Substantive Areas of Clinical Nurse Specialist Practice

CE feature article

Editor’s Note: In 2009, we will publish 6 articles for which 1 to 3 credit hours may be earned as This article has been part of a CNS’s learning activities. Examination questions are provided at the end of this article for designated for CE credit. A your consideration. See the answer/enrollment form after the article for additional information closed-book, multiple-choice regarding the program. examination follows this article, which tests your knowledge of the following objectives: 1. Identify the CNS spheres Substantive Areas of Clinical of influence and the features of this literature review. Nurse Specialist Practice 2. Describe how CNSs manage the care of complex and/or vulnerable populations. A Comprehensive Review 3. Outline the characteristics of CNS practice related of the Literature to educating and supporting staff and WENDY LEWANDOWSKI, PhD; KATHLEEN ADAMLE, PhD facilitating innovation and change within the healthcare system. 3. Explain the limitations im: A comprehensive review of the literature was performed to describe the substantive of this literature review Aclinical areas of clinical nurse specialist (CNS) practice. Background: There is lack of and the confusion about understanding about the role of CNSs. Debates over blending CNS and nurse practitioner roles the CNS role. are common, as are questions and uncertainties about new models of advanced practice nursing endorsed 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: The following 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 conceptual 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 professionals, and consumers. KEY WORDS: advanced nursing practice, clinical nurse specialist

ne of the most important developments in the discipline of nursing has been the Oevolvement 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 environments and patient care needs, they have been challenged to reshape essential characteristics

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).

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

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Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. of their practice, leading at times to a medley of roles and tioner, educator, researcher, change agent, administrator, responsibilities and a sense of ambiguity and confusion. and consultant.5,6 In 1995, the NACNS was formed; it was There is also a lack of understanding about the work of designated as the national organization that addresses CNS the CNS by other nurses and healthcare professionals, ad- practice issues. Two statements have been published by the ministrators, and consumers. Today, new challenges exist. NACNS7,8; these articulate the competencies and outcomes Debates over blending CNS and nurse practitioner roles are of contemporary CNS practice. Until the NACNS pub- common, as are questions and uncertainties about 2 new lished its first statement on CNS practice in 1998, virtually models of advanced practice nursing endorsed by the no change had occurred in the conceptualization of the American Association of Colleges of Nursing (AACN)—the CNS role since its roots in the 1960s. The second edition of clinical nurse leader (CNL) and the doctorate of nursing the Statement on Clinical Nurse Specialist Practice and practice (DNP)—and the implications of these models for Education provides in-depth information and explanation CNSs. To enhance understanding of the CNS role and its of CNS practice, competencies, and outcomes and also contribution to healthcare, it is important to explore what introduces a conceptual model of CNS practice referred to nurses who are practicing in the CNS role say about the as the ‘‘spheres of influence.’’ In developing this model, nature of their work and examine both outcome and descrip- NACNS aggregated and integrated traditional CNS sub- tive research related to CNS practice. roles with the intent to illuminate a more coherent, effective In the spring of 2006, the National Association of basis for CNS practice. The 3 spheres of CNS influence are Clinical Nurse Specialists (NACNS) commissioned a proj- patient/client sphere, nurses and nursing practice sphere, ect to examine areas of CNS clinical practice in the and organization/system sphere. published literature and to answer the following question: Within the patient/client sphere of influence, CNS clini- ‘‘What are the substantive clinical areas of CNS practice?’’ cal expertise is acknowledged as the foundation for prac- A comprehensive review of literature was performed with tice. According to NACNS,8 clinical expertise comprises the aim of summarizing and critically evaluating published advanced knowledge and skill to ‘‘assess, diagnose, and literature, conference proceedings, and dissertation/thesis treat illness among patients’’ and to promote health by re- abstracts and of describing in depth the substantive clinical ducing risk behaviors and encouraging healthy lifestyles. areas of CNS practice. The purpose of this article is to Illness includes symptoms that are physiological, psycho- report the findings of this review. logical, or environmental in origin and/or functional problems that interfere with independent living.8 Within the nurses and nursing practice sphere, CNSs improve patient CONCEPTUAL BASIS FOR CNS PRACTICE: outcomes through leading and interacting with nursing per- A BRIEF HISTORY sonnel, thereby improving nursing practice. Assisting nursing personnel to ensure that their practice is evidence-based Specialization in nursing can be traced back to the early is a key component of this sphere, as is facilitating transi- 1900s when Florence Nightingale recruited and taught tions for patients and families from acute care settings to women how to deliver improved patient care to wounded home and community environments. Clinical nurse special- soldiers in the Crimean War; however, the role of CNS was ists also provide initiative and guidance in the development not formally introduced until the 1940s when Frances of policies, procedures, protocols, and best practice guide- Reiter1 first coined the term nurse clinician to describe lines.8 Within the organization/system sphere, CNSs imple- specialists whose intent was to establish higher quality ment innovative patient care programs that focus on patient patient care. Reiter stated that the nurse clinician should care needs. Clinical nurse specialists are also change agents have advanced knowledge and expertise in clinical practice for the improvement of quality and cost-effective patient and be capable of displaying a high degree of judgment and outcomes.8 competence in providing nursing care in a specialized area. During the next 3 decades, the CNS role was further examined by nursing leaders and organizations. Hildegard METHODS 2 Peplau’s quintessential article in 1965 described the CNS A comprehensive review of the literature was performed to as having expertise in nursing practice in the care of answer the following question: What are the substantive complex patients. Peplau advocated for graduate education areas of CNS clinical practice as reported in published in nursing, specifying the need to prepare the CNS at the literature, conference proceedings, and dissertation/thesis master’s level with a clinical focus. In 1965, the American abstracts? Operational definitions and criteria for including Nurses Association (ANA) followed suit and issued a or excluding literature, proceedings, and abstracts were position paper, which supported the graduate education determined a priori. Clinical nurse specialist was opera- of the CNS. By 1980, ANA put forth a Social Policy tionally defined as a registered nurse who is a student in or Statement, which specified that the CNS is an expert in a graduate of a master’s in nursing program with a focus in selected area of nursing and has studied with supervised 3 4 clinical specialization. Clinical practice was defined as any practice at the graduate level. Today, ANA defines the activity directed toward the patient/family, nurse/staff, and/ CNS as an advanced practice nurse who integrates and or organization/system by a CNS in a healthcare setting. applies a wide range of theoretical and evidence-based knowledge and is licensed, certified, and/or approved to Research and Anecdotal Articles practice. Education is at the master’s or doctoral levels. For many years, the scope of CNS practice was The following electronic databases were searched from their described in terms of subroles, including expert practi- inception until July 2006: Cumulative Index to Nursing and

