The second recommendation in the Institute of Medicine's Future of Nursing1 report calls for nurses to lead and diffuse collaborative improvement efforts. Public and private funders, healthcare organizations, nursing education programs, and nursing associations are called upon to expand opportunities for nurse to lead and manage initiatives and research directed at improving patient outcomes by transforming practice and improving the systems and environments in which services are delivered. Within healthcare systems, clinical nurse specialists (CNSs) currently are leading such improvements evidenced by the articles and conference abstracts appearing in this journal. Nonetheless, this work often is invisible to the larger healthcare community, policy makers, and the public. Sadly, too often it is invisible to the system in which the CNS works. For CNSs to remain relevant in this fast-paced era of healthcare reform, dissemination of outcomes is critical. Publishing articles in peer-reviewed journals has long been the criterion standard of scholarly dissemination, and as a journal editor, I've heard plenty of reasons why that manuscript never quite happened. However, journal publication is not the only venue for dissemination and failure to write a manuscript is not the only reason for invisibility.

Being able to disseminate outcomes of CNS practice begins with clarity of performance expectations. For clarity in expectations, a good place to start is the National Association of Clinical Nurse Specialists Statement on Clinical Nurse Specialist Practice and Education,2 which lists expected outcomes by domains of practice-patients, nurses/nursing practice and organization/system. Performance expectations should be delineated in CNS job descriptions or other employment documents and serve as the basis for performance review. Performance expectations guide individual practice goals, serve as a basis for determining priorities when demands exceed time and resources, and identify areas for professional development. Mutually negotiated outcome expectations are a road map to successful performance.

System-level outcomes can fail to reflect the contributions of CNSs because CNS practice activities are not linked to the outcome. Increased staff hand washing, reduced inpatient pressure ulcers, improved outpatient medication reconciliation, and many, many, many other improvements result from CNS practice. Asked about their contributions, CNSs are likely to cite "leadership." While it is true that CNSs are frequently assigned to lead these types of initiatives, in these situations a drill-down of leadership is needed to identify the specific activities, relationships, and time required to bring the project to fruition. CNSs chair committees, communicate across disciplines, conduct needs assessments, locate and review relevant literature, analyze internal data, evaluate new equipment, conduct bedside rounds, mentor staff, conduct information sessions for physician residents, organize trials for revised procedures, lead order set or protocol development, and, and, and[horizontal ellipsis]. The list is long. Once the improvement is achieved, little acknowledgement is given to the time, intellect, and skill of the CNS. Not only would it be insightful to know the activities and time of the CNS that produced the result, but it is also crucial. Without a reporting of activities, there is no evidence trail by which to credit to the work of the CNS.

Too few CNSs regularly report practice activities. With multiple competing priorities, it is easy for a CNS to be pulled in many directions, resulting in many activities and few outcomes. A good record of activities provides the data necessary to link activities to outcomes; it also allows individual CNSs to analyze how work time is spent and to negotiate priorities. On a regular basis, monthly or quarterly, CNSs should prepare and distribute activity reports related to assigned projects and resulting outcomes. The report should be sent, whether requested or not, to relevant managers and administrators. CNS contributions are much more visible in the organization when administration has a tangible report of outcomes and the activities and time required.

Any report is not complete without fiscal outcomes. CNS practice is sometimes revenue generating, particularly in outpatient settings; however, it is more likely that CNSs contribute to cost avoidance. Intervening with complex patients to reduce length of stay, avoiding overuse of costly equipment, decreasing waste, standardizing procedures, and initiating timely referrals are all cost avoidance strategies routinely used by CNSs. Fiscal outcomes of CNS practice should be attached to the report. At first, it may be difficult to identify fiscal outcomes; systems may not be adept at tracking clinical cost avoidance. CNS should consult with the business office or a fiscal officer and make an informed best effort. To any person who points out that the estimates are incorrect, thank them for reading the report and ask for assistance in being more accurate.

An annual report should summarize activities and outcomes across the year and form the basis of the annual performance report. The collective outcomes of all CNSs in a system should be organized into an annual report and sent to the board of directors. For any and all reports, make sure to include your name, credentials, and title-Clinical Nurse Specialist-spelled out, no abbreviations!

As CNSs get more adept at reporting activities and linking CNS practice to outcomes, the reporting format will morph into a more concise, accurate report. With data, CNSs will develop new insight into their practice, priorities, and time management. Most importantly, CNSs will become much better at articulating contributions made to improvement projects. Of course, publications are important, but there are other important venues for reporting outcomes. CNSs are ready for expanded opportunities to lead and manage initiatives directed at improving patient outcomes, transforming practice, and improving the systems and environments in which services are delivered. It starts with being clear about expectations for practice, keeping track of activities, and making sure everyone involved can identify CNS contributions.

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