1. Goudreau, Kelly A. DSN, RN, CNS

Article Content

As a clinical nurse specialist, you deal with the issue of staff competence on a daily basis. It is you who is drawn in when a nurse does not seem to be performing well and needs some remediation, and it is you who is often tasked with working closely with that nurse to assess and assist him or her. Ensuring that staff members who provide care are competent and safe in the provision of patient care is a part of a clinical nurse specialist's professional responsibility. But what does competence really mean?


In the clinical setting, we have often used completion of educational modules and tests to validate that nurses are competent and able to perform the duties of their assigned scope of practice. The addition of role-playing and use of psychomotor skills demonstration has been beneficial to the learning experience and, therefore, the assessment process. However, how many nurses have you seen who can respond appropriately to the educational content but cannot then perform the skill, task, or complex thought process involved in the competency when called on in a real situation? Thankfully, in my experience, the number is extremely low. However, those few who could not bring the educational content and real life into synergistic balance created a situation where the tools we use to assess their ability seemed inadequate.


Where did the concept of competence and, subsequently, the idea of competencies come from? Competence used to be considered a concept with much more depth than seems to be interpreted today. Brezinka (1988) described competence as a stable component of personality that is valued by the community in which we live, a virtue, a general sense of excellence and goodness, and being up to those tasks that life presents us. It seems that the definition today has shifted toward competency rather than competence. Competency in turn is defined as the accomplishment of specific and discrete tasks and skills to a level determined as adequate based on standards and expectations (InfED Encyclopedia, 2006; Herringer, 2002). These 2 definitions, seemingly at odds with each other, describe a personality trait versus a set of tasks and skills. Perhaps, that is why our instruments do not seem adequate when we are working with someone who just does not seem to "get it." The implication and expectation of the 2 seemingly conflicting definitions is that behavior can be objectively weighed and measured. Thus, we work at creating lists of tasks and skills and quantifying actions and expectations that become longer with each refinement and iteration. The difficulty is that there always has to be some uncertainty about what is being measured. The role of overall judgment is sidelined because it cannot be quantified on a list, yet that is what we are trying to assess.


How is competence determined? A generally held premise about how to assess competence comes from the publications from the Unit for Development of Adult Continuing Education (UDACE) in the United Kingdom, which published a number of documents on the topic in the late 1980s. UDACE (1989) made the statement that "competence is concerned with what people can do rather than what they know" (p 6). Assumptions in competence assessment include that it is:


* an assessment of skills being completed within a specific context;


* a description of what someone can do;


* based on clearly defined and widely accessible standards; and


* a time-specific "snapshot" of abilities (Tight, 1996).



As a result, we create those standards and lists of expectations. How, though, do we capture the thought process that we think of as critical thinking or analytical thought?


Recent developments and innovations are spreading in the world of education and training in the form of simulation. Although simulation has been used for decades in training and recertifying pilots, it is only just making inroads into the high-risk arena of healthcare. Educational institutions are creating simulation laboratories and using manikins that are technologically advanced enough to simulate with lifelike quality the occurrence of a health situation that warrants immediate attention and application of skills and knowledge in a simulated crisis. The intent is to assess competency and perhaps capture that lost element of competence.


The National League for Nursing has been conducting research on the use of simulation in the educational environment since 2003 (Jeffries and Rizzolo, 2005). Their foci in 8 pilot sites located around the nation are to assess the efficacy of using simulation in the educational environment and develop faculty that can use simulation as a teaching technique. Also under question is whether student participation in simulation as an educational process and outcomes assessment makes a difference in competency. They are now in the third year of the 3-year study, so it is still too soon to tell what the final outcomes will be. They are reporting, however, a definitive increase in the confidence level of the students as compared with those who did not use simulation in their educational experiences.


Larew et al (2006) described their work on simulation in the academic environment as complex, time consuming, and costly. They note that students who have "[horizontal ellipsis]higher levels of competency progress faster through the scenario, identify more problems, practice a wider range of assessments and interventions, and resolve a larger number of problems" (p 20). Their work, too, is ongoing. Jones et al (2002) described work done in assessing ongoing competency for hospital-based skills assessments. They described an assessment of simulation versus traditional methods of reviewing nursing skills competency in a face-to-face assessment process. They reported no statistical difference between the 2 modalities in use.


