Joining of 2 Powerful Nursing Forces,the Clinical Nurse Specialist and Clinical Nurse Leader

Nurse executives in 2 adult, acute care hospitals support utilization of the clinical nurse specialist (CNS) and clinical nurse leader (CNL), as master’s prepared roles with specialized education, training, and content expertise in clinical care. Utilizing both roles created a dynamic structure to facilitate high quality patient care that is efficient, safe, and cost effective. As the nursing shortage continues to grow and demands of health care continue to expand, the CNS and CNL will ensure high quality care through implementation of evidence-based practice, ongoing quality improvement initiatives, and providing an added layer of clinical care and decision-making support for bedside nurses.     

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.     

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.     

Evolution of the perioperative clinical nurse specialist role

Perioperative nursing roles continue to rapidly change as we enter the twenty-first century. The need for strong leadership skills, expert clinical skills, creative management, ongoing continuing education, and research continues to grow in every department of surgical services. The clinical nurse specialist plays an important role in addressing each of these needs. Great opportunities exist within the field of nursing for perioperative nurses to expand their practice using their creativity, ideas, and skills. Using the clinical nurse specialist in the perioperative setting can foster creativity, stimulate development of new methods based on research, and maximize the delivery of high quality care by the entire OR staff.     

Autonomy and the developing role of the clinical nurse specialist

The role of the clinical nurse specialist has developed in response to social, technological and political changes that have impacted upon the delivery of health care. Nursing has traditionally been associated with femininity and in a paternalistic health structure the concept of nursing care can be devalued because autonomous nurses may threaten the balance of power. Autonomy is a multi-faceted concept and yet, if nurses have the courage to embrace both the traditional values of nursing and the expertise that their caring role brings to health care, they will be able to develop their own competence and autonomous practice. Nurses may not need autonomy in order to enhance their roles but they do need to concentrate on the concept of care as a team phenomenon. This notion is included in the UKCC's higher level of practice initiative which may direct specialist practice in the future. A negative element to nurse specialization is that nursing care can become fragmented, thus compromising the continuity and accountability of patient care.     

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.     

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.     

专科护士在护理专业中的角色和地位

对“专科护士”(CNS)的概念和执业标准 ,CNS的工作内容、角色作用和在实践中遇到的问题 ,以及CNS在护理专业发展中的意义作了简要的介绍和分析。CNS是在护理专业化进程中产生的 ,是高级临床护理工作者。在一些国家的卫生保健系统中 ,CNS活跃在各种护理服务场所 ,可有其专门的工作岗位和相应的岗位职责 ,为服务对象提供常规的医疗护理工作未能提供或未能系统地提供的专门化护理服务。多年来 ,CNS所做的工作体现了护理工作在卫生保健事业中的独特作用和价值 ,丰富了护理学知识体系 ,对护理学科的发展做出了贡献。我国CNS的培养和使用尚处于起步阶段 ,其发展是符合卫生保健事业的需求的 ,也给临床护士在专业上的发展展示了一个全新的领域     

Australian clinicians and educators identify gaps in specialist cardiac nursing practice.

Change is endemic in both the health care and higher education sectors in Australia. Consequently professional roles and educational pathways must also evolve and adapt, often catalysed by those in leadership positions. Two national Delphi panels, one of cardiac nurse educators and the other of cardiac nurses, were convened to answer the question 'What knowledge, skills and attitudes are required for an expert nurse practising in the highly technological cardiac care environment?' Respondents indicated on a Likert scale the importance of 107 items to the nurse's role in both the 'real' and 'ideal' worlds of practice. Overall there was very strong agreement between the two panels with results indicating that Australian nurses perform close to their ideal in many areas of practice. For 31 of the items, both panels identified that the reality of practice is quite far from their ideal. Both panels agree that 10 of the behaviours are carried out or valued very little in practice. Reasons why nurses are not carrying out these elements of the role to their satisfaction are discussed and remediation strategies suggested. The findings can inform both curriculum development and clinical practice. In the dynamic health care arena, the nursing profession continues to respond to community and professional needs, seeking to establish sound research-based practice and maintain a high quality of clinical care and nursing management. The development of competencies by the Confederation of Critical Care Nurses (1996) is a good example of professional groups taking the initiative both in defining the practice role and providing tools that assist educational bodies to develop programs appropriate for a practice based discipline. Specialty nursing practice is 'under the microscope' in Australia as the profession seeks the best methods to weight nursing activities, measure nursing outcomes and recruit, retain and justify the use of specialist practitioners.     

