substantive areas of clinical nurse specialist...

Editor’s Note: In 2009, we will publish 6 articles for which 1 to 3 credit hours may be earned aspart of a CNS’s learning activities. Examination questions are provided at the end of this article foryour consideration. See the answer/enrollment form after the article for additional informationregarding the program.

Substantive Areas of ClinicalNurse Specialist Practice

A Comprehensive Reviewof the Literature

WENDY LEWANDOWSKI, PhD; KATHLEEN ADAMLE, PhD

Aim: A comprehensive review of the literature was performed to describe the substantive

clinical areas of clinical nurse specialist (CNS) practice. Background: There is lack of

understanding about the role of CNSs. Debates over blending CNS and nurse practitioner roles

are common, as are questions and uncertainties about new models of advanced practice nursingendorsed by the American Association of Colleges of Nursing. To better understand the role of the

CNSs and plan for new models of advanced practice nursing, it is important to know what CNSs

say about the nature of their work and examine research related to CNS practice. Method: Thefollowing databases were searched using the terms clinical nurse specialist or advanced nursing

practice: Cumulative Index to Nursing and Allied Health Literature, Medline, PsychInfo, Academic

Search Premier, ProQuest Dissertations and Theses, PapersFirst, and ProceedingsFirst. Criteria

for inclusion in the sample were determined a priori. Data were extracted from each article and

abstract using thematic content analysis. Findings: The final sample included anecdotal articles(n = 753), research articles (n = 277), dissertation/thesis abstracts (n = 62), and abstracts from

presentations (n = 181). Three substantive areas of CNS clinical practice emerged: manage the

care of complex and vulnerable populations, educate and support interdisciplinary staff, and

facilitate change and innovation within healthcare systems. Conclusions: There is a clear con-

ceptual basis for CNS practice, which is substantiated in the literature. Clinical nurse specialists

must continue to define this scope of practice to organizations, administrators, healthcare profes-

sionals, and consumers.

KEY WORDS: advanced nursing practice, clinical nurse specialist

One of the most important developments in the discipline of nursing has been theevolvement of clinical nurse specialists (CNSs), a role that dates back to the early

1940s. Over the ensuing decades, as CNSs have responded to changing healthcare environ-ments and patient care needs, they have been challenged to reshape essential characteristics

This article has beendesignated for CE credit. Aclosed-book, multiple-choiceexamination follows thisarticle, which tests yourknowledge of the followingobjectives:1. Identify the CNS spheres

of influence and thefeatures of this literaturereview.

2. Describe how CNSsmanage the care ofcomplex and/or vulnerablepopulations.

3. Outline the characteristicsof CNS practice relatedto educating andsupporting staff andfacilitating innovationand change withinthe healthcare system.

3. Explain the limitationsof this literature reviewand the confusion aboutthe CNS role.

CE fea tu re a r t i c l e

VOLUME 23 | NUMBER 2 73

Clinical Nurse SpecialistA Copyright B 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Author Affiliations: Kent State University, College of Nursing, Ohio.

Support for this project was given by the National Association of Clinical Nurse Specialists.

Corresponding author: Wendy Lewandowski, PhD, 5431 Brainard Road, Solon, OH 44139 (wlewando@

kent.edu).

9Copyright @ 200 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

of their practice, leading at times to a medley of roles andresponsibilities and a sense of ambiguity and confusion.There is also a lack of understanding about the work ofthe CNS by other nurses and healthcare professionals, ad-ministrators, and consumers. Today, new challenges exist.Debates over blending CNS and nurse practitioner roles arecommon, as are questions and uncertainties about 2 newmodels of advanced practice nursing endorsed by theAmerican Association of Colleges of Nursing (AACN)—theclinical nurse leader (CNL) and the doctorate of nursingpractice (DNP)—and the implications of these models forCNSs. To enhance understanding of the CNS role and itscontribution to healthcare, it is important to explore whatnurses who are practicing in the CNS role say about thenature of their work and examine both outcome and descrip-tive research related to CNS practice.

In the spring of 2006, the National Association ofClinical Nurse Specialists (NACNS) commissioned a proj-ect to examine areas of CNS clinical practice in thepublished literature and to answer the following question:‘‘What are the substantive clinical areas of CNS practice?’’A comprehensive review of literature was performed withthe aim of summarizing and critically evaluating publishedliterature, conference proceedings, and dissertation/thesisabstracts and of describing in depth the substantive clinicalareas of CNS practice. The purpose of this article is toreport the findings of this review.

CONCEPTUAL BASIS FOR CNS PRACTICE:A BRIEF HISTORY

Specialization in nursing can be traced back to the early1900s when Florence Nightingale recruited and taughtwomen how to deliver improved patient care to woundedsoldiers in the Crimean War; however, the role of CNS wasnot formally introduced until the 1940s when FrancesReiter1 first coined the term nurse clinician to describespecialists whose intent was to establish higher qualitypatient care. Reiter stated that the nurse clinician shouldhave advanced knowledge and expertise in clinical practiceand be capable of displaying a high degree of judgment andcompetence in providing nursing care in a specialized area.