It is too early to tell if the use of simulation in the classroom and the clinical environment will provide the "missing link" between the traditional definition of competence as articulated by Brezinka (1988) and the current definition of competency. More research and more work on clearly defining competence versus competency are needed. Competence and competency are areas that clinical nurse specialists have to deal with on the front lines of healthcare on a daily basis. It is too easy to fall into defining the lists of required competencies and then assessing each individual and his or her capabilities in performing the required skills according to the established standard. There is so much more to competence, though, and it is that part of the challenge that really warrants our attention and energy.


Think about what competence really means to the patients whom you and the staff serve. Identify how you can role model competence for the nursing staff and for your peers. Think about how to capture an assessment of that competence and validate that the staff carry it as well. This is where there is much work that can be done, needs to be done, and will be done by clinical nurse specialists in collaboration with the researchers.




Brezinka C. Competence as an aim of education. In Spiecker B, Straughan R, eds. Philosophical Issues in Moral Education and Development. Milton Keynes: Open University Press; 1988.


Herringer JM. Once isn't enough when measuring staff competence. Nurs Manage. 2002;33(2):22.


Smith MK. InfED Encyclopedia. Competence and competency. 2005. Available at: Accessed September 30, 2006.


Jeffries PR, Rizzolo MA. Year two-end of year report: designing and implementing models for the innovative use of simulation to teach nursing care of ill adults and children. 2005. Available at: Accessed September 30, 2006.


Jones T, Cason CL, Mancini ME. Evaluating nurse competency: evidence of validity for a skills recredentialing program. J Prof Nurs. 2002;18(1):22-28.


Larew C, Lessans S, Spunt D, Foster D, Covington BG. Innovations in clinical simulation: application of Benner's theory in an interactive patient care simulation. Nurs Educ Perspect. 2006;27(1):16-21.


Tight M. Key Concepts in Adult Education and Training. London: Routledge; 1996.


UDACE. The Challenge of Change. Leicester: NIACE for UDACE; 1989.


NACNS Updates

NACNS Holds Fourth Invitational Summit for CNS Community

The National Association of Clinical Nurse Specialists (NACNS) hosted the fourth invitational summit for the CNS Community on July 21 to 22 atSigma Theta Tau headquarters in Indianapolis, Ind. The focus of the 2006 Summit was education and practice competencies of doctorally prepared CNSs.

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A total of 35 individuals representing NACNS and the following organizations attended: American Association of Critical Care Nurses, American Association of Critical Care Nurses Certification Corp, American Nurses Association, American Nurses Credentialing Center (ANCC) and the ANCC Commission on Certification, American Psychiatric Nurses Association, American Society of PeriAnesthesia Nurses, Association of PeriOperative Registered Nurses, Association of Rehabilitation Nurses, Board of Certification for Emergency Nursing, Commission on Collegiate Nursing Education (CCNE) and the CCNE Board of Commissioners, Emergency Nurses Association, National League of Nursing-AC, Oncology Nursing Society, and the Quad Council/Association of Community Health Nursing Educators.


Activities during the Summit included a panel presentation on DNP programs, a comparison of the CNS competencies from the NACNS Statement on Clinical Nurse Specialist Practice and Education (2004) with competencies listed in the proposed Doctor of Nursing Practice Essentials (American Association of Colleges of Nursing, 2006), and group discussions on differences in competencies between master's prepared and doctorally prepared CNSs. Results of the discussions indicated that the CNS competencies listed in the Statement were still relevant overall and identified several areas needing additional development. The summit concluded with a discussion of next steps and follow-up for NACNS. In response to recommendations, NACNS will be updating the White Paper on the Nursing Practice Doctorate (2005) and will convene a group of CNS stakeholders from NACNS and other nursing specialty organizations to develop curriculum recommendations and competencies for doctoral-level CNS programs.