Nurse prescribing by children’s nurses: views of doctors and clinical leads in one specialist children’s hospital

Aim. To explore the views of doctors and clinical leads (CLs), who care for children and young people, on nurse prescribing in one specialist children’s hospital. Background. Nearly 14,000 nurses in the UK have virtually the same prescribing rights as doctors. Benefits of nurses adopting this role have been reported, but doctors do have some concerns. Increasing numbers of specialist nurses involved in the care of children in the hospital setting are undertaking prescribing training. No research has explored the views of health care professionals on nurse prescribing in this setting. Design. A subset of qualitative data taken from a larger study that adopted an intrinsic case study design. Method. Interviews were conducted between October 2006–July 2007 with 11 doctors and three clinical leads in one specialist children’s hospital. A thematic analysis was conducted on the interview data. Results. Nurse prescribing improved access to medicines and continuity of care. Concerns included the need for doctors to have confidence in the ability of the nurse who wanted to become a prescriber, the selection of nurses for prescribing training, the effects of nurse prescribing on the individual roles and responsibilities of doctors and nurses’ clinical skills. Conclusion. Doctors and clinical leads working in a specialist children’s hospital in the UK recognise that nurse prescribing makes a positive contribution to the delivery of services. However, it is important that nurses have the appropriate clinical skills and doctors understand nurse prescribing. This will only take place if there is good communication across professional boundaries. Relevance to clinical practice. Selection processes for the prescribing programmes must ensure that students have the necessary course prerequisites. Communication across professional boundaries is crucial to the successful implementation of nurse prescribing in the care of children and young people in the hospital setting.     

Role of the occupational health nurse in the year 2000: perspective view.

From a historical perspective, occupational health nursing practice has changed in response to historic events and societal needs. The occupational health nurse today is expected to meet a variety of challenges and assume various roles within occupational health service settings. These roles require a sophisticated knowledge base and problem solving skills which are empirically based and multidisciplinary in their approach. The occupational health nurse can effect on local and public health issues through research and influence on public values and opinion. With the increasing demand for health care cost containment, occupational health nurses must meet the challenges of today and those of the future through program planning, research, and policy making.     

Advanced practice nursing and the role of the pediatric critical care nurse practitioner

Advanced practice nursing, since its inception in the early 1960s, has constantly changed in an effort to establish standardized core graduate education, specialization of practice, and autonomy, now common in the 1990s. Nurse practitioners, nurse midwives, and certified registered nurse anesthetists have followed in the footsteps of the clinical nurse specialist by enhancing their practice through advanced education. Nurses in these advanced areas are graduating from established programs with a master's of science in nursing and a specialty in their chosen field. The pediatric critical care nurse practitioner is one such specialty. This article highlights the results of a national survey that described pediatric critical care nurse practitioner practice over a broad geographic area. With change as a constant, nurses will look to the future of advanced practice roles, which are ever changing, and continue to provide safe, quality care to patients.     

Illuminating the clinical nurse specialist role of advanced practice nursing: a qualitative study

As the advanced practice nursing initiative in Canada gains momentum, effort is being directed towards clarifying and defining advanced practice roles. A qualitative study was undertaken to increase understanding of the clinical nurse specialist role of advanced practice. Sixteen nurses who worked in advanced practice roles, organizing and providing healthcare for children with complex health needs and their families across the continuum of care, participated in in-depth conversations about the nature of their practice, the knowledge that informs it and the factors that influence it. Findings suggest that clinical nurse specialists have a unique role in the organization and delivery of healthcare for specialized populations with complex health needs in their dual focus on the system level of healthcare and on population health needs. Initiatives directed to children and families within the study participants' specialties included program development, consultation and educational outreach and the development of clinical guidelines and policies. Although the nurses described their practice as focusing both on individual children and families and on the population of children and families within their specialty, it is at the population level that they see their greatest potential for contributing to the delivery of high-quality, cost-effective healthcare.     