During the next 3 decades, the CNS role was furtherexamined by nursing leaders and organizations. HildegardPeplau’s2 quintessential article in 1965 described the CNSas having expertise in nursing practice in the care ofcomplex patients. Peplau advocated for graduate educationin nursing, specifying the need to prepare the CNS at themaster’s level with a clinical focus. In 1965, the AmericanNurses Association (ANA) followed suit and issued aposition paper, which supported the graduate educationof the CNS. By 1980, ANA put forth a Social PolicyStatement, which specified that the CNS is an expert in aselected area of nursing and has studied with supervisedpractice at the graduate level.3 Today, ANA4 defines theCNS as an advanced practice nurse who integrates andapplies a wide range of theoretical and evidence-basedknowledge and is licensed, certified, and/or approved topractice. Education is at the master’s or doctoral levels.

For many years, the scope of CNS practice wasdescribed in terms of subroles, including expert practi-

tioner, educator, researcher, change agent, administrator,and consultant.5,6 In 1995, the NACNS was formed; it wasdesignated as the national organization that addresses CNSpractice issues. Two statements have been published by theNACNS7,8; these articulate the competencies and outcomesof contemporary CNS practice. Until the NACNS pub-lished its first statement on CNS practice in 1998, virtuallyno change had occurred in the conceptualization of theCNS role since its roots in the 1960s. The second edition ofthe Statement on Clinical Nurse Specialist Practice andEducation provides in-depth information and explanationof CNS practice, competencies, and outcomes and alsointroduces a conceptual model of CNS practice referred toas the ‘‘spheres of influence.’’ In developing this model,NACNS aggregated and integrated traditional CNS sub-roles with the intent to illuminate a more coherent, effectivebasis for CNS practice. The 3 spheres of CNS influence arepatient/client sphere, nurses and nursing practice sphere,and organization/system sphere.

Within the patient/client sphere of influence, CNS clini-cal expertise is acknowledged as the foundation for prac-tice. According to NACNS,8 clinical expertise comprisesadvanced knowledge and skill to ‘‘assess, diagnose, andtreat illness among patients’’ and to promote health by re-ducing risk behaviors and encouraging healthy lifestyles.Illness includes symptoms that are physiological, psycho-logical, or environmental in origin and/or functional prob-lems that interfere with independent living.8 Within thenurses and nursing practice sphere, CNSs improve patientoutcomes through leading and interacting with nursing per-sonnel, thereby improving nursing practice. Assisting nurs-ing personnel to ensure that their practice is evidence-basedis a key component of this sphere, as is facilitating transi-tions for patients and families from acute care settings tohome and community environments. Clinical nurse special-ists also provide initiative and guidance in the developmentof policies, procedures, protocols, and best practice guide-lines.8 Within the organization/system sphere, CNSs imple-ment innovative patient care programs that focus on patientcare needs. Clinical nurse specialists are also change agentsfor the improvement of quality and cost-effective patientoutcomes.8

METHODS

A comprehensive review of the literature was performed toanswer the following question: What are the substantiveareas of CNS clinical practice as reported in publishedliterature, conference proceedings, and dissertation/thesisabstracts? Operational definitions and criteria for includingor excluding literature, proceedings, and abstracts weredetermined a priori. Clinical nurse specialist was opera-tionally defined as a registered nurse who is a student in orgraduate of a master’s in nursing program with a focus inclinical specialization. Clinical practice was defined as anyactivity directed toward the patient/family, nurse/staff, and/or organization/system by a CNS in a healthcare setting.

Research and Anecdotal Articles

The following electronic databases were searched from theirinception until July 2006: Cumulative Index to Nursing and

CL IN ICAL NURSE SPEC IAL I STA74


Allied Health Literature (1937), Medline (1966), PsychInfo(1987), and Academic Search Premier (1984). Major andminor subject headings were searched using clinical nursespecialist or advanced practice nurse or advanced nursingpractice. The search was refined to include only peer-reviewed journals written in English. Editorials, interviews,and letters were excluded from the search. To be selected,the article was required to focus on CNS clinical practice.The first author of anecdotal articles was required to be aCNS. If this was not specified in the article, the first author’sname was searched using http://www.google.com or he/shewas contacted via e-mail. Anecdotal articles were excluded ifthe first author’s status could not be determined. Figure 1summarizes the search of peer-reviewed journals.

Ten percent (n = 1,030) of the initially retrieved citationswere included in the final sample; of these, 73% (n = 753)were anecdotal articles, and 27% (n = 277) were researcharticles. Research articles included randomized controlledtrials of CNS interventions, as well as descriptive (eg,survey) and qualitative (eg, phenomenology) studies,related to exploring dimensions of CNS clinical practice.Most articles in the sample (n = 363) were published inadvanced practice nursing journals; 33% (n = 340) were injournals targeting a nursing specialty, for example, oncol-ogy, critical care, home health; 16% (n = 165) were injournals for the general practicing nurse; 7.5% (n = 78)were in medical journals; 6.5% (n = 67) were in nursingmanagement journals; and the remainder (n = 17) were innursing research journals.

