The 2002 Strategic Plan of the National Association of Clinical Nurse Specialists (NACNS) called for a systematic review and, where necessary, revision of the Statement on Clinical Nurse Specialist Practice and Education. The NACNS board wanted to assure the readership that the statement reflected contemporary clinical nurse specialist (CNS) practice and required education. To that end, a national task force, chaired by Dr Angela Clark, was convened. The task force comprised practicing CNSs and educators and included a few of the authors who had participated in the development of the original statement. I had the fortune to be part of the group.
Although the original statement was published in 1998, the thinking behind its purpose and position began as early as 1995. Healthcare was embroiled in managed care and cost reductions while at the same time trying to improve patient satisfaction. This was the era of fixed cost reductions, bed downsizing, and nurse uprisings. The CNS fell victim to these trends and many questioned the scope and value of the role. Some CNSs changed their titles and/or slid into newly created roles that were established to respond to the healthcare initiatives mentioned. The statement was written in this climate and had as its purpose the articulation of the critical importance of the CNS role to the delivery of effective and efficient quality nursing care. The statement spoke to the contribution of the role in all 3 spheres of influence (patient, caregiver, and system), the required competencies for CNS practice, the resultant anticipated outcomes, and, therefore, the necessary standards for CNS education. The document was used by many to revise and revitalize educational programs and to craft performance-based role summaries, as well as support the defense of the role in many healthcare systems. The statement was viewed by many nurse leaders as a significant and provocative contribution to the nursing literature; it not only voiced a firm position on the need for CNSs in healthcare delivery but also clearly articulated the essence and scope of professional nursing practice and the need for the CNS role as a separate and distinct advanced practice role.
As I did my line-by-line review of the document within the context of a 2002 healthcare climate, I was impressed with how the statement has stood the test of time. Despite incredible social outcries and upheavals of the late 1990s, resulting, at times, in 360[degrees] turnabouts and the continued emphasis on cost reductions and revenue enhancements, the foundation for CNS practice and education put forth in the statement remained solid, appropriate, and useable. What was missing however were the contemporary linguistics driven out of a new and/or an expanded vision for healthcare in the new millennium. As a CNS/nurse administrator, I am engulfed in initiatives and strategies related to improved patient safety, evidence-based practice, and the measurement of nurse-sensitive outcomes, as well as compliance with ever-changing and expanding regulations and standards. Improved cost per case and enhanced revenue per program are again the mantra of this decade. However, these strategic imperatives now must be carried out in the face of daunting adversity: the soon-to-be worst nursing shortage in history, waning nurse satisfaction with and loyalty to individual health care systems, increasing consumerism in healthcare, public outcry regarding safe medical practices, increasing professional accountability for expected quality outcomes in care management, and the daily explosion of new knowledge/evidence that affect healthcare in general and nursing practice in particular. There are new credentials to be sought and certifications to be acquired (eg, Magnet status) to remain competitive, be the employer of choice, and be the desired provider for healthcare among consumers.
The CNS competencies outlined in the statement are implicit in many of the issues mentioned, trends, and opportunities. However, for the statement to be a contemporary and an effective tool for its customers, the role of the CNS must be made explicit in them. There is no doubt that CNS contributions are critical to patient safety. Whether it be through failure-mode analysis, root cause investigation, and/or evidence-based affordances, the CNS-regardless of specialty or venue-possesses the competencies in advanced assessment, diagnosis, synthesis, and project management to be a leader in this work. It is one thing to identify nurse-sensitive outcomes; it is quite another to ensure that the measurement of and interventions for these outcomes are reliable, valid, and state of the art-a perfect fit for CNS contribution. The role of the CNS in multidisciplinary care management is evidenced in the literature. The statement must speak to the tools needed by some practitioners in care management, whether that be the knowledge to diagnose and treat disease or the need for prescriptive authority. The educational standards surrounding those issues should be clear and prescriptive to assure consistent outcomes wherever CNSs practice. I also see a tremendous role for the CNS in knowledge diffusion. As evidence-based practice brings changes within the delivery system, the CNS is obligated to help sustain and spread the knowledge so that all patients and practitioners benefit where possible.
The original statement outlined the generic competencies that a CNS needed to accomplish the challenges mentioned. The outcomes associated with this knowledge and skill had to be made more contemporary. Therefore, the statement was revised and enhanced. Contributions of the CNS were made more explicit and the standards for CNS education more reflective of contemporary CNS practice. As the role of the CNS evolves and responds to the needs of patients, providers, and systems, the Statement on Practice and Education needs to evolve and respond.