Clinical nurse specialists are those registered nurses who serve as clinical experts in the evidence based nursing practice in different specialized areas by the integration of their advanced knowledge in assessing, diagnosing and treating the illness of the patients, although their role extends beyond the provision of patient care (O’connell, Gardner & Coyer, 2014).
The main goal of the clinical nurse is to provide safe, cost effective and quality care, while working within the health care system. This report aims to discuss about the role of the clinical nurse specialist in a health care setting based on nursing theories and evidence based literature. It also focusses on the different national and the international practice standards of the CNS along with a clear explanation of the role on their health care system.
Role of Clinical Nurse Specialist based on major themes
Role of CNS in New Zealand
The role of clinical nurse specialist (CNS) is now common throughout New Zealand. This role is mainly undertaken by a nurse who has a significant experience in the field of clinical speciality and has the required advanced learning the area of specialist cares (DiCenso, Guyatt & Ciliska, 2014). A CNS during the episodes of care undertakes assessment and then organizes tests, plans and then initiates the care in order to meet the special requirement of the service users with any specific healthcare problems.
The CNs is defined as a registered nurse (RN) by the Nursing Council of New Zealand. The CNS through both practice and masterate level of education is an expert in the clinical area (DiCenso, Guyatt & Ciliska, 2014). Roberts, Floyd and Thompson (2011) are of the opinion that several competencies are an integral part of the CNS role and this mainly includes effective clinical practice along with coaching, proper guidance, consultation, proper research followed by leadership, collaboration and ethical decision-making process. The CNS mainly emphasize on the direct patient care with proper clinical nursing skills, knowledge and wisdom (Roberts, Floyd & Thompson, 2011).
Role of CNs in Australia
In Australia, the title of the CNS mainly refers to a persuasive position over a clinical career path. The process of establishment of the CNS role was mainly drive by a process of industrialization which is followed by a financial progression in order to enable the nursing professionals to progress professionals without facing any circumstance to leave the bedside of the patients in order to take up positions in education or training and administrative works.
Yet, a CNS have to take care of both the administrative and the educative duties in Australia (Twigg & McCullough, 2014). However, the study conducted by Twigg and McCullough (2014) revealed that CNS mainly does managerial work and other clerical activities in comparison to other RN. This disproportionate level of indirect care can challenge their defined role. Thus there still exists a confusion in the exact role of a CNS.
Role of CNS in Continuous Professional Development
According to the Australian Health Practitioner Regulation Agency (AHPRA) (2018), a CNS must strive for the continuous professional development in order to satisfy their professional duties. According to the Nursing and Midwifery Board of Australia (NMBA) (2018), an NNBA CNS must engage into activities in order to meet the NMBA’s registration standard for continuous professional development (CPD).
CPD mainly aims to enable the CNS to maintain, improve and to broaden their professional standards in order to increase their level of knowledge, expertise and competence. This will help them to manage both their clerical and the healthcare work effectively along with meeting other obligations in the ethical and safe and competent practice. In order to practice CNP, undergoing reflective practice is an essential part. Thus role of a CNS is to practice proper reflection in order to improve their clinical proficiency.
Consideration of the safety and Quality Guidelines
The NMBA are also of the opinion that it is the role of the CNS to take into consideration of the safety and the quality guidelines of the care process. These safety and the quality guidelines mainly deals with the proper medication management in order to avoid the risk of medication error (Nursing and Midwifery Board of Australia., 2018). The effective management of medication mainly deals with the proper use of the computerized physicians order entry (CPOE) and training the nursing professionals that is the registered nurse in handling the CPOE. The role of the CNS also deals with critical thinking skills. The role of critical thinking is effective in clinical decision making process and this must be undertaken under active collaboration with the physicians (Radley et al., 2013).
