Welcome to another new year of the journal. As is tradition, the turn of a new year is a time for reflection and visioning. In October, I was privileged to share in the National Association of Clinical Nurse Specialists (NACNS) Wisconsin Affiliate of Clinical Nurse Specialists' 10-year anniversary conference and celebration. "Honoring Our Past, Embracing Our Future" was the conference theme, a theme befitting a new decade for the affiliate and a new year for all of us. I recall that, before the NACNS existed, there were local clinical nurse specialist (CNS) groups pocketed throughout the country serving as beacons for networking, professional development, and regulatory leadership. It was at one of those regional CNS conferences that Pauline Beecroft, the founding editor of this journal, asked attendees to complete a questionnaire as part of her effort to garner publisher support for a new CNS journal. Thanks to her persistence, this CNS journal was established in 1986. The journal's title, Clinical Nurse Specialist: The Journal for Advanced Practice Nursing, reflects a core mission of CNSs as a force within nursing for advancing the practice of nursing.
The mission to advance practice has deep roots in the profession. Early on, it was recognized that the profession needed clinically expert leadership for improving and contemporizing nursing practice. For example, the 1923 Goldmark report found inadequate application of science and theory to practice in nursing education, and the 1948 Brown report recommended greater emphasis on developing clinical knowledge and skills for direct patient care.1 The Brown report further recommended that clinical nursing specialties be developed for putting greater emphasis on clinical leadership and discriminative judgment in practice. To address the Brown report recommendations, the then small group of national nurse leaders (few nurses held graduate degrees) began discussing the idea of an advanced clinical nursing expert. Reiter, the first dean of New York University's graduate school of nursing, described this idea of a clinical expert as a master clinician who uses discriminative judgment in determining care priorities and selecting nursing measures to achieve therapeutic objectives. In 1966, Reiter wrote that this clinical expert "[horizontal ellipsis]would be committed to 'hacking' her way down through the personnel pyramid so that her professional knowledge and judgment are exerted on behalf of every patient."2 Now, 50 years later, many CNSs find this quote to be an appropriate description of their daily efforts to advance nursing practice in the mega systems in which healthcare is delivered.
A distinctive difference exists between the CNS role and other advanced practice nursing (APN) roles (nurse practitioner, nurse midwife, and nurse anesthetist). These APN roles are heavily focused on providing services that frequently overlap with those of other disciplines, such as in the primary care setting where physicians, physician assistants, and nurse practitioners work collaboratively providing the same or similar care to clients. We need these skilled providers and more of them to meet the growing demands for care. However, although these APN roles deliver much needed direct care to clients, their role competencies do not include expectations for leading, advancing, directing, and supporting the delivery of nursing care by other nurses and nursing personnel within specialty. Clinical nurse specialists are the bedside elbow consultants to practicing nurses. We monitor their skills, identify patterns of problems among patient groups, and deal with system barriers to quality care delivery. We assure best practices, craft innovative interventions, and promote wise use of resources for the best possible clinical and fiscal outcomes. Clinical nurse specialists leave footprints for other nurses to follow in solving problems amenable to nursing interventions.
In addition, the CNS role is a specialist role. A specialist has narrower, in-depth knowledge as compared with a generalist nurse with broad but shallower knowledge. Graduate education was designed as the mechanism for developing the specialized in-depth knowledge for the CNSs. Today, as population health emerges as a priority care focus, the need grows for expert clinical specialty nurses to manage groups with similar health-related problems, such as heart failure, chronic obstructive pulmonary disease, or diabetes. Clinical nurse specialist specialty practice is timelier today than ever!
An enormous body of literature exists describing the CNS role and practice, starting in the 1960s. The Table summarizes some of the key role functions and practice competencies from the early literature. Discussion with attendees at the Wisconsin affiliate conference confirmed the salient nature of these early descriptions for today's CNS role and practice. Yet, the CNS role is often described with a caveat that it is poorly understood despite being consistently described during the years. Among the possible reasons for a perceived lack of understanding is the early failure to develop practice competencies and curricular guidelines. The American Nurses Association's 1986 Role and Scope of the Clinical Nurse Specialist,10 issued from its then newly formed Council of Clinical Nurse Specialists, was one of the first professional organizations to address the CNS role regardless of practice specialty. Unfortunately, the document did not delineate practice competencies. Not until 1995, with the formation of the NACNS and subsequent publication of the Statement on Clinical Nurse Specialist Practice and Education,11,12 did CNSs have a national professional organization to develop practice competencies and curricular recommendations for competency achievement. Various iterations of the competency updates exist, but no curricular recommendations exit beyond those in the NACNS Statement, now outdated. Nurse educators were reluctant to create CNS curricular guidelines, preferring to adapt the curricula to local and regional needs for nursing specialty practice. As a result, the practice of CNSs varied, and with no published competences to serve as a "common denominator," it was difficult to see from the outside the consistent elements across CNSs as they practiced in different specialties and settings.
The lack of competencies and curricular recommendations is not the only contributing factor to the CNS being a poorly understood advanced practice role. What is nursing? What do nurses do? Nursing practice is illusive to the public and profession alike. Nursing care remains invisible and imbedded in the room rate for most hospitals. In outpatient settings, nursing care is equally invisible, unless the care provided generates a billable charge. Nursing struggles to define its many positive contributions to patients and the public good. Because nursing is invisible, it should come as no surprise that articulating nursing practiced at an advanced level is a very daunting task. It's made more difficult by the lack of support within some circles in nursing and insidious undermining as if there is a best APN role. Thus is the challenge of the CNS role, the original graduate-level-prepared advanced nursing clinical specialty expert, born of nursing as a workforce charged with continuously advancing practice. The CNS makes critically important contributions to the nursing professions' social mandate by helping ensure continued relevance to the public good.
This journal, as it starts its 31st year, has been a repository for nursing practiced at the advanced level. It supports a body of literature chronicling CNS history, shares a wealth of ideas for advancing practice, and serves as an introduction to the next 50 years of CNS practice. Happy New Year!
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