Dissertation and Thesis Abstracts

ProQuest Dissertations and Theses were searched fromJanuary 1943 through July 2006 using the search termsclinical nurse specialist or advanced practice nurse or ad-vanced nursing practice. The following inclusion/exclusioncriteria were used to select and retrieve abstracts: (a) thefocus of the study was related to CNS clinical practice and

(b) the study was not published and selected as an eligiblejournal article. Figure 2 summarizes the search for disserta-tion and thesis abstracts. Sixty-two (n = 62) dissertation andthesis abstracts were included in the final sample.

Abstracts From Conference Proceedings

PapersFirst (1993) and ProceedingsFirst (1993) weresearched from their inception to July 2006 using the searchterms clinical nurse specialist or advanced practice nurse oradvanced nursing practice. Research and nonresearchpaper and poster presentations were eligible. Abstractswere selected if the focus of the presentation was related toCNS clinical practice and was not published and selected asan eligible journal article. For abstracts of nonresearchpresentations, a CNS was the first author; if this could notbe determined from the abstract, the first author’s namewas searched using http://www.google.com or he/she wascontacted via e-mail. No research abstracts were excludedif first author’s status could not be determined. Figure 3shows the search for abstracts from conference proceed-ings. One hundred eighty-one (n = 181) abstracts of paperand poster presentations were included in the final sample.

Qualitative Data Analysis

Data were extracted from each article and abstract (N =1,273) using thematic content analysis. First, on the basis ofthe research question ‘‘What are the substantive clinicalareas of CNS practice?’’ all relevant sections of each eligiblearticle and abstract were highlighted and separated, forminga subtext. The second stage involved defining contentcategories. Categories emerged from carefully but openlyreading the subtext. Sorting material was a circular process;it involved careful reading, suggesting categories, sortingsubtext in to categories, generating ideas of new categories,and refining the categories. Three categories or substantiveareas of CNS clinical practice were created and named asfollows: (a) manage the care of complex and vulnerablepopulations, (b) educate and support interdisciplinary staff,and (c) facilitate change and innovation within healthcaresystems. In the next stage, all sentences in the subtext wereFigure 1. Database results: Peer-reviewed journals.

Figure 2. Database results: Dissertation and thesis abstracts.



assigned to a relevant substantive area (category). Thecontents of each substantive area of CNS clinical practicewere described to give an understanding of the subtext. Last,descriptions were reduced to create parsimony; salient,essential characteristics in each substantive area of CNSclinical practice were listed (Tables 1, 2, and 3).

Several techniques were used to enhance the trust-worthiness of the findings. Multiple reviews of the datawere performed to avoid premature closure of coding, forexample, formation of the subtext. An extensive audit trailof memoranda was kept; memoranda were used through-out the analysis to record decisions about determining andnaming substantive areas of CNS practice and assigning

subtext to one of the final domains. Substantive areas ofCNS clinical practice and descriptions of the contents ofeach area were presented to and discussed by a large groupof CNSs and graduate students in adult and psychiatricmental health CNS programs. This served to help validatethe accuracy and completeness (saturation) of the substan-tive areas that emerged from the review.

Quantitative Data Analysis

After completion of the qualitative analysis, a tool wasdeveloped to code each article and abstract (N = 1,273) onthe following nominal variables: (a) type of publication, (b)year of publication, (c) country of publication, (d) type ofsetting(s) described, (e) substantive area(s) of CNS clinicalpractice described, (f) type of complex/vulnerable popula-tion(s) served, and (g) inclusion/exclusion of outcome data.Data recorded on the coding tool were entered into an SPSSfile. Frequencies and percentages for each nominal variablewere calculated using SPSS (SPSS Inc, Chicago, Illinois) for

Table 2. Substantive Area of ClinicalNurse Specialist Practice:Educate and SupportInterdisciplinary Staff

1. Education

a. Educate interdisciplinary staff

i. Provide formal classes

ii. Provide informal, bedside teaching

iii. Provide and/or facilitate patient care conferences

iv. Provide and/or facilitate teaching rounds

v. Provide orientation for new staff

vi. Conduct unit-based research forums

b. Provide role-modeling, preceptorship, and mentoring

c. Disseminate knowledge through publication and conferencepresentations

2. Consultation

a. Provide case consultation

b. Provide administrative consultation

i. Develop forums for staff communication

ii. Assist in conflict resolution among staff

iii. Inform staff of organizational changes

c. Evaluate and introduce new technology

3. Collaboration

a. Serve as communication link between researcher andpractitioner

i. Assist in developing evidence-based plans of care

ii. Assist with research utilization

b. Collaborate with nurse manager

i. Assist with financial planning for units

ii. Assist in recruiting and retaining staff

iii. Contribute to formal and informal evaluation of nursingstaff

iv. Coordinate work activities on unit

v. Serve as unit spokesperson

c. Collaborate on clinical research projects

d. Collaborate with academic institutions to educateundergraduate and graduate nurses