Meeting the needs of the family: the role of the specialist nurse in the management of brain death.

Clinical nurse specialist roles have existed in the USA for many years, yet here in the UK such roles are a relatively new concept for nurses and the profession of nursing. In the UK clinical nurse specialists have worked primarily in outpatient settings, however, the role is rapidly developing in primary care and specialized care settings. One specific dimension of the clinical nurse specialist role in critical care relates to the needs of the family when brain-stem death is suspected. This concept of death--brain death--is very difficult for most people to comprehend as it challenges all our previous beliefs concerning death and dying. During this traumatic time nurses and other health care professionals face the daunting task of supporting the family through this enforced emotional crisis as they attempt to come to terms with the diagnosis of clinical brain death. To enable families to understand brain death and the implications and outcomes of such a diagnosis it is vital they receive information, support and guidance from experienced health care personnel. The following account is a discussion of the key role of the specialist nurse in relation to meeting the needs of the families of brain-stem dead patients. This review seeks to highlight the clear dimensions of the clinical nurse specialist role within a critical care setting. It relates specifically to meeting the needs of families who have experienced clinical brain death in an immediate family member. It suggests that the infinite value of the role must be acknowledged and utilized to ensure the provision of holistic care for patients and families at this traumatic time.     

Mental health nursing in New Zealand primary health care

International literature and New Zealand health policy is giving increased emphasis to the role of the primary health care sector in responding to mental health issues. These issues include the need for health promotion, improved detection and treatment of mild to moderate mental illness, and provision of mental health care to some of those with severe mental illness who traditionally receive care in secondary services. These developments challenge specialist mental health nurses to develop new roles which extend their practice into primary health care. In some parts of New Zealand this process has been under way for some time in the form of shared care projects. However developments currently are ad hoc. There is room for considerable development of specialist mental health nursing roles, including roles for nurse practitioners in primary mental health care.     

糖尿病专科护士以临床需求为导向的工作实践与效果

目的探讨专科护士依据临床需求为导向的工作实践。方法对糖尿病专科护士进行糖尿病知识与技能的培训,由其负责培训联络护士,并对糖尿病患者进行健康教育,建立糖尿病专科护理门诊及护理会诊制度,比较实施前后糖尿病相关知识与操作技能、糖尿病专科护理质量及非糖尿病专科患者对糖尿病健康教育的满意度等。结果糖尿病专科护士工作量增加,糖尿病专科护士及联络护士护理质量提高,患者和医生的满意度提高等。结论依据临床需求进行专科护士的临床实践效果好,有利于提升糖尿病专科护士的专业价值感,充分调动主观能动性,提高护理质量。     

A literature review of advanced clinical nursing practice in the United States of America

Advanced nursing practice in the United States of America has evolved over the past decades in two related but distinct directions:- the nurse practitioner (NP) and the clinical nurse specialist (CNS). This two-role evolution was in response to social demands for increased access to affordable, quality primary health care, and at the same time to the specialised nursing care requirements of increasingly complex patients. Thus, nurse practitioners became synonymous with primary and clinical nurse specialists with specialised, acute care. There is evidence that there is an advanced practice role for both the CNS and the NP and that much of the knowledge, skills and competencies are shared depending on the clinical situation. There have been successes and failures in the development of the two roles. The clinical nurse specialists have a more respectable image among the powerful nursing education elite, but nurse practitioners are widely recognised by consumers and other health care professionals and are valued by cost-conscious managers as a viable, cheaper alternative to physicians. The literature suggests it may well be time to take the best attributes of the two roles and merge them under the term 'advanced nurse practitioner'.     