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Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Allied Health Literature (1937), Medline (1966), PsychInfo (1987), and Academic Search Premier (1984). Major and minor subject headings were searched using clinical nurse specialist or advanced practice nurse or advanced nursing practice. 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 a CNS. If this was not specified in the article, the first author’s name was searched using http://www.google.com or he/she was contacted via e-mail. Anecdotal articles were excluded if the first author’s status could not be determined. Figure 1 summarizes the search of peer-reviewed journals. Ten percent (n = 1,030) of the initially retrieved citations were included in the final sample; of these, 73% (n = 753) were anecdotal articles, and 27% (n = 277) were research articles. Research articles included randomized controlled Figure 2. Database results: Dissertation and thesis abstracts. trials of CNS interventions, as well as descriptive (eg, survey) and qualitative (eg, phenomenology) studies, related to exploring dimensions of CNS clinical practice. (b) the study was not published and selected as an eligible Most articles in the sample (n = 363) were published in journal article. Figure 2 summarizes the search for disserta- advanced practice nursing journals; 33% (n = 340) were in tion and thesis abstracts. Sixty-two (n = 62) dissertation and journals targeting a nursing specialty, for example, oncol- thesis abstracts were included in the final sample. ogy, critical care, home health; 16% (n = 165) were in journals for the general practicing nurse; 7.5% (n = 78) were in medical journals; 6.5% (n = 67) were in nursing Abstracts From Conference Proceedings management journals; and the remainder (n = 17) were in PapersFirst (1993) and ProceedingsFirst (1993) were nursing research journals. searched from their inception to July 2006 using the search terms clinical nurse specialist or advanced practice nurse or Dissertation and Thesis Abstracts advanced nursing practice. Research and nonresearch paper and poster presentations were eligible. Abstracts ProQuest Dissertations and Theses were searched from were selected if the focus of the presentation was related to January 1943 through July 2006 using the search terms CNS clinical practice and was not published and selected as clinical nurse specialist or advanced practice nurse or ad- an eligible journal article. For abstracts of nonresearch vanced nursing practice. The following inclusion/exclusion presentations, a CNS was the first author; if this could not criteria were used to select and retrieve abstracts: (a)the be determined from the abstract, the first author’s name focus of the study was related to CNS clinical practice and was searched using http://www.google.com or he/she was contacted via e-mail. No research abstracts were excluded if first author’s status could not be determined. Figure 3 shows the search for abstracts from conference proceedings. One hundred eighty-one (n = 181) abstracts of paper and 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 of the research question ‘‘What are the substantive clinical areas of CNS practice?’’ all relevant sections of each eligible article and abstract were highlighted and separated, forming a subtext. The second stage involved defining content categories. Categories emerged from carefully but openly reading the subtext. Sorting material was a circular process; it involved careful reading, suggesting categories, sorting subtext in to categories, generating ideas of new categories, and refining the categories. Three categories or substantive areas of CNS clinical practice were created and named as follows: (a) manage the care of complex and vulnerable populations, (b) educate and support interdisciplinary staff, and (c) facilitate change and innovation within healthcare Figure 1. Database results: Peer-reviewed journals. systems. In the next stage, all sentences in the subtext were