Table 1. Substantive Area of ClinicalNurse Specialist Practice:Manage the Care of Complexand/or Vulnerable Populations

1. Expert Direct Care

a. Provide expert, in-depth, specialized assessment

i. Develop and implement assessment tools

b. Provide evidence-based and/or theory-driven treatment andcare of illness, symptoms, and responses to illness usingadvanced concepts related to the nursing process

c. Provide patient/family education

d. Develop methods of risk identification

e. Use strategies that promote health and wellness

f. Monitor and prescribe medication

g. Order and interpret laboratory and diagnostic tests

h. Perform advanced procedures

2. Care Coordination/Collaboration

a. Facilitate movement of patients/families through and acrosshealthcare settings

b. Facilitate healthcare system access

i. Identify proactively high-risk patients/families

ii. Provide case management

iii. Provide outcomes management

iv. Provide discharge planning

v. Provide community follow-up

c. Advocate for patient/family

i. Serve as liaison between patient/family and nurse/interdisciplinary team

d. Facilitate communication among interdisciplinary teammembers

Figure 3. Database results: Paper and poster presentations.



Windows software. To establish inter-rater reliability, arandom sample of 48 (n = 48) articles/abstracts were codedby a second reviewer. Cohen .9 was greater than 0.6, andP G .001 for all categories rated by the 2 reviewers, indi-cating high inter-rater reliability.

RESULTS

Description of the Sample of Articlesand Abstracts

Articles and abstracts included in the comprehensive reviewrepresented 10 countries, including the United States(83%), United Kingdom (10%), Canada (4%), Australia(2%), New Zealand (0.2%), Hong Kong (0.2%), Ireland(0.1%), The Netherlands (0.1%), Switzerland (0.1%), andTaiwan (0.1%), and spanned the years 1975 through2006. Nearly half (49.8%) of the articles and abstractsdescribed CNS practice in an acute care setting. Communitysettings such as outpatient clinics, home healthcare, andschools (27%); extended care facilities (1.5%); and reha-bilitation hospitals (0.5%) were also represented. The typesof populations served by CNSs in their clinical practices andthe frequencies by which each population appears in thearticles and abstracts reviewed are listed in Table 4. Out-come information related to CNS practice was included in45% of the articles and abstracts in the sample. Twenty-fourpercent of the outcome information was data based, and21% was anecdotal.

First Substantive Area: Manage the Care ofComplex and/or Vulnerable Populations

In nearly 75% (n = 951) of the articles/abstracts reviewed, asubstantive area of CNS clinical practice described wasrelated to managing the care of complex and/or vulnerable

populations of patients and families (Table 1). Within thissubstantive area, 3 essential characteristics of CNS practiceemerged: CNSs manage the care of complex and/orvulnerable populations through expert direct care, coordi-nation of care, and collaboration. As an expert direct carepractitioner, CNSs integrate current, comprehensive spe-cialty knowledge into clinical practice and provide evidence-based and/or theory-driven treatment and care of illness,symptoms, and responses to illness using advanced conceptsrelated to the nursing process. According to Benner, the‘‘CNS has the greatest access and understanding of how aparticular disease is experienced personally and how thedisease is understood from medical and pathophysiologicalperspectives.’’10(p40) Patient and family education is woveninseparably into expert practice. For instance, a wealth ofliterature reveals the oncology CNS’s recognition that canceris understood to be a genetic disease and approaches toprevention, diagnosis, and therapeutic management of can-cer are increasingly genetically based. Oncology CNSs inte-grate into clinical practice an understanding of thefundamental biology of carcinogenesis and the molecularrationale underlying strategies to prevent, diagnose, andtreat cancer.11–15 Another prominent example surfacing inthe literature is specialization in pain management; CNSsuse advanced knowledge of neurobiological mechanisms ofpain, as well as information about pharmacological andcomplementary therapies, to reduce the suffering of patientswith acute, chronic, and cancer pain.16–28 Psychiatric mentalhealth CNSs use advanced knowledge about psychiatricdisorders and psychotherapeutic modalities to manage care

Table 4. Types of Populations Served

PopulationaFrequency,

n (%)

Psychiatric mental health and chemicaldependency

133 (10.4)

Oncology 101 (7.9)

Geriatric 92 (7.2)

Critically ill 87 (6.8)

Cardiopulmonary 81 (6.3)

Pediatric 61 (4.8)

Obstetric/gynecologic 40 (3.1)

Wound and continence 40 (3.1)

Diabetes 37 (2.9)

Pain 31 (2.4)

Terminally ill 28 (2.2)

Surgical 21 (1.6)

Neurological 20 (1.6)

HIV/AIDS 19 (1.5)

Renal and transplant 17 (1.3)

Physical and/or sexual abuse 12 (0.9)

Otherb 52 (4.1)

Unknown 448 (35)

aMultiple populations were discussed in some articles/abstracts.bOther includes burns, caregivers, gastrointestinal disease, incarcerated,

orthopedics, and rural poor.