Therapeutic relationships
Development of the therapeutic relationship with the patients and their family members can also be considered as an important role which falls under the scope of practice of the CNS. The development of the therapeutic relationships is based on the proper execution of the inter-professional communication skills, both verbal and non-verbal communication skills. Proper verbal communication skills along with active listening helps the generate a trustworthy relationships with the service users and their family members and this in turn increases the overall patient’s participation in the care plan and devising patient centred care (Arnold & Boggs, 2015).
Standards of practice associated with the role of clinical nurse specialist
The practice standard outlines what the profession of clinical nurse specialist expects from the members and act for guiding the professional nursing practice. It is the practice standards that provides a frame work for developing the competencies among the clinical nurse specialists.
One of the standards of practice is responsibility and accountability of the nurses. Nurses always have to work within their scope of practice, on the basis of the current nursing knowledge, experience, professional judgment, competence, experience within the area of job description. Nurses are liable to function within the stipulated legislation and statutory requirement (College of Emergency Nursing Australasia. 2018). A CNC is accountable to demonstrate an advanced knowledge and synthesis of advanced nursing care practice in a clinical setting.
ACNC generally applies evidence based research and abroad range of theories in the medical practice by the use of the critical thinking skills and clinical reasoning. A CNS can develop and assess innovative approaches in health care in case of complex health care issues. Patient advocacy is another standards of practice for a clinical nurse specialist. They advocate the client in a shared decision making by assisting them in the assessment of the capacities of the clients to participate in the decision making process and choose appropriate treatment regimen. A proper CNS should consider that the patients are getting equal access to health care. Another domain of the clinical nurse specialist is communication (Nursing and Midwifery Board of Australia., 2018).
The CNS should be able to demonstrate interpersonal communication and leadership skills for promotion of collaborative care approach among the different departments of hospital or a community. A CNS communicates in a concise, clear, timely and accurate ways with the patients for ensuring a continuity of care. One of the most important domain of practice standard are leadership and teamwork. A CNS will be able to perform effectively as the member of a team. They should be aware of the expectations and should be aware of their own roles within the team and should be able to respond promptly to emergency situations (Nursing and Midwifery Board of Australia., 2018).
Being a leaders a CNS should have a complete knowledge about his/her team members and how they are contributing to health care. In a word, assists or leads the team to provide a safe care to the patients. One of the essential role of a nurse leader is to manage critical incidents and stressful conditions within a health care. Some of the main performance criteria of the CNS within this domain involves implementation of the crisis interventions as when required, support to the staff caring for the patients, identification of the potential conflicts and managing them effectively (College of Emergency Nursing Australasia. 2018).
They should also build emotional intelligence within the team. Another important domain is the professional development of CNS. A CNS should be able to understand the weaknesses, strengths and skills to support their own professional development.
Nurses have to practice in a diverse environment and also have to consult with the general nurses. The CNs uses their skills in advanced knowledge for clarifying and giving different essential information about clinical issues (Nursing and Midwifery Board of Australia., 2018).
One of the important practice standards that is common to both the national and the international standard is functioning within an ethical frame work. A CNS should be able to value the dignity and the integrity of the patients and should be able to restore confidentiality of the patient information and should practice within the legal guidelines associated with the ethics (College of Emergency Nursing Australasia, 2018). Continuous quality improvement is another domain of the practice standards. A CNS should be able to thrive for the promotion of a culture of quality improvement within the clinical care setting.
The codes of practice of the clinical nurse specialist are almost similar across the international standards. One such practice standards noted in Canadian nursing council is that CNS are responsible for encouraging the systems within a clinical care setting that facilitates research activities (Clinical nurse specialist association of Ontario, 2018). They are also accountable to manage and maintain the hospital resources including management of the faulty equipment (Kilpatrick et al., 2014). In a nutshell the competency standards or the practice standards of a CNS are no less than a physician.