The nurse specialist role in Hong Kong: perceptions of nurse specialists, doctors and staff nurses

AIM: The purpose of this study is to review and delineate the impact in terms of the perceived importance as well as the role components of nurse specialists in Hong Kong. RATIONALE: The Nurse Specialist Scheme was launched in 1994 in Hong Kong. Studies in the West showed that there were impacts on the roles of other members among the health care team. However, minimal local published work has been carried out in reviewing the scheme. DESIGN: The design of the study was nonexperimental. Data were collected by self-administered questionnaires. The questionnaire adopted was developed by O'Mullan (1995), and the five roles studied were administration, clinical practice, consultation, education and research. To ensure the contextual relevancy and consistency of the questionnaire, content validity and test-retest reliability tests were performed. The content validity index was 0.85 and the test-retest reliability (Spearman's rho coefficient) ranged from 0.57 to 0.97. Subjects were obtained by stratified convenience sampling technique. The ratios for subject selection among the doctors, ward managers, nursing officers and registered nurses were 3:1:3:10, respectively. Because of the small numbers for nurse specialists, they were all included in the study. The final sample consisted of 11 nurse specialists, 47 ward managers, 56 nursing officers, 110 registered nurses and 15 doctors (n=239). RESULTS: The results showed that there were significant differences in the perceptions of importance of the administration, clinical practice, education and research roles, and the frequency of occurrence of the clinical practice and research roles. This was further verified by the Fisher's Least Significant Differences (LSD) test. CONCLUSIONS: A regulatory system of the nurse specialist was recommended to monitor the development of the nurse specialist role and practice and to ensure the safety of the public with regard to the emerging role. Both the implications and limitations are discussed.     

New Zealand general practice nurses' roles in mental health care

MCKINLAY E., GARRETT S., MCBAIN L., DOWELL T., COLLINGS S., & STANLEY J. (2011) New Zealand general practice nurses' roles in mental health care. International Nursing Review 58 , 225–233 Aim: To examine the roles of nurses in general practice interdisciplinary teams caring for people with mild to moderate mental health conditions. Background: Supporting mental health and well‐being is an important aspect of primary care. Until now nurses in general practice settings have had variable roles in providing mental health care. The New Zealand Primary Mental Health Initiatives are 26 government‐funded, time‐limited projects using different service delivery models. Methods: An analysis was undertaken of a qualitative data set of interviews, which included commentary about nurses mental health work collected from the different project stakeholders throughout a 29‐month external evaluation. Findings: Two main groups of roles for nurses within the general practice interdisciplinary team were identified: specialist mental health nurses working in newly created roles and practice nurses working in existing roles. Barriers exist to the development of the latter roles. Conclusions: Mental health care is a key role in general practice as this is where people frequently present. Internationally, nurses represent a large workforce with the potential to provide effective mental health care. This study found that attitudinal, structural and professional barriers are restricting New Zealand practice nurse role development in the care of those with mild to moderate mental health conditions. There is potential to develop their role within a structured pathway by workforce development and recognition of the value of interdisciplinary care. Given the shortage of mental health professionals this will be an important aspect of the improvement of primary mental health care.     

Expected roles and utilization of specialist nurses in Japan: the nurse administrators’ perspective

onishi m. & kanda k. (2010) Journal of Nursing Management 18, 311–318
Expected roles and utilization of specialist nurses in Japan: the nurse administrators’ perspective Aim This study explored (1) expected roles for specialist nurses in Japan and (2) nurse administrators’ experience-based management strategies for effective implementation of these roles. Background In Japan, specialist nurses have begun to be recognized as valuable human resources. However, managerial issues in utilizing specialist nurses, including unclear roles and lack of reports on effective management strategies, remain. Method Three focus-group discussions were conducted. Nine nurse administrators participated. Data were analysed using qualitative content analysis techniques. Results The expected roles for specialist nurses were: (1) facilitating general nurses’ learning; (2) monitoring and improving the patient care standard; and (3) developing new roles for nursing. Two management strategies were: (1) enhancing specialist nurses’ influence, and (2) enhancing specialist nurses’ motivation. Conclusions Specialist nurses are important human resources able to assume responsibility for process improvement in nursing care. Effective ways to enhance specialist nurses’ influence and motivation include developing their management and communication skills, and coordinating their workload and relationships with other health care professionals. Implications for Nursing Management Process improvement indicators may be useful for evaluating specialist nurses’ work. Nurse administrators can contribute to effective implementation of specialist nurses’ roles not only by clarifying their roles but also by empowering them to keep up with changing organizational needs.