Clinical Nurse Specialists: Leaders in Improving Patient Outcomes

Each year, the first week of September is recognized as Clinical Nurse Specialist (CNS) Week, and what better time to recognize the CNS’s unique contributions to healthcare.

As one of the four advanced practice registered nurse (APRN) roles — the others are certified registered nurse anesthetist, certified nurse midwife and certified nurse practitioner — the CNS leads and collaborates with other members of the interprofessional team to enhance care delivery and improve outcomes for patients and families. A recent article in Critical Care Medicine describes how CNSs contribute to the interprofessional team:

• Provide clinical expertise and education
• Coordinate the development and implementation of a plan of care
• Implement evidence-based practices
• Lead quality initiatives
• Conduct research
• Promote effective communication

To better understand and appreciate this vital APRN role — especially if you are considering a CNS career path — let’s take a look at CNS role requirements, scope of practice, core competencies and overall impact.

CNS Role Requirements

Practicing as a CNS involves formal education, licensure and board certification requirements.

The “Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education” defines APRN practice and describes a model of regulation to ensure patient safety by aligning APRN roles. The Consensus Model specifies that:

• CNS practice requires education at the graduate (Master of Science) or postgraduate level (Doctor of Nursing Practice) from an accredited nursing program, where CNS candidates develop core competencies in care delivery from wellness through acute care.
• Like all other APRNs, the CNS serves as a direct care provider and therefore the role requires a clinical practicum of a minimum of 500 hours.
• CNSs must be certified through a nationally accredited professional certification organization before they can practice.
• State licensing boards governed by each state’s regulations and statutes determine practice components within a given state.

These extensive requirements support CNSs in preparing for the demanding, multifaceted responsibilities of their role.

Sometimes, I am asked how the CNS role differs from that of a nurse practitioner (NP). An NP focuses primarily on the medical management and procedural aspects of care. The CNS uses advanced knowledge, clinical inquiry, innovation, change management and critical thinking to improve nursing practice and teamwork in order to positively impact clinical management of the patient.

CNS Scope of Practice and Core Competencies

Clinical knowledge and expertise in a specialty area, such as critical care, trauma or pediatrics, form the foundation of CNS practice. The CNS integrates patient care across a continuum from wellness to acute care through three spheres of impact: patient/family, nurse/nursing practice and organization/system.

Key elements of CNS practice include creating environments and teams through mentoring, and also empowering nurses and others to implement evidence-based practices to alleviate distress, facilitate ethical decision-making, promote effective communication and lead quality initiatives.

In its Statement on Clinical Nurse Specialist Practice and Education, the National Association of Clinical Nurse Specialists (NACNS) outlines CNS core competencies that describe essential skills and behaviors used to achieve desired outcomes within the three spheres of impact. Examples of these CNS core competencies within critical care CNS practice include:

Patient/Family Sphere

• CNS core competency: Implement evidence-based nursing interventions and national guidelines into practice
  • Examples: Integrating accepted guidelines such as Surviving Sepsis Campaign, AACN Healthy Work Environment Standards and end-of-life care into unit practice
• CNS core competency: Consult with patients with complex needs
  • Examples: Implementing prone positioning protocol, addressing hospital-acquired conditions (HACs)
• CNS core competency: Evaluate the impact of nursing interventions on patient outcomes
  • Example: Gathering and assessing outcomes data before and after implementing strategies to address “never events” and other quality patient care indicators such as hospital-acquired pressure injury (HAPI) and/or central line-associated bloodstream infections (CLABSIs)

Nurse/Nursing Practice Sphere

• CNS core competency: Consult with nurses caring for patients with complex needs
  • Example: Working with a unit direct care nurse to interpret and apply hemodynamic values or address ethical challenges
• CNS core competency: Assess nursing practice and processes to identify improvement opportunities
  • Examples: Creating educational programs, promoting certification, mentoring nurses in the use of evidence-based practices
• CNS core competency: Lead nurses in planning, implementing and evaluating change
  • Example: Leading interprofessional rounds and ensuring recommendations are incorporated into patient care

Organization/System Sphere

• CNS core competency: Consult with the interprofessional team to integrate the needs, preferences and strengths of a population into the healthcare plan to optimize outcomes and patient experiences within a healthcare system
  • Examples: Sharing best practices with another intensive care unit (ICU) or hospital, leading and/or participating in the development, implementation and evaluation of standard practices in targeted temperature management
• CNS core competency: Lead and participate in systematic quality-improvement and safety initiatives based on precise problem/etiology identification, gap analysis and process evaluation
  • Examples: Serving as chair of a health system’s ICU nursing practice council and/or representing ICU nursing practice on health system committees, leading research studies and presenting findings in publications or podium presentations at national conferences

As you can see, the work of the CNS touches all aspects of healthcare operations and care delivery.

CNS Impact on Healthcare

CNSs are the glue in healthcare — organizational connectors using evidence and leveraging relationships to move projects forward that significantly impact patient and system outcomes.

CNSs engage and collaborate with a wide range of interprofessional team members, including physicians, NPs, physician assistants, nurses, respiratory therapists, pharmacists, dieticians, physical and occupational therapists, case managers and hospital administrators. This collaboration enhances the patient and family experience and improves resource utilization and outcomes.

There are various examples in the literature of how CNSs have decreased HAPIs, ICU length of stay, CLABSIs, mechanical ventilation days and ICU readmissions, to name just a few. As an integral leader in the implementation of evidence-based practice, research and quality initiatives, CNSs substantiate the components necessary to achieve or maintain Magnet or Pathway designations.

CNSs also improve the bottom line of organizations through revenue generation and cost avoidance strategies. They can generate revenue by billing for services, including patient care, consultations and ordering durable medical equipment. They achieve cost avoidance through implementation of improved practices that reduce HACs, for example, which decreases the potential for financial penalties from payors due to those HACs and readmissions.

The COVID-19 pandemic has magnified the impact of CNSs on patients, families, nurses, hospitals and health systems. CNSs have designed and implemented pronation protocols, personal protective equipment conservation strategies, critical care education, cross-training of non-ICU nurses to support ICU nurses in team-based staffing, self-care strategies and peer support.

Within the nursing profession, the CNS is uniquely qualified to lead clinical practice. In my own CNS practice, I am proud of the work I did to enhance the end-of-life experience for patients and families (standard order sets, evidence-based protocols, interprofessional collaboration), as well as for the nurses caring for them (educational programs, The Pause, debriefing).

What have been your greatest successes as a CNS?