Impact of Clinical Nurse Specialist’s (CNS) role on the healthcare system
Clinical Nurse Specialists (CNSs) generally work with healthcare systems, home healthcare clinicians and patients to help patients to achieve their health objectives. They also bring their skill set and proficiency to the specialised area like community health, cardiology or oncology. Abilities and skills of a CNS can influence significantly three spheres or groups. These groups are the clinician, the organisation and most importantly the patients (Kilpatrick et al., 2015). Therefore, the various way the abilities and skill set of a CNS can have impact on the healthcare system is described below:
In home healthcare
The primary objective of the home healthcare is to provide the maximum level of independence possible to the patient. It requires coordination and various methods of care providing spread amongst several systems. CNS’s qualities like consultation, leadership, advocacy and collaboration can help achieve this objectives. CNSs can help and have an impact on home healthcare system in the context of Patient Transitions and Chronic Disease Management (Adams, 2015).
Patient Transitions: Patients who are returning and transitioned to home life from acute care will require more social needs compared to earlier self. Qualities like relationship building skills and ability to establish trust of CNSs will be really helpful in this regard. Additionally, patients returning from acute care might need proper care planning process and interventions. CNSs can contribute in this regard with their expert assessment skills and understanding of contemporary, evidence based approach. They can also provide informative advocacy to the patients. Consequently, these will enhance the sensitivity and effectiveness of the whole healthcare system (Adams, 2015).
Chronic disease management: Due extremely complex needs of the chronic disease management amongst the suffering patients, clinicians providing homecare have to be ready for the long term management of the chronic diseases. To this extent, home visit is become mandatory in episodic manner. During their visit, clinicians will provide consultation, coaching, assessment and advocacy. Coincidentally, these qualities are also the strength of CNSs and they are trained to provide this kind of services to the patients. Hence, CNSs can take burden and responsibility of the clinician’s shoulder while clinicians will be lend their service in other urgent matter needed attention (Adams, 2015).
In cost and quality of healthcare
Research evidence have suggested that the impact CNSs role can lessen the cost of healthcare system by implementing evidence based quality improvement. These can be performed in many different way which are depicted below:
Decreased cost of chronic condition care: CNSs are notable for their effective coaching to patients suffering with chronic illness with the promotion of self- care. Various research studies have reported the CNSs effort in case and this, in turn, effects lesser number of readmission for this patient reducing the cost on healthcare system (National Association of Clinical Nurse Specialists, 2013).
Reduce stay length for acute and community based settings: CNSs can improve the consequences of stroke by performing practiced guidelines and development of best available tools for practice. Subsequently, this action can reduce the length of stay in acute and community based settings and thus reducing the cost for healthcare system.
Prevention of HACs (Hospital Acquired Conditions): Patients can get affected in the hospital by various harmful pathogens during their stay in hospital. Patients can get infected by catheter associated urinary tract infections (CA-UTI), pressure ulcers, Methicillin-resistant Staphylococcus aureus (MRSA), and central line associated bloodstream infections (CLABSI). These increase the cost and burden for both the patient and healthcare system. CNSs can prevent this with their expertise and guidance and thus reducing cost on the healthcare system (Fox et al., 2015).
Decreased overall cost for employer in Wellness care: CNSs can use their expertise detect curable chronic disease such as heart failure and diabetes in their early stage. CNSs manage Wellness company can assess for this disease and can help their employees stay healthy.
Prevention of readmission: A patient has a very good chance of readmission in the hospital within 30 days of his/ her release if certain criterion are not met. CNSs have required knowledge and position to counsel and guide the patient so that this does not happen. This enhances the quality of the service provided by the healthcare if a patient does not to readmit again (National Association of Clinical Nurse Specialists, 2013).
In nursing and health care practice
CNSs works with the whole institutional staff of a healthcare system as well as the physicians. They are first to come in contact with patient admitted to the hospital. They also coordinated with the physicians during the treatments of the patients. They also provide counsel to the patients before their release. Additionally, they have come contact with the whole institutional staff in a healthcare organisation. CNSs bring the staff with the up-to date contemporary information and policies regarding a particular treatment and thus improving the quality of the total service of that healthcare organisation (Kramer et al., 2017).