Table 3. Substantive Area of ClinicalNurse Specialist Practice:Facilitate Change andInnovation WithinHealthcare Systems

1. Change Agency

a. Assess needs of patients/families/communities, nurses, andorganizations

b. Develop research-based protocols, policies/procedures,clinical pathways, and standards of care

c. Cultivate unit culture that values research utilization andevidence-based practice

d. Promote quality improvement

i. Identify and prioritize quality improvement issues

ii. Develop indicators and methods to measure patientoutcomes

iii. Perform unit-based quality improvement studies

iv. Perform audits

e. Introduce innovative models of care

f. Develop, implement, and evaluate programs

g. Participate on advisory and policy-making boards, andcommittees



of persons with a wide range of psychiatric and mentalhealth problems, including depression,29–42 psychiatricemergencies,43–46 addictive disorders,47–52 and mental healthproblems related to medical illness.53–62

As expert direct care providers, CNSs provide an in-depth specialized assessment; this includes gathering infor-mation from a variety of sources, interpreting results fromlaboratory and diagnostic testing, and examining the multi-plicity of patterns that evolve from the interplay of an arrayof biopsychosocial factors.20,45,63–74 Creation of novelassessment tools and implementation of these in clinicalsettings have also been described.75–80 Medication monitor-ing and prescribing emerge in the literature as componentsof expert direct care and are used by CNSs in disease andsymptom management,81–89 although most literature hasbeen directed toward the prescribing practices of psychiatricmental health CNSs. Health and wellness promotion90–100

and risk identification101–110 are also described as integral toCNS expert practice. For instance, in many acute caresettings, high-risk, high-resource utilization patients areidentified by the CNS within the first 24 hours of admission.Identification is often based on age, severity of illness, clin-ical diagnosis, history of frequent admissions, fixed financialresources, inadequate psychosocial support, cognitive deficit,and/or decreased coping capacity.110–112

Another important element of CNS clinical practice iscoordination of the care of complex and/or vulnerablepopulations by organizing, coordinating services, and facil-itating communication among interdisciplinary team mem-bers. Advocating for family-centered care and serving as aliaison between the patient/family and team members arediscussed as an essential characteristic of CNS practice. Forinstance, the care of patients and families struggling withend-of-life decisions is frequently overseen by the CNS whoensures a coordinated, dedicated, and comprehensiveapproach to care and promotes open lines of communica-tion between all disciplines.113–121 Another prominentexample is the effort by CNSs to assess the needs of and toteach, support, and advocate for family members whoassume caregiving roles.118,122–132

A major feature of coordination of care is the facili-tation of patients and families through and across health-care settings, ensuring ‘‘seamless’’ provision of care. Inaddition to facilitating system access and proactivelyidentifying high-risk patients and families, providing casemanagement is frequently discussed as an integral part ofCNS clinical practice.133–165 As a case manager, the CNSuses clinical expertise to assess, monitor, mutually plan,and coordinate healthcare services to respond to theindividualized needs of complex patients and families. Asa case manager, the CNS focuses on health restoration andmaintenance that emphasize the importance of empower-ing patients and families to maximize self-care capabilities.Interdisciplinary and interagency collaborations are impor-tant aspects of case management.

Outcomes management has been another way for CNSsto coordinate care to manage complex and/or vulnerablepopulations. Within an outcomes management framework,the CNS functions as an ‘‘attending nurse’’ for a populationof patients by overseeing interdisciplinary care delivery andoutcomes measurement.166–170 Clinical nurse specialists arealso active in discharge planning, which prepares patients

and families for the next phase of care and assists inmaking arrangements for that transition.128,171–179 Last,CNSs coordinate care by providing direct communityfollow-up by way of home visits or through telephonemanagement.172,180–185 This latter aspect of CNS practiceemerged in the literature over the past 2 decades, with thetrend in healthcare of early discharge from acute caresettings. Discharge planning and community follow-uphave been termed advanced practice nurse transitional carein the literature and have been studied extensively inrandomized controlled trials with samples of very lowbirth weight infants,186–191 vulnerable elders,192–198 post-surgical cancer patients,199–201 and patients with chronicobstructive pulmonary disease.202

Second Substantive Area: Educate and SupportInterdisciplinary Staff

Clinical practice directed toward educating and supportinginterdisciplinary staff was described in 67% (n = 849) of thearticles and abstracts reviewed (Table 2). Essential character-istics of this substantive area of CNS practice are education,consultation, and collaboration. Clinical nurse specialistsassess, plan, implement, and evaluate teaching-learningexperiences for the staff nurse and other members of theinterdisciplinary team.203–225 A variety of teaching-learningstrategies are discussed in the literature, including the use offormal classes and presentations, informal bedside teaching,patient care conferences, teaching rounds, grand rounds, andcompetency-based orientation programs. Mentoring, rolemodeling, and preceptorship are other ways that the CNSeducates neophyte nurses.226–236

