomes, increasing patient satisfaction, and reducing cost, is driving changes across healthcare systems. The Institute of Medicine's Future of Nursing2 recommendations unequivocally declared nursing as integral to the health of the nation, not only in the delivery of care but also to the design of the healthcare system. Strong evidence continues to emerge linking nurse staffing and nursing practice environments to patient outcomes.3-7 The achievement of positive outcomes will be closely tied to the evidence-based resource decisions made in practice environments. Clinical nurse specialists must be at the decision-making table. To fully contribute, the CNS must be positioned for full partnership within the organizations in which they practice, provide leadership to the work of clinical outcomes management, and serve as a catalyst for professional development.



The organizational structure, and the reporting relationships defined within, is critical to the success of CNSs. The most effective models for the future position CNSs as partners with colleagues in management, leading organizations whose core business is patient care. Contemporary governance models delineate the accountabilities of clinicians from the accountabilities of managers, with accountability for clinical practice vested in direct care providers and accountability for practice environment owned by managers. Clinical nurse specialists must be full members of the leadership team in the healthcare organization. Partnership means the CNS is fully engaged in strategic planning on par with managers and administrators of the organization, has a complete understanding of the organization's "big picture," and has meaningful voice in matters impacting the organization's ability to provide exceptional patient care. As a fully participating partner, CNSs must understand the "business" of healthcare and the constraints accompanying reform initiatives. A deep appreciation for the context of practice enables the CNS to realistically and effectively lead changes in practice and in the system of care.


The ideal organizational structure is flat, with a partnership between the nurse director (who is the frontline manager) and CNS leading each patient care unit, with both reporting to the chief nursing officer. The director provides resource management and the CNS provides clinical leadership. This powerful partnership creates the support nurses need to deliver excellent, safe, high-quality, cost-effective care.


At present, too few of our organizations are structured with nurse director-CNS partnerships (each master's prepared) at the point of care. More typical, the CNS is in a reporting relationship with an administrator in a multilayered management structure. This undermines the concept of equitable partnerships and is a result of costly layers of management that are unnecessary in a professional nursing organization with authentic shared decision making. Clinical nurse specialists must initiate the conversation about the importance of organizational positioning with nurse executives and nursing management teams. Evaluate together how the organizational structure enables (or impedes) a powerful leadership dyad in support of exceptional clinical practice.



The work of nursing can arguably be described as clinical outcomes management. As such, it is logical to look to our advanced practice experts to lead clinical work. This leadership manifests itself in a number of ways:


* Clinical nurse specialist practice serves as a model to all nurses. It showcases the very best of application of current evidence, interdisciplinary collaboration, and patient and family engagement.


* Clinical nurse specialists drive outcomes management within specialties and across in assigned clinical areas of responsibility. Clinical nurse specialists lead, coach, and mentor direct care nurses in identifying key quality indicators for the population served and use data to monitor progress and drive improvement. For example, CNSs support achieving 100% adherence to the Central Line Associated Blood Stream Infection Bundle8 and Ventilator Associated Pneumonia Bundle9 on units where patients have indwelling central venous catheters or are on ventilators.


* Clinical nurse specialists are an obvious choice to lead their organizations in cross-continuum initiatives for improving care of defined populations through use of best evidence and interdisciplinary teams. Examples include CNS-led teams to achieve certification as a Joint Commission-certified Primary Stroke Center or Joint Replacement Center.10


* Clinical nurse specialists ensure that the evidence linking nurse staffing and the practice environment to patient outcomes is clearly understood by all those who make resource decisions. Financial reimbursement will increasingly be tied to outcomes. There will be a combination of carrots and sticks, with exceptional outcomes financially rewarded and hospital-acquired conditions and readmissions penalized. Critical to an organization's success will be the relationship between staffing and outcomes. Clinical nurse specialists must partner with the nursing leadership team to "connect the dots" for the organization.




There is perhaps no more urgent or vital role for CNSs than serving as a catalyst for professional development. The Institute of Medicine report calls on nursing to lead, yet too many nurses are far from prepared for this newly envisioned future. Much work is needed to create a shared vision of the rights and obligations of membership in a professional discipline and of our individual obligations as professional healthcare providers. Too few nurses understand that, like all licensed, clinical professions, there are accountabilities to fulfill. Shared governance structures serve as a framework for ownership of practice. Clinical nurse specialists are uniquely positioned in a leadership triad, with the direct care nurse leaders and the managers, to advance the work of the profession through the governance structure. For CNSs, a highest priority is ensuring that nurses are focused on driving the patient outcomes and creating the patient experience that is critical to the success of the organization.


Equally important, CNSs shape the thinking and aspirations of individual nurses. Conversations about professional goals, the importance of advanced degrees, and the affirmation of specialty certification are examples. Clinical nurse specialists initiate journal clubs, lead interdisciplinary case reviews, facilitate grand rounds, and, in the process, teach direct care nurses how to do the same. Many of us can recall being influenced by more senior professionals, observing their performance, and seeking their wisdom. Clinical nurse specialists are uniquely positioned at a point of care to model the behaviors to which all nurses should aspire.


The future of nursing and the future of healthcare are inextricably linked. There is much work ahead, and there is no role more vital to our future than that of CNS. It is time for CNSs in every setting to step up and choose to lead in an era of reform.




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8. The CLABSI Bundle. Accessed October 2013. [Context Link]


9. The VAP Bundle. Accessed October 2013. [Context Link]


10. The Joint Commission. Certification. Accessed October 2013. [Context Link]