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Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Table 2. Substantive Area of Clinical Nurse Specialist Practice: Educate and Support Interdisciplinary 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 Figure 3. Database results: Paper and poster presentations. vi. Conduct unit-based research forums b. Provide role-modeling, preceptorship, and mentoring assigned to a relevant substantive area (category). The c. Disseminate knowledge through publication and conference contents of each substantive area of CNS clinical practice presentations were described to give an understanding of the subtext. Last, 2. Consultation descriptions were reduced to create parsimony; salient, a. Provide case consultation essential characteristics in each substantive area of CNS b. Provide administrative consultation clinical practice were listed (Tables 1, 2, and 3). i. Develop forums for staff communication Several techniques were used to enhance the trust- ii. Assist in conflict resolution among staff worthiness of the findings. Multiple reviews of the data iii. Inform staff of organizational changes were performed to avoid premature closure of coding, for c. Evaluate and introduce new technology example, formation of the subtext. An extensive audit trail of memoranda was kept; memoranda were used through- 3. Collaboration out the analysis to record decisions about determining and a. Serve as communication link between researcher and naming substantive areas of CNS practice and assigning practitioner i. Assist in developing evidence-based plans of care ii. Assist with research utilization Table 1. Substantive Area of Clinical b. Collaborate with nurse manager Nurse Specialist Practice: i. Assist with financial planning for units Manage the Care of Complex ii. Assist in recruiting and retaining staff and/or Vulnerable Populations iii. Contribute to formal and informal evaluation of nursing 1. Expert Direct Care staff a. Provide expert, in-depth, specialized assessment iv. Coordinate work activities on unit i. Develop and implement assessment tools v. Serve as unit spokesperson b. Provide evidence-based and/or theory-driven treatment and c. Collaborate on clinical research projects care of illness, symptoms, and responses to illness using d. Collaborate with academic institutions to educate advanced concepts related to the nursing process undergraduate and graduate nurses c. Provide patient/family education d. Develop methods of risk identification e. Use strategies that promote health and wellness subtext to one of the final domains. Substantive areas of f. Monitor and prescribe medication CNS clinical practice and descriptions of the contents of g. Order and interpret laboratory and diagnostic tests each area were presented to and discussed by a large group h. Perform advanced procedures of CNSs and graduate students in adult and psychiatric 2. Care Coordination/Collaboration mental health CNS programs. This served to help validate a. Facilitate movement of patients/families through and across the accuracy and completeness (saturation) of the substan- healthcare settings tive areas that emerged from the review. b. Facilitate healthcare system access i. Identify proactively high-risk patients/families Quantitative Data Analysis ii. Provide case management After completion of the qualitative analysis, a tool was iii. Provide outcomes management developed to code each article and abstract (N = 1,273) on iv. Provide discharge planning the following nominal variables: (a)typeofpublication,(b) v. Provide community follow-up year of publication, (c) country of publication, (d)typeof c. Advocate for patient/family setting(s) described, (e) substantive area(s) of CNS clinical i. Serve as liaison between patient/family and nurse/ practice described, (f) type of complex/vulnerable popula- interdisciplinary team tion(s) served, and (g) inclusion/exclusion of outcome data. d. Facilitate communication among interdisciplinary team Data recorded on the coding tool were entered into an SPSS members file. Frequencies and percentages for each nominal variable were calculated using SPSS (SPSS Inc, Chicago, Illinois) for

