Clinical Nurse Specialists

Abstract and Introduction

Abstract

The complex care of patients with chronic conditions threatens the stability of healthcare economics. Clinical nurse specialists, in roles that leverage full scope of practice, positively impact the Triple Aim and are vital to meeting this rising need.

Introduction

We live in an era where over 50% of health care is devoted to attention around chronic conditions (Ward, Schiller, & Goodman, 2014), which account for 7 of the top 10 causes of deaths and contribute to 74% of all deaths in the United States (Murphy, Xu, Kochanek, & Arias, 2018). With the tsunami of older adults expected to reach 98 million by 2060 (U.S. Department of Health and Human Services [HHS], 2016), the provision of care for persons with chronic conditions poses increasing economic burdens. Care of this population accounts for 86% of U.S. healthcare costs (Gerteis et al., 2014) and becomes even more inordinate in individuals with multiple chronic conditions and complex social determinants of care (Craig, Eby, & Whittington, 2011). The National Association of Clinical Nurse Specialists (NACNS) sensed this urgency and appointed a taskforce to demonstrate clinical nurse specialists (CNSs) as leaders in the care of patients with chronic conditions (NACNS Chronic Conditions Task Force, 2017). This article includes information from the work of taskforce members as well as additional evidence that CNSs are uniquely prepared to lead and manage populations of patients with chronic conditions and positively affect health care and nursing economics.

Table 1. CNS Competencies and Spheres of Practice
CNS Competency	Patient Sphere	Nursing Sphere	System Sphere
Direct Care	Prescribes pharmacologic/non-pharmacologic interventions, diagnostics, equipment, procedures, and treatments.*	Evaluates nursing practice using safety, timeliness, effectiveness, efficiency, efficacy, and patient-centered care.	Leads and develops innovative, cost-effective programs or protocols.
Consultation	Provides direct care to select patients based on the CNSs specialty.*	Provides consultation to nurses/staff.	Consults to obtain resources to facilitate achieving identified outcomes.
Systems Leadership	Manages medications, clinical procedures, and other interventions for populations of patients.*	Determines nursing practice and system interventions that promote patient, family, and community safety.	Coordinates care of patients with use of system and community resources to achieve optimal outcomes.*
Collaboration	Initiates interprofessional team meetings, patient consultations, and demonstrates skillful communication within the treatment team.	Establishes collaborative relationships within and across settings to promote clinical excellence.	Provides leadership for establishing, improving, and sustaining collaborative relationships.
Coaching	Designs health information and patient education appropriate to developmental and health literacy levels, learning needs, and cultural values and beliefs.	Mentors staff nurses, graduate students, and others to develop their careers.	Provides leadership in conflict management and negotiation to address problems in the system.
Research	Implements, assists, and guides others in evidence-based clinical inquiry.	Evaluates improvement or redesign of care delivery processes.	Leads in the system-wide implementation of quality improvements and innovations.
Ethical Decision Making, Moral Agency, and Advocacy	Facilitates patient and family understanding of the risks, benefits, and outcomes of proposed healthcare regimens promoting informed decision-making.	Evaluates the impact of legislative and regulatory policies as they apply to nursing practice and patient or population outcomes.	Applies ethical principles to resolving concerns across the three spheres of influence.

Table 1. CNS Competencies and Spheres of Practice

CNS Competency

Patient Sphere

Nursing Sphere

System Sphere

Direct Care

Prescribes pharmacologic/non-pharmacologic interventions, diagnostics, equipment, procedures, and treatments.*

Evaluates nursing practice using safety, timeliness, effectiveness, efficiency, efficacy, and patient-centered care.

Leads and develops innovative, cost-effective programs or protocols.

Consultation

Provides direct care to select patients based on the CNSs specialty.*

Provides consultation to nurses/staff.

Consults to obtain resources to facilitate achieving identified outcomes.

Systems Leadership

Manages medications, clinical procedures, and other interventions for populations of patients.*

Determines nursing practice and system interventions that promote patient, family, and community safety.

Coordinates care of patients with use of system and community resources to achieve optimal outcomes.*

Collaboration

Initiates interprofessional team meetings, patient consultations, and demonstrates skillful communication within the treatment team.

Establishes collaborative relationships within and across settings to promote clinical excellence.

Provides leadership for establishing, improving, and sustaining collaborative relationships.

Coaching

Designs health information and patient education appropriate to developmental and health literacy levels, learning needs, and cultural values and beliefs.

Mentors staff nurses, graduate students, and others to develop their careers.

Provides leadership in conflict management and negotiation to address problems in the system.

Research

Implements, assists, and guides others in evidence-based clinical inquiry.

Evaluates improvement or redesign of care delivery processes.

Leads in the system-wide implementation of quality improvements and innovations.