Plan to Attend the 2007 NACNS Convention

Plan to spend your spring vacation in sunny Phoenix, Ariz, attending the 2007 National Association of Clinical Nurse Specialists (NACNS) convention to be held from February 28 to March 3. The convention will provide an excellent opportunity for clinical nurse specialists from all specialties to meet and learn from one another. The 2007 conference features the opening keynote presentation "Optimizing Quality and Safety: Unique Contributions of the CNS" by Marianne Chulay, DNSc, RN, FAAN, and a closing presentation by Bernadette Melnyk, PhD, RN,CPNP, NPP, FAAN, FNAP. There will also be 30 concurrent presentations and more than 30 posters about clinical practice, research, and CNS education.


In addition to the regular conference, there will be 2 preconference sessions on February 28, 2007. Participants will be able to attend both the annual Educators' Summit, "Creating a Culture of Quality Care and Safety," for CNS program faculty and other educators and our ever-popular legislative/regulatory training to assist CNSs to become effective advocates for CNSs in their home states.


A new addition to the conference this year will be a postconference session on Saturday, March 3, 2007, from 1 to 5 PM. The title of the postconference is "Clinical Nurse Specialists: Leaders in Falls Prevention Outcomes," and it will be presented by Pat Quigley, PhD, MPH, ARNP, CRRN, Deputy Director of VISN 8 Patient Safety Center, and Gail Powell-Cope, PhD, ARNP, FAAN, Associate Chief of Nursing Service for Research at Tampa, Va, and the Director of the VA RR&D Research Award Enhancement Program in patient safety technology. Materials for this session can be previewed at


Complete conference information will be available via the NACNS Web site,, in mid-November.


News From Our Affiliates

CACNS Affiliate News

The California Clinical Nurse Specialists (CACNS) Network Board had a very successful marketing Board meeting. Board members sent out almost 2,000 invitations to the "Annual Conference: CNS Outcomes: Ensuring Safety and Quality," at the Rancho Las Palmas Spa and Resort last November 4. In addition, the CNS Network plans to recommend a revision of its bylaws to include member representation from 3 regional areas for our large state. These areas will include Northern, Central, and Southern California. Our membership continues to stay large, with more than 262 active members statewide. Finally, the president of the CACNS Affiliate, Margaret Talley, will be serving a 2-year term on the National Association of Clinical Nurse Specialists Affiliate Advisory Committee.


Submitted by Margaret Talley, RN, MN, CNS.


News from the Clinical Nurse Specialist Foundation

The Clinical Nurse Specialist (CNS) Foundation met for its face-to-face Board meeting in July in Indianapolis. At the meeting, the Board focused on many of its strategic initiatives, one of which is the 1,000 for $1,000 campaign. There are currently 63 donors who have donated at the $1,000 level or greater. Your support of CNS education and research is needed by becoming a member of this campaign. Remember, the goal is to raise $1,000,000 in 5 years. Another initiative was Board education on development and fundraising. One plan from this educational session was to contact all donors and thank them for their support and solicit their help in developing more donations in support of the mission of the CNS Foundation.


Another initiative of the Foundation is the third annual Gala, which will be held in Phoenix, Ariz, during the National Association of Clinical Nurse Specialists (NACNS) conference. Dr Sue Davidson has agreed to be the chair for this event again. At the Gala, the Foundation will premiere a video on CNS practice across the country. The video will be used to enhance fundraising efforts and to increase the awareness of CNS outcomes in today's healthcare environment. If you have ideas for featuring CNS work in the video or if you have video materials that you would like incorporated into the video, please contact Dr Brenda Lyon at


Thanks to many of you who donated to the Don Dayhoff Memorial fund. A scholarship will be awarded to an Indiana CNS from this fund. There will also be 2 other scholarships awarded at the Gala. Silver Oak Search Consultants, a firm dedicated to promoting nurse leadership since 1989, has committed funds for CNS students, which the Foundation will award as one scholarship for a CNS student and support for 4 other CNS students who present abstracts at the conference. A third scholarship will be awarded from the CNS Foundation.


The CNS Foundation continues to work on the CNS Foundation Web page. The case statement and the ability to make donations will be added to the site. This will also be the mechanism for students to receive information on applying for the scholarships to be awarded.