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Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Table 3. Substantive Area of Clinical populations of patients and families (Table 1). Within this substantive area, 3 essential characteristics of CNS practice Nurse Specialist Practice: emerged: CNSs manage the care of complex and/or Facilitate Change and vulnerable populations through expert direct care, coordi- Innovation Within nation of care,andcollaboration.Asanexpert direct care Healthcare Systems practitioner, CNSs integrate current, comprehensive spe- 1. Change Agency cialty knowledge into clinical practice and provide evidence- a. Assess needs of patients/families/communities, nurses, and based and/or theory-driven treatment and care of illness, organizations symptoms, and responses to illness using advanced concepts b. Develop research-based protocols, policies/procedures, related to the nursing process. According to Benner, the clinical pathways, and standards of care ‘‘CNS has the greatest access and understanding of how a c. Cultivate unit culture that values research utilization and particular disease is experienced personally and how the evidence-based practice disease is understood from medical and pathophysiological d. Promote quality improvement perspectives.’’10(p40) Patient and family education is woven i. Identify and prioritize quality improvement issues inseparably into expert practice. For instance, a wealth of ii. Develop indicators and methods to measure patient literature reveals the oncology CNS’s recognition that cancer outcomes is understood to be a genetic disease and approaches to iii. Perform unit-based quality improvement studies prevention, diagnosis, and therapeutic management of can- iv. Perform audits cer are increasingly genetically based. Oncology CNSs integrate into clinical practice an understanding of the e. Introduce innovative models of care fundamental biology of carcinogenesis and the molecular f. Develop, implement, and evaluate programs rationale underlying strategies to prevent, diagnose, and g. Participate on advisory and policy-making boards, and treat cancer.11–15 Another prominent example surfacing in committees the literature is specialization in pain management; CNSs use advanced knowledge of neurobiological mechanisms of pain, as well as information about pharmacological and complementary therapies, to reduce the suffering of patients Windows software. To establish inter-rater reliability, a with acute, chronic, and cancer pain.16–28 Psychiatric mental random sample of 48 (n = 48) articles/abstracts were coded 9 health CNSs use advanced knowledge about psychiatric by a second reviewer. Cohen . was greater than 0.6, and disorders and psychotherapeutic modalities to manage care P G .001 for all categories rated by the 2 reviewers, indi- cating high inter-rater reliability.

RESULTS Table 4. Types of Populations Served

Description of the Sample of Articles Frequency, and Abstracts Populationa n (%) Articles and abstracts included in the comprehensive review Psychiatric mental health and chemical 133 (10.4) represented10countries,including the United States dependency (83%), United Kingdom (10%), Canada (4%), Australia Oncology 101 (7.9) (2%), New Zealand (0.2%), Hong Kong (0.2%), Ireland (0.1%), The Netherlands (0.1%), Switzerland (0.1%), and Geriatric 92 (7.2) Taiwan (0.1%), and spanned the years 1975 through Critically ill 87 (6.8) 2006. Nearly half (49.8%) of the articles and abstracts Cardiopulmonary 81 (6.3) described CNS practice in an acute care setting. Community Pediatric 61 (4.8) settings such as outpatient clinics, home healthcare, and Obstetric/gynecologic 40 (3.1) schools (27%); extended care facilities (1.5%); and reha- Wound and continence 40 (3.1) bilitation hospitals (0.5%) were also represented. The types Diabetes 37 (2.9) of populations served by CNSs in their clinical practices and Pain 31 (2.4) the frequencies by which each population appears in the Terminally ill 28 (2.2) articles and abstracts reviewed are listed in Table 4. Out- Surgical 21 (1.6) come information related to CNS practice was included in Neurological 20 (1.6) 45% of the articles and abstracts in the sample. Twenty-four percent of the outcome information was data based, and HIV/AIDS 19 (1.5) 21% was anecdotal. Renal and transplant 17 (1.3) Physical and/or sexual abuse 12 (0.9) b First Substantive Area: Manage the Care of Other 52 (4.1) Complex and/or Vulnerable Populations Unknown 448 (35) a In nearly 75% (n = 951) of the articles/abstracts reviewed, a Multiple populations were discussed in some articles/abstracts. bOther includes burns, caregivers, gastrointestinal disease, incarcerated, substantive area of CNS clinical practice described was orthopedics, and rural poor. related to managing the care of complex and/or vulnerable