Case consultation is described often by CNSs as a way tobridge the gap between knowledge and practice and therebypromote the clinical expertise of staff in meeting patients’and families’ needs.52,56–62,237–251 The expertise of the CNSis maximized, and the staff members are assisted in acquiringnew perspectives and approaches to problem solving, whichare then generalized to a variety of patient care situationssuch as caring for patients with complex wounds,245,249

disruptive behaviors,57 persistent pain,239 and mental healthdifficulties.56–62,243,250,251 The CNSs’ use of administrativeconsultation in clinical practice is also reported in the litera-ture. In this type of consultation, nurse managers request theexpert help of the CNS to resolve difficulties in achievingorganization or management objectives.248,252–262 Severalareas of CNS administrative consultation are described: (a)developing forums for staff communication, includinginforming staff of organizational changes103,253,254,263; (b)assisting with conflict resolution among staff248,253,254; and(c) evaluating, making recommendations, and acquiringproducts264–267 such as specialty beds,265 invasive monitor-ing equipment,267 and clinical computer systems.266

Collaborating or working jointly with nurses and otherdisciplines also surfaced as a major characteristic of CNSclinical practice. With evidence-based nursing emerging as awidely accepted paradigm for contemporary professionalnursing practice, a substantial amount has been writtenabout the collaborative role of the CNS to assist nurses tounderstand and integrate research into practice.217,268–280

Clinical nurse specialists also regularly collaborate with nursemanagers to provide opportunities and an environment for



the staff members to meet their professional needs andgoals.144,281–288 In collaboration, the CNS and nurse man-ager remove obstacles, provide guidance, and encourageprofessional growth of the staff. A variety of joint CNS-nursemanager responsibilities are documented in the literature,including financial planning, recruitment and retention ofstaff, scheduling, and evaluation of staff.

Conducting research requires specific skills and knowl-edge and a significant time commitment. Collaboration withresearchers from nursing and/or other disciplines has beendescribed often in the literature as a means by which theCNS becomes involved and contributes to the research pro-cess.289–294 Through participation on collaborative researchprojects, CNSs generate ideas for study, provide access topatient/family populations, possess political skills within aninstitution that can benefit the research team, and helpintegrate findings into practice. Recently, CNSs have alsobegun to write about collaborative models with academicinstitutions to educate nurses at both the undergraduate andgraduate levels.295–297

Third Substantive Area: Facilitate Innovationand Change Within Healthcare Systems

Clinical nurse specialists play an important role in facilitatingchange and innovation, ensuring the delivery of optimumpatient care across the spectrum of healthcare. This sub-stantive area of practice is documented in 63% (n = 801) ofthe articles and abstracts reviewed (Table 3). Clinical nursespecialists have been very active in developing, implementing,and evaluating new programs to meet the needs of patients,families, communities, nurses, and organizations. Countlessexamples of these programs are reported in the litera-ture17,37,55,92,93,97,298–335: (a) symptom management pro-grams such as sensory retraining for fecal incontinence299

and pain management17,300; (b) disease management pro-grams such as management of heart failure302,304,306,309,313

and diabetes305,307,315; (c) outreach programs targeting un-derserved populations such as rural populations,37,298,318,323

the homeless,319 and prison system populations93; and (d)preventive programs such as coping skills education,324,333

survivors of cancer counseling and support,55,325 and pa-renting skills instruction.331 Innovative programs that targetspecific areas of need within organizations are also described.Examples include a ‘‘critical care bug team’’ implemented todecrease the incidence of ventilator-associated pneumonias336

and a ‘‘rock and roll’’ critical care program developed toprevent complications from immobility.337

Administrators have relied upon CNSs to develop research-based protocols,229,338–347 clinical pathways,348,349 guide-lines,278,350–356 and policies357–366 in their institutions. Forinstance, CNSs have championed policy changes related toassessment and treatment of pain.16,17,21,24,25,300,359–361,363–366

Within acute care settings, CNSs have also pressed for policychanges related to visitation and involvement of family inpatient care. One such policy change gives families the optionto be present during invasive procedures and resuscitationefforts, for example, ‘‘family presence.’’357 Clinical nursespecialist clinical practice also involves promoting qualityimprovement. Developing indicators and methods to measurepatient outcomes is described often.166,367–373 Clinical nursespecialists anticipate, identify, and prioritize quality improve-

ment areas related to nursing practice and are responsible forinitiating unit-based quality improvement studies, many ofwhich have been disseminated in the literature. Examplesinclude studies that have been directed toward improvingoutcomes for patients with diabetes in acute care settings374;patients receiving sedation, analgesia, and neuromuscularblockage367; patients and families in intensive care units113;and patients with nosocomial infections.375

