Do hospital-based palliative care clinical nurse specialists de-skill general staff?

A large number of clinical nurse specialists work within the area of palliative care, particularly in the acute hospital setting. This article presents the qualitative findings of an evaluation study that looked at the impact of the clinical nurse specialist within a palliative care team in a large acute hospital in the North-West of England. A total of 31 interviews were conducted with stakeholders from across the hospital setting. The data were analysed for emerging themes using a case and cross-case analysis. The results indicated that the senior stakeholders and the palliative care team felt that the clinical nurse specialists might be de-skilling the general nursing and medical staff, while junior staff did not perceive that they were being de-skilled. This article discusses potential explanations for this, including the possibility that junior staff may not be fully aware of the role of palliative care clinical nurse specialist. The impact that clinical nurse specialists are having on empowering the junior staff is also discussed and recommendations for further research are suggested.     

Cultural perspectives on nursing in the 21st century.

By the year 2000, more than one fourth of the US population will consist of individuals from culturally diverse groups. Increasing numbers of international visitors and exchange students will use the US health care delivery system, and US nurses will engage in international interchanges with increasing frequency. To keep pace with these population and health care trends, US nurses will need to base their nursing care on a theoretically sound foundation that draws on knowledge from the physical, natural, and behavioral sciences, as well as on research-based theories from transcultural, cross-cultural, and international nursing. The purposes of this article are to (1) trace past, present, and future population trends among minority groups in the United States; (2) examine the ways in which transcultural nursing has provided a framework for meeting the health care needs of culturally diverse people; (3) identify current issues and trends in transcultural nursing; and (4) suggest ways in which nurses can prepare for the increasing numbers of culturally diverse individuals who are projected to need nursing care in the future.     

Senior clinical nurse specialist pilot position in Hong Kong

This article reports findings of a consultancy project commissioned by Hospital Authority, Hong Kong, to explore the scope of service, role competence, and contribution to patient service of senior-position clinical nurse specialists. Three clinical nurse specialists were selected for this project. The consultant guided and monitored effects of initiatives proposed by each clinical nurse specialist. The evaluation strategies were dependent on the nature of the projects proposed by the senior clinical nurse specialist. Data were collected through nonparticipant observation and interviews to address the overall consultancy project aims. This study shows that the role components of clinical nurse specialists were common across different countries. The value of the clinical nurse specialist to initiate strategies to promote cost-effective and quality care were confirmed, but the career development of these specialists remains a concern in a healthcare environment with constraining resources.     

A phenomenological investigation into the role the clinical nurse specialist

This research study adopts a phenomenological approach to investigate how a group of clinical nurse specialists think and experience their role. It reviews the literature on the clinical nurse specialist from 1943, when Frances Reiter first coined the phrase 'nurse clinician', to the present time, when individuals are committed to a range of initiatives aimed at improving the quality of the British National Health Service and patient care. The study investigates and analyses their views and conveys the personal meaning of clinical nurse specialists 'lived experience' in the role. Findings of the study suggest that clinical nurse specialists are experienced practitioners who strive to be in positions in which they influence patient care and utilize advanced knowledge, expertise and leadership skills in a multidisciplinary environment. The literature proposes that for the role to be recognized and accepted individuals need to be educated at an advanced level, demonstrate practice based in research and have a firm base as a specialist in nursing. The findings clearly suggest that while the role of the clinical nurse specialist can be influenced in a positive manner by the organization and guided by the individual, it is important to acknowledge that the role is in a transitional phase. Finally, the research suggest the importance of establishing a clear role definition in a creative and supportive environment allowing for a autonomy, professional growth and the development of individuals as clinically competent nurse specialists.     

Clinical nurse specialist participation on a collaborative research project. Barriers and benefits

Clinical nurse specialists are expected to contribute to the development of new nursing knowledge through research activities. Competing demands require constant juggling of time and priorities, and activities, such as research, often do not receive the attention they deserve. Research requires specific skills and knowledge and significant time expenditure. Collaborative research is an appropriate way for the clinical nurse specialist to both contribute to research and improve his or her research skills. This article discusses two pediatric critical care clinical nurse specialists' participation in a collaborative research team led by university faculty. The study was designed to reduce family uncertainty and stress and to increase staff nurse competency in providing family care. The ability of the clinical nurse specialists to contribute to the research team was enhanced by knowledge of the research process, good communication skills, and clinical expertise in the specific population of interest. Challenges for the clinical nurse specialists included limited experience in conducting clinical research and balancing clinical and research priorities. Both clinical nurse specialists and the university faculty benefited from this collaboration. The clinical nurse specialist, with expertise in a clinical specialty, is able to bridge the gap between the academic and clinical sites, making clinical research more likely. At the same time, working with expert researchers allows the clinical nurse specialist to increase his or her research skills.     