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Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. of persons with a wide range of psychiatric and mental and families for the next phase of care and assists in health problems, including depression,29–42 psychiatric making arrangements for that transition.128,171–179 Last, emergencies,43–46 addictive disorders,47–52 and mental health CNSs coordinate care by providing direct community problems related to medical illness.53–62 follow-up by way of home visits or through telephone As expert direct care providers, CNSs provide an in- management.172,180–185 This latter aspect of CNS practice depth specialized assessment; this includes gathering infor- emerged in the literature over the past 2 decades, with the mation from a variety of sources, interpreting results from trend in healthcare of early discharge from acute care laboratory and diagnostic testing, and examining the multi- settings. Discharge planning and community follow-up plicity of patterns that evolve from the interplay of an array have been termed advanced practice nurse transitional care of biopsychosocial factors.20,45,63–74 Creation of novel in the literature and have been studied extensively in assessment tools and implementation of these in clinical randomized controlled trials with samples of very low settings have also been described.75–80 Medication monitor- birth weight infants,186–191 vulnerable elders,192–198 post- ing and prescribing emerge in the literature as components surgical cancer patients,199–201 and patients with chronic of expert direct care and are used by CNSs in disease and obstructive pulmonary disease.202 symptom management,81–89 although most literature has been directed toward the prescribing practices of psychiatric 90–100 Second Substantive Area: Educate and Support mental health CNSs. Health and wellness promotion Interdisciplinary Staff and risk identification101–110 are also described as integral to CNS expert practice. For instance, in many acute care Clinical practice directed toward educating and supporting settings, high-risk, high-resource utilization patients are interdisciplinary staff was described in 67% (n = 849) of the identified by the CNS within the first 24 hours of admission. articles and abstracts reviewed (Table 2). Essential character- Identification is often based on age, severity of illness, clin- istics of this substantive area of CNS practice are education, ical diagnosis, history of frequent admissions, fixed financial consultation,andcollaboration. Clinical nurse specialists resources, inadequate psychosocial support, cognitive deficit, assess, plan, implement, and evaluate teaching-learning and/or decreased coping capacity.110–112 experiences for the staff nurse and other members of the Another important element of CNS clinical practice is interdisciplinary team.203–225 A variety of teaching-learning coordination of the care of complex and/or vulnerable strategies are discussed in the literature, including the use of populations by organizing, coordinating services, and facil- formal classes and presentations, informal bedside teaching, itating communication among interdisciplinary team mem- patient care conferences, teaching rounds, grand rounds, and bers. Advocating for family-centered care and serving as a competency-based orientation programs. Mentoring, role liaison between the patient/family and team members are modeling, and preceptorship are other ways that the CNS discussed as an essential characteristic of CNS practice. For educates neophyte nurses.226–236 instance, the care of patients and families struggling with Case consultation is described often by CNSs as a way to end-of-life decisions is frequently overseen by the CNS who bridge the gap between knowledge and practice and thereby ensures a coordinated, dedicated, and comprehensive promote the clinical expertise of staff in meeting patients’ approach to care and promotes open lines of communica- and families’ needs.52,56–62,237–251 The expertise of the CNS tion between all disciplines.113–121 Another prominent is maximized, and the staff members are assisted in acquiring example is the effort by CNSs to assess the needs of and to new perspectives and approaches to problem solving, which teach, support, and advocate for family members who are then generalized to a variety of patient care situations assume caregiving roles.118,122–132 such as caring for patients with complex wounds,245,249 A major feature of coordination of care is the facili- disruptive behaviors,57 persistent pain,239 and mental health tation of patients and families through and across health- difficulties.56–62,243,250,251 The CNSs’ use of administrative care settings, ensuring ‘‘seamless’’ provision of care. In consultation in clinical practice is also reported in the litera- addition to facilitating system access and proactively ture. In this type of consultation, nurse managers request the identifying high-risk patients and families, providing case expert help of the CNS to resolve difficulties in achieving management is frequently discussed as an integral part of organization or management objectives.248,252–262 Several CNS clinical practice.133–165 As a case manager, the CNS areas of CNS administrative consultation are described: (a) uses clinical expertise to assess, monitor, mutually plan, developing forums for staff communication, including and coordinate healthcare services to respond to the informing staff of organizational changes103,253,254,263;(b) individualized needs of complex patients and families. As assisting with conflict resolution among staff248,253,254;and a case manager, the CNS focuses on health restoration and (c) evaluating, making recommendations, and acquiring maintenance that emphasize the importance of empower- products264–267 such as specialty beds,265 invasive monitoring patients and families to maximize self-care capabilities. ing equipment,267 and clinical computer systems.266 Interdisciplinary and interagency collaborations are impor- Collaborating or working jointly with nurses and other tant aspects of case management. disciplines also surfaced as a major characteristic of CNS Outcomes management has been another way for CNSs clinical practice. With evidence-based nursing emerging as a to coordinate care to manage complex and/or vulnerable widely accepted paradigm for contemporary professional populations. Within an outcomes management framework, nursing practice, a substantial amount has been written the CNS functions as an ‘‘attending nurse’’ for a population about the collaborative role of the CNS to assist nurses to of patients by overseeing interdisciplinary care delivery and understand and integrate research into practice.217,268–280 outcomes measurement.166–170 Clinical nurse specialists are Clinical nurse specialists also regularly collaborate with nurse also active in discharge planning, which prepares patients managers to provide opportunities and an environment for

