Everyday brings a new challenge, but a clinical nurse specialist (CNS) colleague of mine wouldn't have it any other way. A CNS to the bone, she takes each day anew and tackles her responsibilities with intelligence, grace, and humor. I asked her what she does in a day. There are the usual items-consult with staff regarding individual patient problems, assist with new nurse orientation, provide programs for house staff, attend a seemingly never-ending list of committee meetings. This morning she meets with the staff development department about revising the unit-based orientation program, and in the afternoon she is presenting a review of length-of-stay outlier data to the management team. This she explained over a quick cup of coffee.

More formally, multiple role-delineation studies have been conducted during the years to capture the CNS role tasks and job responsibilities. A review of CNS job descriptions formed the basis of the 1998 NACNS Statement on CNS Practice and Education.1 This review led to abandoning the traditional subroles-practitioner, educator, consultant, researcher, administrator-and gave rise to a framework that describes how CNS practice takes place in 3 spheres of influence-patients/families, nurses/nursing personnel, and systems/organizations. This shift helped us to see that what we do is less a list of items that sort neatly into subroles by function and more a result of the competencies actualized in CNS practice.

Some of the important work of CNSs remains formally unarticulated. Ask a staff nurse what a CNS does. You will hear responses such as "consult with difficult patients." What too often goes unspoken is that the CNS encouraged me when I was overwhelmed, smoothed over a tense situation, and comforted me when a was feeling like a failure for things that I could not control. She or he explained things to physicians when I could not find the words; helped management realize that the equipment needed updating; changed policies that were creating roadblocks. The CNS is a safe person-someone to vent to about the system, the staff, the manager; someone to help me regain perspective and keep a sense of humor. A friend, a mentor, a colleague. This perspective of the other things that the CNS contributes is less well documented but recurrently discussed.

I considered the other things when I read Linda Aiken and colleagues' study that explored the association between patient-nurse ratios and patient mortality, failure to rescue, and factors related to nurse retention. 2 The results demonstrated that among surgical patients, patient-nurse ratios were associated with patient mortality-each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission and a 7% increase in the odds of failure-to-rescue (deaths following complications). And, each additional patient per nurse was associated with a 23% increase in the odds of burnout and a 15% increase in the odds of job dissatisfaction. I can't help but wonder about the level of support for nurses in the systems studied. Is it reasonable to speculate that when registered nurse staff was downsized, leading to increased patient-nurse ratios, that CNS staff was also reduced or eliminated? I think so, at least for many hospitals. The 1990s was a time of reduction in hospital-based CNS positions-although that data are mostly anecdotal. Considering the other things CNSs provide for staff, it is reasonable to speculate that patient mortality, nurse burnout, and job dissatisfaction can be aggravated by the loss of CNS positions.

Not all hospitals and healthcare systems experienced a reduction in CNS positions. CNS positions on the East and West Coasts decreased more drastically than in other parts of the country. The West Coast, in particular, saw tremendous focus on health maintenance organizations (HMOs) for care delivery. With an HMOs focus on primary care, nurse practitioners (NP) jobs grew whereas CNS positions disappeared. Schools shifted programs and prepared NPs in record numbers. Now, nurse administrators are heavily recruiting for CNSs, but because of downsizing of CNS educational programs, there is a scarcity of CNSs available to fill the growing number of positions. This increased need for CNSs provides clear evidence of the important contributions CNSs make to the healthcare system.

What do CNSs do? We are experts in the care of a specialty population. Our expertise is tensile strength for the system-cutting across departments, units, providers. We strengthen nursing practice by bridging the gap between knowledge and practice. Bridging means shepherding ideas, linking resources, engaging stakeholders, and serving as the consummate champion for the cause. Educational programs are responding. In 1997, there were 143 CNS programs in the United States. By 2000, that number had grown to 183-an increase of 40 programs in 3 years. 3 What we do makes a difference. And we're coming back. We are leaders, mentors, and vanguards for nursing practice with the staff and with the system. We advance nursing by bringing cutting-edge care to the patient's bedside. We make a difference in patient mortality and staff burnout. It's our challenge to prove it in ways other than our absence. The journal is seeking databased manuscripts that focus on outcomes of CNS practice. You may not have considered adding a manuscript to the list of things you do in a day, but we must meet the challenge of articulating what we do.

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