Therefore, from the above conclusion, it can be seen that Clinical Nurse Specialist’s role have a wide spread impact on the healthcare system by reducing total cost of the healthcare system and enhancing the quality.
Conclusion
Thus from the above discussion, it can be conclude that under the New Zealand and the Australian perspective, the CNs plays a vital role in improving the overall process of care via increasing the safety and promoting quality improvement in the practice. A CNS also helps in the development of the therapeutic relationships with the patients and their family members in order to increase the scope for the patient centred care. However, the CNS at time become busy in giving training to the RN and doing other administrative or clerical activities which hampers the care giving process at the bed-side.
References
Adams, J. H. (2015). The role of the clinical nurse specialist in home healthcare. Home healthcare now, 33(1), 44-48.
Arnold, E. C., & Boggs, K. U. (2015). Interpersonal Relationships-E-Book: Professional Communication Skills for Nurses. Elsevier Health Sciences.
Australian Health Practitioner Regulation Agency. (2018). Clinical Nurse Practitioner. Access date: 6th December 2018. Retrieved from: https://www.ahpra.gov.au/Search.aspx?q=clinical+nurse+practitioner
Clinical nurse specialist association of Ontario, (2018).Standards of Practice for CNS.Access date: 6.12, 2018.Retrieved from: https://cns-ontario.rnao.ca
College of Emergency Nursing Australasia. (2018). Practice Standards for the Emergency Nursing Specialist. Access date: 6.12, 2018.Retrieved from: https://www.cena.org.au
DiCenso, A., Guyatt, G., & Ciliska, D. (2014). Evidence-Based Nursing-E-Book: A Guide to Clinical Practice. Elsevier Health Sciences.
Fox, C., Wavra, T., Drake, D. A., Mulligan, D., Bennett, Y. P., Nelson, C., … & Bader, M. K. (2015). Use of a patient hand hygiene protocol to reduce hospital-acquired infections and improve nurses’ hand washing. American Journal of Critical Care, 24(3), 216-224.
Kilpatrick, K., DiCenso, A., Bryant-Lukosius, D., Ritchie, J. A., Martin-Misener, R., & Carter, N. (2013). Practice patterns and perceived impact of clinical nurse specialist roles in Canada: results of a national survey. International Journal of Nursing Studies, 50(11), 1524-1536.
Kilpatrick, K., Reid, K., Carter, N., Donald, F., Bryant-Lukosius, D., Martin-Misener, R., … & DiCenso, A. (2015). A systematic review of the cost effectiveness of clinical nurse specialists and nurse practitioners in inpatient roles. Can J Nurs Leadership, 28(3), 56-76.
Kramer, M., Brewer, B. B., Halfer, D., Hnatiuk, C. N., MacPhee, M., Duchscher, J. B., … & Schmalenberg, C. (2017). Impact of professional nursing practices on patient/nurse outcomes: testing the essential professional nursing practices instrument. Journal of Nursing Administration, 47(5), 278-288.
National Association of Clinical Nurse Specialists. (2013). Impact of the clinical nurse specialist role on the costs and quality of health care. Washington, DC: Author.
Nursing and Midwifery Board of Australia. (2018). Guidelines. Access date: 6th December 2018. Retrieved from: https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/codes-guidelines.aspx
Nursing and Midwifery Board of Australia., (2018).Registered nurse standards for practice. Access date: 6.12, 2018.Retrieved from: https://www.nursingmidwiferyboard.gov.au
O’connell, J., Gardner, G., & Coyer, F. (2014). Beyond competencies: using a capability framework in developing practice standards for advanced practice nursing. Journal of advanced nursing, 70(12), 2728-2735.
Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. (2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association, 20(3), 470-476.
Roberts, J., Floyd, S., & Thompson, S. (2011). The clinical nurse specialist in New Zealand: how is the role defined?. Nursing Praxis in New Zealand, 27(2).
Twigg, D., & McCullough, K. (2014). Nurse retention: A review of strategies to create and enhance positive practice environments in clinical settings. International journal of nursing studies, 51(1), 85-92.
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