A stakeholder evaluation of the impact of the palliative care clinical nurse specialist upon doctors and nurses,within an acute hospital setting

There has been an expansion in the number of palliative care teams based in the acute hospital setting. Although organization of these teams varies both in structure and approach, the clinical nurse specialist is one of the key members. The last decade has seen an escalation in the UK of clinical nurse specialists, and following the Calman-Hine Report and the more recent NHS Cancer Plan, it is anticipated that the number of clinical nurse specialists in palliative and cancer care is likely to grow. This paper presents the qualitative findings of an evaluation study designed to investigate the impact of the clinical nurse specialist within a palliative care team based in an acute hospital setting. A stakeholder evaluation that encompassed 31 tape-recorded semi-structured interviews with senior nurses, consultants, junior doctors and nurses representing different grades were performed. The data was analysed for emerging themes utilising a case and cross case analysis methodology. The results suggested the presence of the clinical nurse specialists is seen as beneficial to both medical and nursing staff. This paper will focus upon exploring these potential benefits, included providing support, advice and education.     

Assessing culturally diverse pediatric clients

For many pediatric nurses, providing culturally sensitive care among children of diverse backgrounds is frustrating and time-consuming because elements of cultural care theory were not assimilated into their educational programs. Using a transcultural model developed by Giger and Davidhizar (1995), pediatric nurses can now integrate a holistic and efficient assessment into the child's treatment plan. Essential health beliefs and practices are synthesized into the model's six components to assist the pediatric nurse in providing culturally appropriate care.     

Developing a CNS role to meet the mental health needs of the underserved

The purpose of this article is to describe a clinical nurse specialist program that prepares psychiatric-mental health nurses for positions in today's mental health care system. Recently, there has been a national increase in psychiatric-mental health nurse practitioner programs and a decrease in psychiatric-mental health-clinical nurse specialist programs. We faced the dilemma that many psychiatric-mental health nurse faculties face in this climate of mental health care delivery changes: how to best prepare psychiatric-mental health nurses for advanced practice. Because of our long history of preparing clinical nurse specialists, we believed the role was a viable one. The clinical nurse specialist role also fit with our university's mission and our beliefs regarding the importance of providing care for underserved populations. The role of the community mental health-clinical nurse specialist is described, and the economic, demographic, and mental health system changes that influenced the development of the community mental health-clinical nurse specialist role are explored. The curriculum and the impact of the program are described and evaluated. Finally, implications regarding the need and the viability of this new role in both psychiatric-mental health nursing and in other specialties as we care for clients in the community are presented.     

The work of clinical nurse specialists (HIV/AIDS) in areas with a low prevalence of HIV infection

The role of the clinical nurse specialists (HIV/AIDS) who work in areas with a low known prevalence of HIV is considered and their contribution to patient care, either directly or indirectly through the education and support of other health care workers, is discussed. Attention is given to the implications for nursing practice and the role of the clinical nurse specialist associated with the relative infrequency of contact with patients who have HIV disease; and some of the issues for people living with HIV/AIDS in rural areas are alluded to. Finally, some of the limitations of the clinical nurse specialist role are delineated and some consideration is given to the future role of clinical nurse specialists for HIV and AIDS.     

A demystification of the clinical nurse specialist role: perceptions of clinical nurse specialists and nurse administrators

Differences of nurse administrators and clinical nurse specialists regarding components of the clinical specialist role were investigated. To be effective in facilitating the maximum use of the abilities of the clinical specialist, it is essential that nurse educators establish a data base about the clinical nurse specialist role from the perspective of employers and the clinical nurse specialists themselves. Subjects were 54 nurse administrators and 35 clinical specialists from a large metropolitan area. The results indicated that, generally, both groups were in agreement except for the research component. Administrators placed a higher value on research than did the clinical specialists. Both groups valued the clinical practice component with the clinical specialists tending to see themselves more heavily committed to direct specialized patient care than did the administrators. The educational component was also valued with the consultant function receiving the highest rating of all the functions surveyed. The administration component was valued least highly of all the components. It is recommended that nurse educators evaluate their educational endeavors in preparation of clinical specialists especially for research functions, and, also, consultation and those functions supportive of nursing staff.     

