1. Coke, Lola A. PhD, ACNS-BC, FAHA, FPCNA, FNAP, FAAN

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With the onset of the pandemic, clinical nurse specialists (CNSs) have had to pivot and perform in new and innovative ways. They are making significant contributions to quality healthcare. New practice and care delivery models have been tested, and rapid changes in delivery of care are occurring daily especially in our intensive care environments. Today's CNS scope of responsibilities encompasses micro, meso, and macro systems levels, and the impact is great. Role responsibilities vary widely, and positioning on the organization chart varies widely as well; CNSs are rising to the occasion. That is the beauty of this role-we are uniquely flexible, change agents! Today's healthcare systems are complex, and CNSs constantly modify their skill set to navigate these systems effectively to promote needed integration of best practices and implementation of systems change processes.


With such a resurgence in the CNS role, it is time to examine how we educate and push for legislation among the states to ensure full scope of practice. There have been improvements in academic curricular design to include quality and process change principles especially in programs with the Doctorate of Nursing Practice as the terminal practice degree. We are seeing new programs being developed, and it is time to ensure these programs develop educational processes to match the work of the CNS. Now is our time to evaluate all aspects of the role and push for changes in education, legislation, and practice.


Using the Clifford Clinical Specialist Functions Inventory of clinical practice, education, administration, and research, the role functions of the CNS were examined from both the CNS and nurse administrator perspectives nearly 3 decades ago. Results demonstrated clinical practice had the highest mean score from both the CNS and leadership perspective, with administrative functions having had the lowest mean score.1 Of clinical practice function items on the inventory, CNSs selected "assesses patient problems" and "prescribes nursing interventions" as the first and second priorities, respectively. Nurse administrators selected "promotes upgrading of nursing care in specific areas" and "assesses patient problems" as the first and second priorities, respectively. Both groups rated "administers routine direct care" as the lowest aspect of clinical practice. Under the education functions on the inventory, both groups ranked "acts as consultant to nursing staff" as the highest priority. Under administrative functions, both groups ranked "takes leadership in defining, maintaining, and interpreting standards of nursing practice" as the highest priority. Finally, under research functions, both groups ranked "assists nursing personnel in utilizing research to effect change" as the most important priority.


Variability in CNS education and role responsibilities continue to emerge in the literature. Although a strength of the CNS role can be the variability in the role responsibilities among healthcare settings, it has resulted in challenges in the delivery of education to best prepare for this vital advanced practice role. In 2014, Foster and Flanders wrote about the challenges in CNS education and practice. They wrote about the Consensus Model for APRN Regulation including the Licensure, Accreditation, Certification, and Education model and the emphasis that APRN roles obtain full scope of practice by 2015. They emphasized that CNSs are well positioned to transform healthcare by exercising the 3 spheres of influence in population-based care. However, at this time in 2014, they identified that education for the CNS role lacked standardization and there were still the barriers of state regulation and role recognition that impacted role development and growth. Many concerns were identified including adequacy of faculty, clinical preceptors, and clinical practicum settings and funding sources for students.2 They pointed out that the CNS is certified to practice across a range from wellness to acute care with a need to expand to a population health focus. Moreover, those with master's degrees need to have options for a seamless transition to Doctorate in Nursing Practice (DNP) studies. The year 2015 has passed, and there is still much work to be done. We need collaborative strategies between academe and practice partners to complete this work.


There is an emerging body of literature that supports the importance of doctoral preparation in the CNS role. The contemporary CNS is a systems leader who manages interprofessional collaborations, systems process change, and quality improvement (QI) initiatives at all levels of the system. For example, in an article by Tussing et al (2018), the impact of being doctorally prepared was demonstrated in the acute care setting. Most CNS practice is in the acute care setting, and the authors denote that a key challenge facing them is "balancing of the continuous need to increase quality of care and patient outcomes while simultaneously decreasing length of stay and overall costs of care."3(p600) The specialized education in project planning and finances received in doctoral programs provide the skills needed to face this challenge. The authors described the critical role of the CNS in designing a unit-based clinical coordinator role that was responsible for patient plans of care, especially at point of discharge. The American Association of Colleges of Nursing DNP Essentials and Competencies provided the framework for this system change. A second project involved the facilitation and education of staff nurses to develop and evaluate unit-level QI processes. A QI workgroup was formed, and a curriculum that included QI principles and evidence-based practice was developed. Role modeling and teaching the importance of QI and bedside scholarship by the CNS was key to teaching the nurses these skills. One project described a change in their nursing care delivery model in an outpatient wound care center, and the improved discharge teaching resulted in an increase in patient satisfaction from 75% to 99%. These authors concluded that "hospital and health system leaders must be open to the contribution of advanced practice nurses in new and redesigned roles. Nurses in these roles must demonstrate their value to healthcare administrators and nurse executives by sharing their outcomes and engaging in empirically based work to substantiate their value" (p 602).


In the practice setting, the findings mentioned in this literature are still highly relevant and remain key facets of the work of the CNS at the micro level. The CNS today needs to be appropriately educated to effectively execute systems level responsibilities and seamless transitions from master's to doctoral preparation need to be available so those in the CNS role can become better educated to practice effectively in today's healthcare environments. As the CNS role emerges in settings other than the acute care environment, educational strategies need to be developed to meet these role needs. This includes emerging roles in infectious disease, diabetes care, palliative care, and ambulatory care settings, to name a few. This includes advocating for more and continued federal traineeships that target the CNS role. Now more than ever, we need innovative doctoral educational programs to prepare nurse scholars to effectively practice in the CNS role. We need to consolidate lobbying efforts at the state level to push for consistency in the CNS scope of practice. Those of us in academe need to push for funding mechanisms so those in CNS roles have the monies to go back to school and obtain the education they need at the doctoral level whenever possible. Finally, like the work conducted in 1986 that examined priorities in the CNS role, a new inventory needs to be developed that reflects the spheres of inventory and current CNS competencies to measure the perceived priorities in today's CNS role, in all the settings where they work. These data can then inform collaborative efforts with executive nurse leaders to effectively actualize all role competencies in the workplace. There is much work to do!




1. Tarsitano BJ, Brophy EB, Snyder DJ. A demystification of the clinical nurse specialist role: perceptions of clinical nurse specialists and nurse administrators. J Nurs Educ. 1986;25(1):4-9. [Context Link]


2. Foster J, Flanders S. Challenges in clinical nurse specialist education and practice. Online J Issues Nurs. 2014;19(2):1. doi:. [Context Link]


3. Tussing TE, Brinkman B, Francis D, Hixon B, Labardee R, Chipps E. The impact of the doctorate of nursing practice nurse in a hospital setting. J Nurs Adm. 2018;48(12):600-602. [Context Link]