The CNS Foundation meets 4 times a year: 2 face-to-face meetings and 2 conference calls. If you are interested in supporting the work of the Foundation, please contact Jan Bingle at The CNS Foundation recently welcomed Jo Ellen Rust, a past president of NACNS, to join the Foundation Board of Directors.


Correction: In the last issue of the newsletter, CNS Foundation Trustee and Bronze donor Don Shuck was misidentified as Donald Shuck. Our apologies to Mr Shuck.


Member Recognition

Joanne Alderman, MSN, RN, C, G-CNS, has been selected as a National Gerontological Nursing Association (NGNA) Fellow. NGNA Fellow status recognizes those who have demonstrated exceptional leadership and contributions to the field of gerontology and gerontological nursing. Fellows are nominated by their peers and are inducted by the NGNA Board. Their role is to advocate for aging and health issues in cooperation with NGNA and to advocate for NGNA's mission and goals. Ms Alderman is a gerontological clinical nurse specialist from Tulsa Regional Medical Center and Meadowbrook Specialty Hospital, Tulsa, Okla. She is well known in the field of gerontological nursing and has served as a member of a national expert panel convened by the American Association of Colleges of Nursing to develop gerontologic competencies for all advanced practice nurses. Ms Alderman has also been active within the National Association of Clinical Nurse Specialists (NACNS) with respect to the Hartford grant and the Long-Term Care Task Force.


Elisa Jang, RN, MS, CNS, Clinical Practice Manager, Critical Care Services at NorthBay Healthcare in Fairfield, Calif, recently accepted an appointment to the RN Panel of Judges for the National Council of State Boards of Nursing. There were 11 panel members who met for a week in Chicago during September to review and recommend standards for the National Council Licensure Examination-RN. Elisa was formally recognized in her organization's newsletter.


Marion G. Mann, RN, MSN, CNS, Clinical Nurse Specialist, Best Clinical Practices, Memorial Health University Medical Center, Savannah, Ga, was selected as a Southeast regional finalist in the Clinical Care category of Nursing Spectrum's 2006 Nursing Excellence Awards. Ms Mann's work implementing best practice protocols that have had a positive impact on clinical outcomes and cost reductions led to her nomination for this award. In addition to her work at Memorial Health University Medical Center, Ms Mann has been leading a campaign for CNSs to be recognized as advanced practice nurses in Georgia. She is also active in NACNS, serving as a co-chair of the NACNS Marketing Committee and president of the Southeast Georgia Affiliate.


Kim Nagy, MS, RN, has begun her new duties as vice president of patient care services and chief nursing officer at Lake Forest Hospital in Lake Forest, Ill. She oversees the practice of nursing at all Lake Forest Hospital facilities and has operational responsibilities for clinical departments at the hospital, its pharmacy, Home Health Care, and the Hunter Family Center for Women's Health. Ms Nagy most recently served as the hospital's executive director of women's services. Her previous duties also included providing strategic planning and development of leading-edge women's services for the Lake Forest Hospital Foundation. Ms Nagy is president of the Illiana Lakeshore Affiliate.


Theresa Posani, PhD(c), RN, CNS, was recently elected to the American Nurses Association's Congress on Nursing Practice and Economics (CNPE). She is currently performing independent consulting on an international basis with her own business-Consult a Nurse Specialist. She recently presented in the Philippines at a Philippine Nurses Association meeting on Acute Coronary Syndrome. Ms Posani also serves as the NACNS representative on the Adult Health Clinical Specialist Certification Examination Panel (CEP). Most recently, she served as the chairperson of the Board on Certification for the Advance Practice Nursing CEP groups and as a representative on the Commission on Certification for the American Nurses Credentialing Center.


