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Florence Nightingale was the first to identify phenomena of concern to nursing. "In watching diseases[horizontal ellipsis]the thing that strikes the experienced observer most forcibly is this, that the symptoms or the sufferings generally considered to be inevitable and incident to disease are very often not symptoms of disease at all, but of something quite different," wrote Nightingale in Notes on Nursing.1(p8) The something quite different she identified were symptoms and functional problems. Nightingale designated nurses as the professional responsible for meeting symptom and functional needs and assisting patients to self-manage.


For decades since Nightingale, across multiple educational options and into the era of nursing science, nurses have continuously provided this unique service to the public-a service that was then and remains now quite different from disease care. The phenomena of concern most central to nursing practice remain those associated with symptoms and functional problems and are now identified as central to achieving nurse-sensitive outcomes-outcomes which focus on how patients and their health problems are affected by nursing interventions.2 In Nurse Sensitive Outcomes: State of the Science, Doran3 included chapters on functional status, symptom management, self-care, and patient safety. The Oncology Nursing Society's list of symptoms experienced by persons with cancer includes pain, fatigue, insomnia, nausea, constipation, anorexia, breathlessness, and diarrhea; functional status concerns include activities of daily living, instrumental activities of daily living, role functioning, activity tolerance, and nutritional status. Safety issues listed by Oncology Nursing Society include preventing infections, falls, and skin ulceration.2 CNSs, with a focus on advancing nursing practice, must be well prepared with knowledge of and interventions for nurse-sensitive outcomes that reflect the phenomena of concern for nursing.


At a recent national conference, I had an opportunity to have lunch with CNS students from several different schools. It seems none of the students seated at my table thought that the physical assessment course they were taking was relevant to their specialty CNS practice. Of particular concern was one school's requirement that they learn to do pelvic examinations. "I'm going to be a cardiac CNS," explained one student, "so why do I have to learn pelvic exams? I don't plan to ever do such an exam in my practice." This brought a round of head-nodding agreement. "If I ever have to do a pelvic exam," explained the soon-to-be rehabilitation CNS, "I'm sure I'll have to learn it all over again because one class does not make you competent for a lifetime especially if you never practice the skill." Other students were taking an advanced pharmacology course, although the community health CNS student stated that a toxicology course would be more relevant to her specialty to help her understand environmental hazards like lead exposure in children. These comments were not new; I have heard similar concerns over the years. Why are CNS students required to take courses that do not inform their specialty practice? Like many CNS programs, these students' programs required them to complete courses in pathophysiology, physical assessment, and pharmacology-one size fits all courses for advanced practice students that focus on primary care and differential diagnosis of disease. No one at my lunch table was taking a formal classroom course that focused on phenomena of concern for nursing or selecting or designing evidence-based interventions for achieving nurse-sensitive outcomes. The students considered content about nurse-sensitive outcomes to be highly valued but quietly tucked in clinical courses, which may account for the students' agreement that the clinical courses are where you really get to learn about being a CNS.


How did we arrive at a point in CNS education where students are required to complete courses that do not inform their specialty CNS practice-courses that do not address phenomena of concern for nursing? Here's one thought. If we again look at history, 10 years ago, in 1996, the American Association of Colleges of Nursing (AACN) published the Essentials of Master's Education for Advanced Practice Nurses.4 While an important document for pulling together what were then very disparate graduate curricula, the Essentials relied heavily on guidelines developed by the National Organization of Nurse Practitioner Faculties. The lack of fit between the Essentials and CNS curricula lies in the failure of the Essentials to make clear content on nursing's phenomena of concern. Sure, all advanced practice nurses address symptoms and functional problems to some degree and from varying perspectives; however, CNS practice focuses on selecting evidence-based or designing innovative nursing interventions for these problems-interventions within the scope of nursing that all registered nurses could implement across the continuum of care. Pharmacological interventions to treat disease are limited to advanced practice nurses with prescriptive authority and depend on the presence of the prescriber. In 1998, with the release of the first issue of the National Association of Clinical Nurse Specialists (NACNS) Statement on Clinical Nurse Specialist Practice and Education5, NACNS leadership met with AACN leadership to discuss recommendations for curricular modifications so that the Essentials would recognize the unique educational content required for all CNS preparation. However, the Essentials has not been updated in the 10 years since first released. So, although the Essentials never did have a strong focus on phenomena of concern for nursing, now more than ever in this contemporary and evolving practice world that recognizes CNSs' contributions to nurse-sensitive outcomes, the Essentials fails to address important curricular content for CNS practice.


CNSs must be well prepared with knowledge of and interventions for the nurse-sensitive outcomes reflective of nursing's phenomena of concern. Between 1998 and 2003, over 50% of CNS programs reported using the NACNS curricular recommendations.6 It is long past due to make sure that all CNS curricula are providing students with content that informs their practice and prepares them to advance the practice of nursing. The NACNS Education Committee is an outstanding group of educators who, by providing leadership for CNS education, have distinguished themselves as the authoritative voice for CNS education. Curricular consultation is available from the NACNS Education Committee. The Essentials of Master's Education document needs to be updated. The NACNS Education Committee is the perfect partner to assist AACN, thereby assuring that the revised Essentials addresses CNS education. It's time for CNS curriculum to fit CNS practice.




1. Nightingale F. In: Notes on Nursing. New York: Dover; 1969:859. [Context Link]


2. Available at: Accessed November 15, 2005. [Context Link]


3. Doran DM. Nurse-Sensitive Outcomes: State of the Science. Boston, MA: Jones & Bartlett; 2003. [Context Link]


4. American Association of Colleges of Nursing. The Essentials of Master's Education for Advanced Practice Nursing. Washington, DC: Author; 1996. [Context Link]


5. National Association of Clinical Nurse Specialists. Statement on Clinical Nurse Specialist Practice and Education. Harrisburg, PA: National Association of Clinical Nurse Specialists; 1998. [Context Link]


6. Walker J, Gerard P, Bayley EW, et al. A description of clinical nurse specialist programs in the United States. Clin Nurse Spec. 2003;17:50-57. [Context Link]