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Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. the staff members to meet their professional needs and ment areas related to nursing practice and are responsible for goals.144,281–288 In collaboration, the CNS and nurse man- initiating unit-based quality improvement studies, many of ager remove obstacles, provide guidance, and encourage whichhavebeendisseminatedintheliterature.Examples professional growth of the staff. A variety of joint CNS-nurse include studies that have been directed toward improving manager responsibilities are documented in the literature, outcomes for patients with diabetes in acute care settings374; including financial planning, recruitment and retention of patients receiving sedation, analgesia, and neuromuscular staff, scheduling, and evaluation of staff. blockage367; patients and families in intensive care units113; Conducting research requires specific skills and knowl- and patients with nosocomial infections.375 edge and a significant time commitment. Collaboration with Clinical nurse specialists have been instrumental in prac- researchers from nursing and/or other disciplines has been tice change at the organizational level by introducing described often in the literature as a means by which the innovative models of nursing practice and patient CNS becomes involved and contributes to the research pro- care.283,320,376–398 Clinical nurse specialist practice mod- cess.289–294 Through participation on collaborative research els283,379,384–386,392,395 and those directed toward changing projects, CNSs generate ideas for study, provide access to healthcare delivery to patients and families in a variety of set- patient/family populations, possess political skills within an tings320,376–378,380–383,387–391,393,394,396–398 have been devel- institution that can benefit the research team, and help oped and/or implemented. Examples of the latter include a integrate findings into practice. Recently, CNSs have also community nursing health promotion model for chronic begun to write about collaborative models with academic childhood illness,378 adaptation of the synergy model for the institutions to educate nurses at both the undergraduate and care of the critically ill patient,388,397 and a model of graduate levels.295–297 healthcare delivery to incarcerated populations.390 With an emphasis on integrating research into practice, CNSs have been involved not only with launching nursing models of Third Substantive Area: Facilitate Innovation 399–403 and Change Within Healthcare Systems research utilization and evidence-based practice nursing but also with cultivating a climate within the clinical setting Clinical nurse specialists play an important role in facilitating that values research.404–416 change and innovation, ensuring the delivery of optimum patient care across the spectrum of healthcare. This sub- LIMITATIONS OF THE REVIEW stantive area of practice is documented in 63% (n = 801) of the articles and abstracts reviewed (Table 3). Clinical nurse Major and minor subject headings of articles and abstracts specialists have been very active in developing, implementing, in the specified databases were searched using 3 search and evaluating new programs to meet the needs of patients, terms: clinical nurse specialist, advanced practice nurse,and families, communities, nurses, and organizations. Countless advanced nursing practice. Although this method yielded a examples of these programs are reported in the litera- large return, it is not possible to determine the amount of ture17,37,55,92,93,97,298–335:(a) symptom management pro- pertinent literature not captured with these 3 search terms. grams such as sensory retraining for fecal incontinence299 Sorting through the vast amount of literature and making and pain management17,300;(b) disease management pro- decisions about whether a particular article and/or abstract grams such as management of heart failure302,304,306,309,313 was eligible (eg, ‘‘Did it meet the inclusion and exclusion and diabetes305,307,315;(c) outreach programs targeting un- criteria set forth a priori?’’) were performed by 1 reviewer. derserved populations such as rural populations,37,298,318,323 Although detailed memoranda were kept by the reviewer, the homeless,319 and prison system populations93;and(d) bias must be considered. preventive programs such as coping skills education,324,333 The criteria stipulating that anecdotal articles and non- survivors of cancer counseling and support,55,325 and pa- research presentations should have first authorship by a renting skills instruction.331 Innovative programs that target CNS may have increased the trustworthiness of the findings specific areas of need within organizations are also described. about CNS clinical practice; however, it was the major Examples include a ‘‘critical care bug team’’ implemented to reason that an article or abstract was excluded from the final decrease the incidence of ventilator-associated pneumonias336 sample and reduced the sample size significantly. Searching and a ‘‘rock and roll’’ critical care program developed to authors’ names using the Internet was successful for nursing prevent complications from immobility.337 faculty whose credentials were listed on college Web sites; Administrators have relied upon CNSs to develop research- this was a less successful method for determining whether an based protocols,229,338–347 clinical pathways,348,349 guide- author in a clinical or foreign setting was a CNS. Very few lines,278,350–356 and policies357–366 in their institutions. For articles or abstracts listed a contact e-mail for the author. instance, CNSs have championed policy changes related to The widespread use of the term advanced practice nurse in assessment and treatment of pain.16,17,21,24,25,300,359–361,363–366 recent literature made it challenging to determine whether Withinacutecaresettings,CNSs have also pressed for policy the article or abstract was indeed describing CNS versus changes related to visitation and involvement of family in nurse practitioner clinical practice (midwifery and nurse patient care. One such policy change gives families the option anesthesia were easily ruled out). This was less problematic to be present during invasive procedures and resuscitation for anecdotal articles and nonresearch presentations that efforts, for example, ‘‘family presence.’’357 Clinical nurse required first authorship by a CNS. A research article or specialist clinical practice also involves promoting quality abstract using the term advanced practice nurse was improvement. Developing indicators and methods to measure included in the final sample, even if the advanced practice patient outcomes is described often.166,367–373 Clinical nurse nurse was not specified as a CNS; this must be acknowl- specialists anticipate, identify, and prioritize quality improve- edged when interpreting the findings.