Clinical nurse specialists have been instrumental in prac-tice change at the organizational level by introducinginnovative models of nursing practice and patientcare.283,320,376–398 Clinical nurse specialist practice mod-els283,379,384–386,392,395 and those directed toward changinghealthcare delivery to patients and families in a variety of set-tings320,376–378,380–383,387–391,393,394,396–398 have been devel-oped and/or implemented. Examples of the latter include acommunity nursing health promotion model for chronicchildhood illness,378 adaptation of the synergy model for thecare of the critically ill patient,388,397 and a model ofhealthcare delivery to incarcerated populations.390 With anemphasis on integrating research into practice, CNSs havebeen involved not only with launching nursing models ofresearch utilization and evidence-based practice nursing399–403

but also with cultivating a climate within the clinical settingthat values research.404–416

LIMITATIONS OF THE REVIEW

Major and minor subject headings of articles and abstractsin the specified databases were searched using 3 searchterms: clinical nurse specialist, advanced practice nurse, andadvanced nursing practice. Although this method yielded alarge return, it is not possible to determine the amount ofpertinent literature not captured with these 3 search terms.Sorting through the vast amount of literature and makingdecisions about whether a particular article and/or abstractwas eligible (eg, ‘‘Did it meet the inclusion and exclusioncriteria set forth a priori?’’) were performed by 1 reviewer.Although detailed memoranda were kept by the reviewer,bias must be considered.

The criteria stipulating that anecdotal articles and non-research presentations should have first authorship by aCNS may have increased the trustworthiness of the findingsabout CNS clinical practice; however, it was the majorreason that an article or abstract was excluded from the finalsample and reduced the sample size significantly. Searchingauthors’ names using the Internet was successful for nursingfaculty whose credentials were listed on college Web sites;this was a less successful method for determining whether anauthor in a clinical or foreign setting was a CNS. Very fewarticles or abstracts listed a contact e-mail for the author.The widespread use of the term advanced practice nurse inrecent literature made it challenging to determine whetherthe article or abstract was indeed describing CNS versusnurse practitioner clinical practice (midwifery and nurseanesthesia were easily ruled out). This was less problematicfor anecdotal articles and nonresearch presentations thatrequired first authorship by a CNS. A research article orabstract using the term advanced practice nurse wasincluded in the final sample, even if the advanced practicenurse was not specified as a CNS; this must be acknowl-edged when interpreting the findings.



Finally, the major analysis used in this review wasqualitative and involved separating text from articles andabstracts based on CNS clinical practice as operationallydefined. Abstracts of dissertations, theses, and presenta-tions gave limited information; these entire manuscriptswere not read. Although the substantive areas of CNSclinical practice and descriptors were presented to a groupof CNSs and graduate CNS students for feedback andsignificant revisions were made based on this feedback, theactual thematic content analysis of the final sample ofarticles and abstracts was performed by 1 reviewer; there-fore, bias must again be considered.

DISCUSSION

Much has been written about the lack of clarity of the CNSrole. This review demonstrates that nurses who areprepared at a graduate level in clinical specialization writeabout their clinical practices in much the same way.Research findings that describe the work of CNSs inclinical settings and CNS practice interventions delineatedin randomized controlled trials are consistent with anecdo-tal reports of CNS clinical practice. Substantive areas ofCNS clinical practice described in the literature are asfollows: (a) managing the care of complex and/or vulner-able populations of patients and families through expertdirect care, care coordination, and collaboration with theinterdisciplinary team; (b) educating and supporting theinterdisciplinary team through education, consultation, andcollaboration; and (c) facilitating change and innovationwithin healthcare systems through change agency. Thesefindings are closely aligned with the spheres of influenceand detailed descriptions of CNS practice and competen-cies set forth by NACNS in their Statement on ClinicalNurse Specialist Practice and Education; therefore, the waythe role is conceptualized is clearly congruent with the wayCNSs describe what they do.

Why then is there so much confusion about the work ofthe CNS? Master’s prepared CNSs clearly understand theCNS role. Confusion about the CNS role may, therefore,lay with nurses who are not CNSs, other healthcareprofessionals, and consumers. One reason for the lack ofunderstanding of the CNS role may be that much of thework of the CNS occurs ‘‘behind the scene’’ of directpatient care. Perhaps increased role diversity has led toincreased anonymity, as many CNSs moved away fromdirect expert care to fulfill other role requirements. Thispoints to a crucial need for CNSs to find creative ways to‘‘connect’’ directly with patients and families and to rolemodel for nurses and members of the interdisciplinary teamspecialized expert nursing care, even when their work takesthem away from the bedside and despite the many facetsand challenges of their role. Marketing is a need repeatedlydiscussed in the literature as being necessary for promotingthe CNS role and its value. Increasing direct contact withpatients and families may be a simple, yet important,overlooked marketing strategy to improve recognition andunderstanding of the CNS role, especially by consumers.

