After 6 years in an exclusively administrative role, I am gradually, and sadly, giving up my identity as a clinical nurse specialist (CNS) and fully embracing a position focused on driving the utilization of the advanced practice roles in my organization. My responsibilities now include determining when a CNS is needed and identifying practice expectations and clinical outcomes for CNSs in the organization. It requires a long lens to see CNSs in the larger context of the organization and to shape the organization's perception and expectations of CNS practice now and for the future. As current CNSs, CNS students, and CNS educators consider the future of this valuable role, some insights may be helpful from a hospital administrator responsible for a variety of advanced practice roles.
As an advanced practice director, I supervise not only CNSs but also nurse clinicians (NCs), bachelor's-prepared nurses with a specialty focus, and advanced practice providers-nurse practitioners and physician assistants. This leadership role requires a nuanced understanding of each role to determine a best fit when an organizational need arises. Once a need for a practice role is identified, the leadership team considers several issues, including the alignment between clinical need and practice competencies, any cost-benefit considerations, and the practicality and ease of recruitment given the local talent pool.
In situations where the clinical need warrants the CNS core competencies as defined by the National Association of Clinical Nurse Specialists (http://www.nacns.org/html/competencies.php), CNSs are preferred. Situations most often seen as requiring a CNS are those needing (1) advanced nursing assessment and clinical management skills, (2) consultation and collaboration in a complex environment, (3) teaching and coaching patients and family caregivers and teaching, coaching, and mentoring nurses and nursing staff, and (4) providing leadership for best-practice initiatives and cost-effective quality improvement. In short, a CNS is needed when the work to be accomplished includes all 3 domains of CNS practice-patient/family, nurses/nursing practice, and system/organization, especially the system domain.
When the clinical need is limited to teaching and coaching of patients and families and/or nursing staff, an NC or nurse educator may be considered, particularly if the scope is narrowly defined. If the direct care need is considerable and medical management of the patient is included, a nurse practitioner or physician assistant is usually the first choice, especially if the practice setting is suitable for generating fee-for-service. In situations where the need is for system-level thinking and involves multidisciplinary participation for broad-scale change in practice, the CNS is the practitioner of choice. Clinical nurse specialists are most effective at working across the system to align scientific evidence, necessary resources, provider groups, and organizational policies and practices for improved clinical outcomes.
In some areas of the country, the current shortage of CNSs can make this job role one of the most difficult to fill. Geographic areas with strong CNS academic programs have a steady stream of graduates, and finding potential applicants is not an issue. However, in some areas where few CNS programs are available, it can be very difficult to recruit CNSs, in general, or CNSs in some specialty areas, in particular. The shortage is being compounded by the Advanced Practice Registered Nurse Consensus Model (https://www.ncsbn.org/4213.htm), with its emphasis on broad, not specialty, populations and retroactive implementation of certification requirements that many current CNSs cannot meet. In some areas of the country, this has created a downward spiral, with the lack of CNSs in clinical practice contributing to myths about the future of the role, all ending up discouraging would-be students from enrolling in CNS programs.
Even when the administrative team determines that the CNS is the preferred role, recruiting challenges may lead to the job being underfilled by an NC or filled with a substitute advanced practice provider. When this occurs, it is important for the organizational leadership to adjust expectations for performance to be consistent with the role competencies. Nurse practitioners placed in jobs better matched for CNSs are often frustrated with the demands of system-level work because it removes them from the direct care they were prepared for and prefer to do. Underfilling the CNS role or substituting another advanced practice provider potentially dilutes the organization's understanding of the CNS role and can lead to a negative impression of CNSs. Providers competent in another area of practice should not be expected to perform as CNSs. However, underfilling the job with an NC or another substitute provider offers an opportunity to develop an excellent nurse into a CNS when the completion of a CNS program (MSN, DNP, or postmaster's CNS certificate) can be part of the hiring expectation.
What organizations need from CNSs is the ability to advance patient care practices, improve clinical and fiscal outcomes, and drive organizational change. Achieving this goal requires an expert clinician who can educate, mentor and motivate, lead, and manage both unit-based and system-wide projects using data and data systems to support proposals and demonstrate outcomes. In short, the CNS should be the go-to role for bringing together multiple disciplines to solve problems. With a 25-year background as a CNS, I could not be more committed to the CNS role. Now, in my administrative role, I have to balance that commitment with the need to ensure cost-effective staff utilization. Clinical nurse specialist programs must ensure that CNS students are developing competencies in the system/organization domain. Clinical nurse specialist students should be pushed beyond their comfort zones to broaden their abilities to create, manage, and evaluate change at the organizational level. Although the CNS role is built on a core competency of expert clinical care, today's healthcare systems need CNSs to be skilled beyond direct care, to recognize their roles as institutional leaders, and to act accordingly!