Education for differentiated role development for NP and CNS practice: one nursing program''s approach

Development of nurse care providers who best meet the public's health care needs is imperative. Some nurses believe the functions of nurse practitioners and clinical nurse specialists should be combined. However, the experience of the authors' nursing program argues otherwise. Two graduate nursing tracks, family nurse practitioner and rural health specialist, were developed to meet the health care needs of rural populations. Although the two tracks share expected competencies and areas of expertise to some extent, differences in practice are apparent in identified domains of practice and terminal competencies. Family nurse practitioner practice focuses on assessment, diagnosis, and management of health and illness conditions of individuals and families across the life span. Clinical nurse specialist practice incorporates traditional roles of client assessment, monitoring and coordination of care, outcome assessment, and client, family, and community education, with a new focus on case management strategies. These differences are important to care delivery in the managed care era.     

Beyond transculturalism: critiques of cultural education in nursing

New and innovative educational approaches are needed to prepare a workforce that responds to diverse needs of people from a wide variety of cultural backgrounds, languages, and worldviews. Despite some movement toward standardization of cultural curricular content, there remains a lack of consensus regarding pedagogical approaches to cultural education in nursing. An increasing number of nurse scholars have identified significant limitations in the process of cultural education in nursing and transcultural nursing theory. These critiques reflect a schism in the discipline regarding foundational theoretical perspectives and conceptualizations of culturally competent health care. This article offers a synthesis of transcultural nursing critiques that have appeared in the nursing literature over the past decade and explicates the philosophical tensions that underlie the varying pedagogical approaches to cultural education in nursing.     

Clinical nurse specialist practice within the Acute Care for Elders interdisciplinary team model

As the complexity of care increases for hospitalized older adults, the clinical nurse specialist is essential for ongoing development of nursing practice and care standards. This article describes the Acute Care of the Elderly (ACE) model for interdisciplinary management of older adults and clinical specialist responsibilities within this interdisciplinary team. Within the model, clinical care specialists utilize clinical expertise and consultation skills reflecting three spheres of practice related to care of high-risk community-dwelling older adults admitted an acute medical unit. The goal for this patient group is to achieve medical stability while preserving maximum functioning. The Acute Care of the Elderly team members include primary nurses (staff nurses), physicians, clinical care specialists, therapies, social workers, dietitians, pharmacists, and a discharge planner. Under the leadership of the primarily nurse, the team develops a comprehensive care and discharge plan, implemented across a care continuum. Using protocols and working together, the team delivers cost-effective, coordinated care that promotes process improvement resulting in practice that is in alignment with current standards of care.     

Nurse specialist assessment and management of palliative care patients who are depressed--a study of perceptions and attitudes

Depression is a frequent symptom in palliative care patients but is often not diagnosed. In the U.K., the majority of patients with advanced cancer are referred to a clinical nurse specialist (CNS) whose remit includes the assessment of psychological symptoms and depression. Clinical nurse specialists have a key role in the diagnosis and management of patients with depression and it is important that they have the skills to do so. A postal questionnaire of all U.K. hospital, hospice, and community palliative care clinical nurse specialist teams was carried out to determine how they assessed depression in their patients. The response rate was 40%. Seventy-nine percent of all clinical nurse specialists believed their skills were poor in this area, and 92% felt they required further training. These beliefs were substantiated by the difficulties nurses encountered in assessing depression and by their beliefs regarding antidepressant medication. Clinical nurse specialists have a pivotal role in improving the detection and management of depression in palliative care patients, and require further training in this area.     

The clinical nurse specialist: a way forward?

The words clinical nurse specialist have been part of the nursing vocabulary for some time, but are these nurses specialized practitioners like many of us, or is there a larger role for them to play? This paper is a piece of reflective writing and is intended to further the debate concerning clinical nurse specialists The paper examines clinical nurse specialists from an intensive care unit perspective It looks at the intensive care unit and the wealth of under-utilized experience these environments contain The paper examines the existing and envisaged roles of clinical nurse specialists, their education and utilization, and also the difficulties that they are likely to face in their evolution, both from within the nursing profession and from outside it     

Definition of an advanced nursing practice role in the NICU: the clinical nurse specialist/neonatal practitioner.