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Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Finally, the major analysis used in this review was understand the work of the CNS and the effect of CNS qualitative and involved separating text from articles and practice on patient outcomes and costs of care has been very abstracts based on CNS clinical practice as operationally limited. The contributions of Brooten et al,186–191 McCorkle defined. Abstracts of dissertations, theses, and presenta- et al,199–201 and Naylor et al192–198 in explicating outcomes tions gave limited information; these entire manuscripts of advanced practice nurse transitional care are prototypical were not read. Although the substantive areas of CNS of the kind of research needed to market the CNS role and clinical practice and descriptors were presented to a group its value. Attention must also be given to how and where of CNSs and graduate CNS students for feedback and literature about CNS practice and outcomes is disseminated. significant revisions were made based on this feedback, the Only 6.5% of the articles in the final sample were found in actual thematic content analysis of the final sample of journals targeting nursing administrators; most paper pre- articles and abstracts was performed by 1 reviewer; there- sentations about CNS practice and outcomes were retrieved fore, bias must again be considered. from annual national NACNS conferences. Disseminating knowledge about CNS practice to a wider audience, DISCUSSION including healthcare administrators, other healthcare professionals, and the public, is crucial to marketing the unique Much has been written about the lack of clarity of the CNS contribution of CNSs in improving clinical and fiscal role. This review demonstrates that nurses who are outcomes of patients, families, and communities. prepared at a graduate level in clinical specialization write Although the versatility of CNS practice has at times about their clinical practices in much the same way. been thought to contribute to ambiguity and improper Research findings that describe the work of CNSs in utilization of CNS expertise, this versatility has also clinical settings and CNS practice interventions delineated allowed CNSs to be responsive to changing healthcare in randomized controlled trials are consistent with anecdo- environments. Created by the discipline of nursing to meet tal reports of CNS clinical practice. Substantive areas of the increasingly complex needs of patients over 6 decades CNS clinical practice described in the literature are as ago, the role of the CNS has evolved as new ways to meet follows: (a) managing the care of complex and/or vulner- societal healthcare needs were sought. For instance, in the able populations of patients and families through expert late 1980s and early 1990s, as managed care environments direct care, care coordination, and collaboration with the took firm hold of how healthcare was delivered, CNSs used interdisciplinary team; (b) educating and supporting the clinical expertise and collaboration skills to deliver effective interdisciplinary team through education, consultation, and case management, discharge planning, and transitional collaboration; and (c) facilitating change and innovation care. Today, with the mandate from consumers and payers within healthcare systems through change agency. These for evidence-based treatments, CNSs have emerged as findings are closely aligned with the spheres of influence leaders in implementing evidence-based practice into clin- and detailed descriptions of CNS practice and competen- ical settings, using clinical expertise, consultation and cies set forth by NACNS in their Statement on Clinical collaboration skills, and knowledge of systems and change. Nurse Specialist Practice and Education; therefore, the way Clinical nurse specialists possess the educational prepara- the role is conceptualized is clearly congruent with the way tion and mobility within healthcare systems to assess and CNSs describe what they do. anticipate trends in healthcare and to respond to ever- Why then is there so much confusion about the work of changing healthcare environments. the CNS? Master’s prepared CNSs clearly understand the Have there been unfavorable consequences for CNSs CNS role. Confusion about the CNS role may, therefore, resulting from increased complexity and diversity of their lay with nurses who are not CNSs, other healthcare role? One consequence has been movement away from professionals, and consumers. One reason for the lack of expert direct care with patients and families. Provision of understanding of the CNS role may be that much of the direct expert advanced nursing care is reimbursed by work of the CNS occurs ‘‘behind the scene’’ of direct insurers; there is no reimbursement mechanism for indirect patient care. Perhaps increased role diversity has led to advanced nursing care. Clinical nurse specialists who do increased anonymity, as many CNSs moved away from not spend a significant portion of their time in direct expert direct expert care to fulfill other role requirements. This reimbursable care have been seen as fiscal liabilities by points to a crucial need for CNSs to find creative ways to some administrators. This has resulted in CNSs having to ‘‘connect’’ directly with patients and families and to role continuously argue and/or demonstrate their worth to model for nurses and members of the interdisciplinary team organizations. Beside fiscal concerns, there is a need for specialized expert nursing care, even when their work takes expert leadership at the bedside as inpatient acuity rises, them away from the bedside and despite the many facets length of hospital stay decreases, and scientific knowledge and challenges of their role. Marketing is a need repeatedly required for safe nursing practice expands. The AACN discussed in the literature as being necessary for promoting recently identified the need for more expert nursing care the CNS role and its value. Increasing direct contact with and leadership at the bedside and responded with the patients and families may be a simple, yet important, creation of the CNL role. Although AACN claims that the overlooked marketing strategy to improve recognition and CNS and CNL roles are distinct yet complementary, nurses understanding of the CNS role, especially by consumers. in the CNL role are envisioned to be the direct providers of Although outcome information was included in about the expert evidenced-based nursing care that will be half of the articles and abstracts in the final sample, only designed and evaluated by the CNS. This leaves the CNS 24% included data-based information. The use of rigorous vulnerable to continued anonymity with consumers and research designs, both quantitative and qualitative, to criticism from skeptics who contend that the expert direct

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