News Briefs

Final Reminder: American Nurses Credentialing Center Certification Exam Eligibility Deadline Drawing Near

A final reminder to clinical nurse specialists (CNSs) seeking initial American Nurses Credentialing Center (ANCC) certification as a CNS. Last year, ANCC granted CNSs a 1-year extension to the January 1, 2006, deadline requiring a minimum of 500 hours of faculty-supervised clinical practica experiences for one to be eligible to take the ANCC CNS exams. The new deadline of January 1, 2007, is fast approaching, and after that time, graduates of programs with less than 500 clinical practica hours will not be eligible to sit for initial certification. If you want to take your initial certification examination before January 2007 and your program did not have 500 faculty-supervised clinical practica hours, you can make up the additional hours postgraduation by working as a CNS. You will need to have your clinical supervisor, who must be board certified or eligible to be board certified, verify that during the year before applying for certification, you made up the difference between the number of supervised clinical practica hours in your CNS program and the 500-hour requirement. To verify the hours you worked, your clinical supervisor must complete and sign part A of Form E-2, available on the ANCC Web site. After January 1, 2007, you will need to make up the additional hours through a faculty-supervised practicum experience by taking clinical courses that can be documented on a transcript. This change reflects the Commission on Collegiate Nursing Education Standards for Accreditation(Amended 2003) on curriculum development in which "the master's curriculum incorporates knowledge and skills identified in The Essentials of Master's Education for Advanced Practice Nursing (AACN, 1996)."


Oklahoma Governor Declares CNS Recognition Day

One hundred fourteen clinical nurse specialists (CNSs), CNS students, nurses, and nurse executives attended the Clinical Nurse Specialist Recognition Day Fall Conference, "Effectiveness of the CNS Role: Quality, Costs, Outcomes and Safety," held on Friday, September 29, in Tulsa, Okla, at the Laureate Hospital Education Center. This conference was sponsored by the Oklahoma Association of Clinical Nurse Specialists, the University of Oklahoma College of Nursing, and the Oklahoma Organization of Nurse Executives. The day began with a proclamation from the Governor of Oklahoma, the honorable Brad Henry, proclaiming September 29, 2006, as Clinical Nurse Specialist Day in the state of Oklahoma. Jan Bingle, MS CNS, chief nursing officer of the Community Health Network in Indianapolis, gave the keynote address. Evidence-based practice presentations were given by CNSs and CNS students. Other presentations included "How to Show Your Worth as a CNS" by Shelly Wells, MS, CNS, MBA, and "The Future of the CNS Role and the Doctorate of Nursing Practice" by Rebecca Phillips, PhD, CNS. The conference also included 3 hours of Advanced Pharmacology hours.


Copies of the Governor's proclamation were handed out to all the attendees. The original copy will be framed and displayed in the College of Nursing at the University of Oklahoma. Conference planners received many grants from pharmaceutical representatives and equipment vendors, which allowed them to hold this sophisticated conference. Jan Bingle commented, "This is just like an NACNS conference."


Scholarship Opportunities From the CNS Foundation

Silver Oak Search Consultants, a firm dedicated to promoting and supporting nursing leadership, has graciously given funds to support clinical nurse specialist (CNS) education. Silver Oak is providing one $1,000 scholarship to be awarded to a CNS student and $4,000 to support 4 students who will display their posters at the 2007 National Association of Clinical Nurse Specialists (NACNS) conference in Phoenix, Ariz. The Foundation will also award 2 other scholarships. One is a $1,000 scholarship from the Don Dayhoff Memorial fund to a CNS student from Indiana. The other $1,000 scholarship is awarded from the CNS Foundation to a CNS student. The application form for all 3 scholarships is the same. The scholarship application form can be found on the CNS Foundation Web page, accessible from the NACNS home page Please click on the logo to obtain the scholarship application and to find out more about the CNS Foundation.


Section Description

NACNS Statement on Clinical Nurse Specialist Practice and Education,Second Edition


This document articulates the core competencies requisite to CNS practice, outlines the outcomes of CNS practice, and provides direction to schools of nursing regarding the preparation of CNSs. Endorsed by the National League for Nursing and American Organization of Nurse Executives (AONE) as "a comprehensive reflection of the contemporary role that Clinical Nurse Specialists play in the delivery of quality nursing care," this updated version contains information for contemporary clinical nurse specialist practice and education. You can purchase your copy through the NACNS Office at a cost of $25 per copy for members of NACNS and $45 per copy for nonmembers. Discounts are offered on purchases of 15 copies or more. Contact the NACNS Office today to order your copy of the Statement.