We surveyed 655 health professionals affiliated with tertiary level neonatal intensive care units in Canada and the United States to define an expanded role for nurses in neonatology and to determine the educational requirements for the role. The role, comprising advanced clinical practice, educational, research, and administrative responsibilities, is a blend of nurse practitioner and clinical nurse specialist activities. Based on survey findings, a neonatal stream within the existing Master of Health Sciences program at McMaster University was developed. To date, 15 clinical nurse specialists/neonatal practitioners (CNS/NPs) are employed in five neonatal intensive care units in Ontario and other related institutions. A randomized trial to evaluate these individuals is in progress.     

Toward an integration of competencies for advanced practice mental health nursing

As new models of health care delivery evolve, the work of advanced practice nurses is growing in importance. Graduate programs in nursing have traditionally prepared advanced practice nurses for separate roles as clinical nurse specialists or as nurse practitioners. However, there are increasing trends toward the blurring of boundaries between these two types of advanced practice roles. Hence, a future blended role is projected by many nurse educators. The merger of clinical nurse specialist and nurse practitioner roles, however, requires corresponding shifts in academic programs. The purposes of this article are to discuss the need for a blended clinical specialist-nurse practitioner role in mental health, to identify populations of clients who would be served by a blended role provider, to discuss the competencies associated with such a role, and to share an approach to the preparation of advanced practice mental health specialist/practitioners.     

The role of the clinical nurse specialist in medical-surgical nursing.

A clinical nurse specialist (CNS) is an expert nurse clinician who focuses on improving nursing care. The CNS role is the subject of a great deal of debate and confusion, but clinical nurse specialists make a valuable contribution to the health care team.     

Nurse specialist led follow-up in lung cancer: The experience of developing and delivering a new model of care

Data from an earlier paper reporting on a study comparing conventional medical follow-up with nurse specialist follow-up of patients with lung cancer demonstrated that follow-up by nurse specialists is safe, effective and can lead to greater levels of patient satisfaction. The process and experience of developing a nurse specialist role in lung cancer follow-up care has not yet been described. The aims of this paper are to describe the preparation and development of a model of nurse led follow-up care, identify key nursing interventions provided within nurse led follow-up care and provide insights into the experiences of nurse specialists providing follow-up care. Data were collected from nurse specialists' patient case-records and from meetings held with the study team. Semi-structured interviews were conducted with the nurse specialists providing follow-up care and the study coordinators. The nature of the nursing role in lung cancer follow-up care is described. In addition, four themes relating to the process of developing a nurse led follow-up role are identified. These are: 'training', 'becoming credible', 'emotional burden' and 'making a difference'. Managing follow-up care for patients with lung cancer can be rewarding for nurse specialists. However, it can also be emotionally demanding. Training and support for such roles is vital and requires further in-depth research.     

Economic evaluation of nurse practitioner and clinical nurse specialist roles: A methodological review

BackgroundAdvanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) have been introduced internationally to increase access to high quality care and to tackle increasing health care expenditures. While randomised controlled trials and systematic reviews have demonstrated the effectiveness of nurse practitioner and clinical nurse specialist roles, their cost-effectiveness has been challenged. The poor quality of economic evaluations of these roles to date raises the question of whether current economic evaluation guidelines are adequate when examining their cost-effectiveness.ObjectiveTo examine whether current guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles.MethodsOur methodological review was informed by a qualitative synthesis of four sources of information: 1) narrative review of literature reviews and discussion papers on economic evaluation of advanced practice nursing roles; 2) quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials; 3) review of guidelines for economic evaluation; and, 4) input from an expert panel.ResultsThe narrative literature review revealed several challenges in economic evaluations of advanced practice nursing roles (e.g., complexity of the roles, variability in models and practice settings where the roles are implemented, and impact on outcomes that are difficult to measure). The quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials identified methodological limitations of these studies. When we applied the Guidelines for the Economic Evaluation of Health Technologies: Canada to the identified challenges and limitations, discussed those with experts and qualitatively synthesized all findings, we concluded that standard guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles and should be routinely followed. However, seven out of 15 current guideline sections (describing a decision problem, choosing type of economic evaluation, selecting comparators, determining the study perspective, estimating effectiveness, measuring and valuing health, and assessing resource use and costs) may require additional role-specific considerations to capture costs and effects of these roles.ConclusionCurrent guidelines for economic evaluation should form the foundation for economic evaluations of nurse practitioner and clinical nurse specialist roles. The proposed role-specific considerations, which clarify application of standard guidelines sections to economic evaluation of nurse practitioner and clinical nurse specialist roles, may strengthen the quality and comprehensiveness of future economic evaluations of these roles.