Although outcome information was included in abouthalf of the articles and abstracts in the final sample, only24% included data-based information. The use of rigorousresearch designs, both quantitative and qualitative, to

understand the work of the CNS and the effect of CNSpractice on patient outcomes and costs of care has been verylimited. The contributions of Brooten et al,186–191 McCorkleet al,199–201 and Naylor et al192–198 in explicating outcomesof advanced practice nurse transitional care are prototypicalof the kind of research needed to market the CNS role andits value. Attention must also be given to how and whereliterature about CNS practice and outcomes is disseminated.Only 6.5% of the articles in the final sample were found injournals targeting nursing administrators; most paper pre-sentations about CNS practice and outcomes were retrievedfrom annual national NACNS conferences. Disseminatingknowledge about CNS practice to a wider audience,including healthcare administrators, other healthcare pro-fessionals, and the public, is crucial to marketing the uniquecontribution of CNSs in improving clinical and fiscaloutcomes of patients, families, and communities.

Although the versatility of CNS practice has at timesbeen thought to contribute to ambiguity and improperutilization of CNS expertise, this versatility has alsoallowed CNSs to be responsive to changing healthcareenvironments. Created by the discipline of nursing to meetthe increasingly complex needs of patients over 6 decadesago, the role of the CNS has evolved as new ways to meetsocietal healthcare needs were sought. For instance, in thelate 1980s and early 1990s, as managed care environmentstook firm hold of how healthcare was delivered, CNSs usedclinical expertise and collaboration skills to deliver effectivecase management, discharge planning, and transitionalcare. Today, with the mandate from consumers and payersfor evidence-based treatments, CNSs have emerged asleaders in implementing evidence-based practice into clin-ical settings, using clinical expertise, consultation andcollaboration skills, and knowledge of systems and change.Clinical nurse specialists possess the educational prepara-tion and mobility within healthcare systems to assess andanticipate trends in healthcare and to respond to ever-changing healthcare environments.

Have there been unfavorable consequences for CNSsresulting from increased complexity and diversity of theirrole? One consequence has been movement away fromexpert direct care with patients and families. Provision ofdirect expert advanced nursing care is reimbursed byinsurers; there is no reimbursement mechanism for indirectadvanced nursing care. Clinical nurse specialists who donot spend a significant portion of their time in direct expertreimbursable care have been seen as fiscal liabilities bysome administrators. This has resulted in CNSs having tocontinuously argue and/or demonstrate their worth toorganizations. Beside fiscal concerns, there is a need forexpert leadership at the bedside as inpatient acuity rises,length of hospital stay decreases, and scientific knowledgerequired for safe nursing practice expands. The AACNrecently identified the need for more expert nursing careand leadership at the bedside and responded with thecreation of the CNL role. Although AACN claims that theCNS and CNL roles are distinct yet complementary, nursesin the CNL role are envisioned to be the direct providers ofthe expert evidenced-based nursing care that will bedesigned and evaluated by the CNS. This leaves the CNSvulnerable to continued anonymity with consumers andcriticism from skeptics who contend that the expert direct



care provided by CNSs is indistinguishable from that ofnon–master’s prepared registered nurses who are consid-ered ‘‘expert’’ practitioners. Clinical nurse specialists mustcontinue to define the expert direct advanced practicecomponent of their role and reassume a direct leadershiprole at the bedside.

Another consequence of increased role diversity has beenthe challenge for educators to develop CNS curricula thatcan prepare students adequately with the competenciesneeded to assume a role with such complexity. In additionto advanced knowledge related to specialty populations (eg,oncology, gerontology), an understanding of organizations,systems, and change is critical, as well as communicationtheories related to consultation and collaboration. Theability to understand the research process and apply it in avariety of ways (eg, evidence-based practice, qualityimprovement) in the clinical setting is also crucial. By2015, AACN envisions that master’s level nursing educationwill be replaced by DNP.417 Universities across the countryare busy in the planning process or have already imple-mented DNP programs. Essentials of doctoral education foradvanced nursing practice, as outlined by AACN,417 arefoundational outcome competencies for all DNP graduates;these bear a strikingly strong resemblance to competenciesrequired for CNS practice. The curricula for CNS are wellsuited for a practice-focused doctoral program, which maybe able to better match program requirements, credits, andtime with the credential earned.

We know much about the role of the CNS. Future workin this area must focus on explicating the components ofthe direct expert practice role of the CNS, for example,how is direct expert care provided by a CNS different fromthe nursing care delivered by a non–master’s preparednurse who has achieved the level of expert? An under-standing of how practicing CNSs blend the diverse ‘‘sub-stantive areas’’ uncovered in this review in their everydaywork is equally important. Through rigorously designedoutcome studies, CNSs must also justify their movementaway from expert direct practice to other non–direct-careaspects of the CNS role, for example, change agency andstaff education. For instance, do educational strategies forstaff translate into improved outcomes for patients andfamilies? How does care coordination by a CNS improvepatient and family outcomes? Clinical nurse specialistshave a clear conceptual basis for practice, which is sub-stantiated in the literature, and must continue to define thisscope of practice to organizations, administrators, nursesand other healthcare professionals, and consumers.

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