1. Section Editor(s): Proehl, Jean A. RN, MN, CEN, CPEN, FAEN

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Clinical nurse specialists (CNSs) are often asked to explain what it is that they do-even by nurses. As compared with a nurse practitioner who takes care of patients (easy to understand), a primary focus of a CNS is to take care of the nurses so they can take care of patients safely and efficiently using the best evidence available. What? The major focus of the CNS's role is to make sure that the stretcher-side nurses have the knowledge, skills, processes, policies, supplies, and equipment they need to provide safe and effective patient care. And still, a look of puzzlement. It's a hard role to explain because it encompasses so much territory.


Clinical nurse specialist is one of the four advanced practice nursing roles identified in the Consensus Model for APRN Regulation (APRN Consensus Work Group and National State Council of State Boards of Nursing QPRN Advisory Committee, 2008) with the other three being nurse practitioner, nurse midwife, and nurse anesthetist. The National Association of Clinical Nurse Specialists (NACNS) defines a CNS as an RN with graduate education as a CNS in a specialized area of nursing practice. The clinical component cannot be underestimated because "Clinical expertise in a specialty is the essence of CNS practice" (NACNS, 2004, p. 14). This is a key difference from the clinical nurse leader who is trained as a generalist, not as a specialist. Also, clinical nurse leader s are not advanced practice nurses.


Sometimes it is easier to describe what a CNS does not do: hiring, firing, disciplinary actions, scheduling, budgeting, and payroll are some key areas outside of the traditional CNS roles and responsibilities. However, the CNS often has input into hiring, firing, and disciplinary actions if clinical care is an issue.


Traditionally, the CNS role has been described as having four major components: expert clinician, educator, researcher, and consultant. Many authors add leader as one of the subroles; however, leadership qualities are really an overarching attribute that enables the actualization of the other roles. In addition, the spheres of influence in which CNSs practice have been identified as patient, nurse/nursing practice, and organization/system (National CNS Competency Task Force, 2010). Table 1 identifies examples of activities in the various roles and spheres of CNS practice. However, many cross boundaries into more than one role or sphere. McCaffrey (1991) used more colorful descriptions to describe the subroles the CNS must play to accomplish all of the main roles. In addition to the roles described by McCaffrey, "information broker" and "cat herder" are key subroles (see Table 2).

Table 1 - Click to enlarge in new windowTable 1. Examples of activities within CNS subroles and spheres of influence: Many activities cross the boundaries into more than one role and sphere of influence
Table 2 - Click to enlarge in new windowTable 2. Subroles of CNS practice

Unfortunately, when finances get tight, relatively well-paid but non-direct care positions like the CNS are often considered "nonproductive" and targeted for elimination. This is a short-sighted solution with long-term consequences. The elimination of CNS positions in the 1990s led to a vicious cycle of decline in enrollment in CNS programs, which led to fewer CNSs. With fewer CNSs, the positions that did exist could not be filled and were often eliminated, which decreased the apparent demand for CNSs. Sadly there are no longer any graduate programs in the United States dedicated to preparing CNSs in emergency care. However, many schools do offer the ability to focus on emergency care through another curriculum such as acute care or critical care.


Changes in health care delivery occur at a furious pace and CNSs are the masters of implementing change. These changes include the introduction of evidence-based practices and more effective and efficient ways to deliver safe care. The work of a CNS is collaboration in action-multidisciplinary and multispecialty teams are convened to address clinical care issues. They keep the emergency nurses of today current with changes in practice and help prepare the emergency nurses of tomorrow. An effective CNS can be a key factor in nurse satisfaction, which helps with both recruitment and retention of qualified emergency nurses, which saves money that would be spent for recruitment and orientation. More satisfied nurses may lead to more satisfaction among patients and that can result in increased patient volumes and reimbursement.


The impact of a CNS is difficult to measure in dollars and cents, but there are many ways in which CNS practice affects the bottom line. In The Youngest Science, Lewis Thomas equated nurses with glue; the glue that holds hospitals together and enables them to function (Thomas, 1983). To build on that analogy, the CNS is the glue that holds the clinical aspects of nursing together, which in turn allows the nurses to function, that is, to take care of patients. If there was ever a time when CNSs were needed, it is now.


-Jean A. Proehl, RN, MN, CEN, CPEN, FAEN


Emergency Clinical Nurse Specialist


Proehl PRN, LLC


Cornish, NH




APRN Consensus Work Group and National State Council of State Boards of Nursing QPRN Advisory Committee. (2008). Consensus Model for APRN Regulation: Licensure, accreditation, certification & education. Retrieved November 16, 2015, from[Context Link]


McCaffrey D. (1991). The unspoken subroles of the clinical nurse specialist. Clinical Nurse Specialist, 5, 71-72. [Context Link]


National Association of Clinical Nurse Specialists. (2004). Statement on clinical nurse specialist practice and education (2nd ed.). Philadelphia, PA: Author. Retrieved from[Context Link]


National CNS Competency Task Force. (2010). Clinical nurse specialist core competencies: executive summary 2006-2008. Philadelphia, PA: Author. Retrieved from


Thomas L. (1983). The youngest science: Notes of a medicine-watcher. New York, NY: Penguin Books. [Context Link]