Ethical Decision Making, Moral Agency, and Advocacy

Facilitates patient and family understanding of the risks, benefits, and outcomes of proposed healthcare regimens promoting informed decision-making.

Evaluates the impact of legislative and regulatory policies as they apply to nursing practice and patient or population outcomes.

Applies ethical principles to resolving concerns across the three spheres of influence.

Table 2. Supporting Literature for the CNS as Leaders in Managing Patients with Chronic Conditions
CNS Specialty	Sphere of Influence
	Patient	Healthcare Provider	Healthcare System
Community-Based	Provides comprehensive, person-centered care. Coordinates health and community resources. Fosters relationships between patient and providers (Ulch & Schmidt, 2013).	Leads interprofessional team, facilitates coordination of care, and translates patient experience to the healthcare team (Ulch & Schmidt, 2013).	Improves clinical outcomes, reduces costs and 30-day readmissions, and improves patient satisfaction (Ulch & Schmidt, 2013).
Directs community-based programs which influence behavioral change in relation to chronic disease (Negley et al., 2016).
Heart Failure	Provides patient advocacy and education. Calls/visits patients at home; investigates areas of nonadherence. Coaches patients to prevent hospital readmissions (Coen & Curry, 2016).	A resource to bedside nurses/staff. Promotes advance care planning and addresses end-of-life concerns (Coen & Curry, 2016).	Leads to decreased 30-day readmissions and translates/conducts research to address gaps in care (Coen & Curry, 2016).
Oncology	Educates, supports, and coordinates care: "The support of a CNS is the most important contributing factor to people's positive experience of care" (Independent Cancer Taskforce, 2015, p. 52).
Pulmonary	Gets early screening for chronic obstructive pulmonary disease and educates on smoking cessation (DeJong & Veltman, 2004).	Educates nurses on management of asthma (Policicchio, Nelson, & Duffy, 2011).
Transitional Care	Partners with patients during inpatient; conducts weekly telephonic appointments after discharge to address issues, makes referrals, educates and provides for psychosocial needs (Baldwin, Black, & Hammond, 2014).	Supports nursing care of patients with complex conditions in ambulatory settings (Negley et al., 2016).	Provides revenue through cost avoidance, reduces readmissions, prescribes care (Baldwin et al., 2014).
CNSs with Prescriptive Authority	CNSs meet patients' needs in the areas of psychiatric medications, non-analgesics, and durable medical equipment (Klein, 2015).		Bridge gaps by prescribing medications missed by primary care providers (Klein, 2015).

Table 2. Supporting Literature for the CNS as Leaders in Managing Patients with Chronic Conditions

CNS Specialty

Sphere of Influence

Patient

Healthcare Provider

Healthcare System

Community-Based

Provides comprehensive, person-centered care. Coordinates health and community resources. Fosters relationships between patient and providers (Ulch & Schmidt, 2013).

Leads interprofessional team, facilitates coordination of care, and translates patient experience to the healthcare team (Ulch & Schmidt, 2013).

Improves clinical outcomes, reduces costs and 30-day readmissions, and improves patient satisfaction (Ulch & Schmidt, 2013).

Directs community-based programs which influence behavioral change in relation to chronic disease (Negley et al., 2016).

Heart Failure

Provides patient advocacy and education. Calls/visits patients at home; investigates areas of nonadherence. Coaches patients to prevent hospital readmissions (Coen & Curry, 2016).

A resource to bedside nurses/staff. Promotes advance care planning and addresses end-of-life concerns (Coen & Curry, 2016).

Leads to decreased 30-day readmissions and translates/conducts research to address gaps in care (Coen & Curry, 2016).

Oncology

Educates, supports, and coordinates care: "The support of a CNS is the most important contributing factor to people's positive experience of care" (Independent Cancer Taskforce, 2015, p. 52).

Pulmonary

Gets early screening for chronic obstructive pulmonary disease and educates on smoking cessation (DeJong & Veltman, 2004).

Educates nurses on management of asthma (Policicchio, Nelson, & Duffy, 2011).

Transitional Care

Partners with patients during inpatient; conducts weekly telephonic appointments after discharge to address issues, makes referrals, educates and provides for psychosocial needs (Baldwin, Black, & Hammond, 2014).

Supports nursing care of patients with complex conditions in ambulatory settings (Negley et al., 2016).

Provides revenue through cost avoidance, reduces readmissions, prescribes care (Baldwin et al., 2014).

CNSs with Prescriptive Authority

CNSs meet patients' needs in the areas of psychiatric medications, non-analgesics, and durable medical equipment (Klein, 2015).

Bridge gaps by prescribing medications missed by primary care providers (Klein, 2015).

Clinical Nurse Specialists

Leaders in Managing Patients With Chronic Conditions

Abstract and Introduction

Abstract

Introduction

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Tables

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Authors and Disclosures

Authors and Disclosures

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