Clinical Nurse Specialist Interest Group

Standards of Practice

• Introduction
• Assumptions
• Domain of Advanced Practice
• Domain of Consultation
• Domain of Education
• Domain of Research
• Domain of Leadership
• Environmental Supports
• Glossary
• Reference List

Introduction
The purpose of this document is to articulate Standards of Practice of the Clinical Nurse Specialist (CNS) within an evolving health care system. The Clinical Nurse Specialist is a nurse with a Masters or Doctorate degree from a nursing program, with a clinical specialty area who functions in the sub-roles of practitioner, leader, consultant, educator, and researcher (Canadian Nurses Association, 1993).

The Clinical Nurse Specialist role was introduced to the Canadian health care system in the early 1970’s. The first position paper by Canadian Nurses Association (CNA) on the role of the CNS was accepted in 1973. Since the 1970’s, the Clinical Nurse Specialist role has become well established in hospital, community and independent practice.

Standards were developed through consultation from across Canada. Several provincial Interest Groups drafted standards for the sub-roles. These drafts were revised through national consultation.

Using a set of criteria, the standards define the uniqueness of the Clinical Nurse Specialist by addressing five domains of practice. The domains of practice include advanced practice, consultation, education, research and leadership.

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Assumptions

1. The CNS is an advanced practitioner who holds a Masters or Doctoral degree from a nursing program and has expertise in a clinical nursing specialty.
2. These Standards of Practice for CNS’s identify the additional minimum expectations for CNSs. It is expected that a CNS is able to meet and exceed all of the requirements of a RN as identified in the professional standards of practice.
3. The role of the CNS includes five inter-related domains: advanced practice, education, research, leadership, and consultation. Although there are variations in the implementation of the subroles, this implementation always includes the practitioner subrole. This mean engaging in practice and/or planning care for complex situations or complex client needs.
4. Specialization in CNS practice includes application of a broad range of theories and research to particular client situations that are within the domain of nursing. Clients may be individuals, groups, families, communities, or populations.
5. The study of nursing science and related arts and sciences provides a basis for advanced practice.
6. The advanced practitioner may work in areas of primary, secondary, tertiary and quadertiary care, in health care agencies, or in an independent practice. Care is provided to clients with varying levels of acuity in highly variable work settings.
7. The CNS may work independently with other nurses or in collaboration with other disciplines or caregivers.
8. The CNS strives to optimize client(s) involvement to the extent possible within cognitive and developmental abilities.

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CNS Domains of Practice

Domain of Advanced Practice

The domain of advanced practice is the foundation of the Clinical Nurse Specialist role. The Clinical Nurse Specialist provides care or plans care for clients with highly complex needs in selected practice situations. All other domains of practice draw upon advanced practice. The role of the Clinical Nurse Specialist as an advanced practitioner is based on autonomy of practice, in-depth theoretical nursing knowledge, clinical experience, and research application.

Performance Standards

The CNS:

1. Demonstrates advanced knowledge and synthesis of advanced nursing practice within a clinical specialty.
2. Applies relevant research and a broad-range of theories to clinical practice using critical thinking and analysis.
3. Demonstrates advanced health assessment and clinical decision-making within a clinical specialty.
4. Develops and evaluates innovative approaches and programs for complex practice issues.
5. Advocates for client-focused decision-making within the health care deliver system by:
   a) continuously assessing clients’ capabilities to participate in decision-making and use appropriate decision-makers when necessary.
   b) Involving clients in decisions related to their care.
   c) Expanding other caregivers’ understanding of the subjective experience of clients.
6. Supports clients in decision-making regarding health care by:
   a) Providing clients with the information required to make health care choices regarding care, treatment, and participation in clinical research.
   b) Facilitating the process of clients’ decision-making about health choices.
7. Demonstrates advanced knowledge and synthesis of therapeutic counselling modalities.
8. Promotes an intra-and inter-disciplinary collaborative approach in clinical decision-making by:
   a) Demonstrating interpersonal communication and leadership skills to promote collaborative care among various disciplines in hospital and/or community.
   b) Assessing, analyzing, identifying priorities evaluating and creating plans for highly complex situations with clients and other caregivers.
   c) Referring the care of the client to appropriate health care professional when the client’s health situations outside the CNS’s scope of practice or clinical competence.
   d) Demonstrating skills and ability to practice when following clients across settings.
9. Acts as a role model demonstrating advanced nursing practice.

Outcome

1. Clients experience care which is client-centered, innovative, and satisfying.
2. Clients demonstrate optimum health

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Domain of Consultation

Nurses practice in diverse and complex environments and may require consultation with a CNS. Consultation may be requested by nurses, other health professionals, clients, families, or groups. The consultations may be informal or formal. The focus of the consultation may be at the individual, group, program, or systems level.

The CNS uses advanced knowledge and skills to assist in clarifying issues, exploring options, facilitating change, creating new possibilities. The CNS may clarify, recommend and/or educate. Consultation with care providers allows the CNS to influence the plan of care for clients/families and provide learning to the consultee which can be applied to future situations.

Performance Standards

The CNS:

1. Demonstrates advanced knowledge and synthesis of theory related to consultation for individuals, groups and systems.
2. Determines the focus of the consultation with the consultee.
3. Develops a collaborative relationship with the consultee.
4. Clarifies different perceptions of stakeholders.
5. Negotiates the type and duration of involvement.
6. Plans, recommends and collaborates with the consultee.
7. Documents analysis, findings, and recommendations.
8. Negotiates with consultee a process for follow up.

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Domain of Education
Nursing knowledge is constantly evolving and increasing in complexity. The CNS helps nurses in meeting the current and future needs of individuals, families, communities, populations and the profession by sharing current knowledge.

Performance Standards

The CNS:

1. Demonstrates advanced knowledge and synthesis of teaching and learning theories for individuals and groups.
2. Participates in learning needs assessment related to the professional development of nurses and others.
3. Identifies individuals and systems facilitators and barriers to professional education.
4. Identifies and/or creates resources for learning.
5. Facilitates the implementation of planned learning experiences. Presents rounds and/or workshops on areas of expertise at local, regional, provincial, national and/or international forums.
6. Acts as a role model and clinical expert in the area of clinical specialty.
7. Assists in the skill development of nurses (e.g. relationship development, problem solving, critical thinking, clinical skills, etc).
8. Identifies learning issues and problems, and assists nurses in strategizing and solving problems related to learning.
9. Evaluates the effects of educational experiences on nurses’ behaviour, and client and system outcomes.
10. Supports nurses in professional development and career planning in furthering their educational qualifications.

Outcome

1. Nurses and others will identify and utilize the CNS as a resource in meeting learning needs.
2. Nurses and others will demonstrate the acquisition of knowledge and skills in their clinical practice.
3. Clients will benefit from the application of current theory and research based practice.

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Domain of Research

Nursing research is integral to the development of nursing theory and nursing practice. The CNS facilitates others understanding and application of research. The CNS contributes to the research process through application of research findings and may develop and implement research projects.

Performance Standards

The CNS:

1. Expands the scientific base of nursing practice by utilizing, facilitating, and conducting research in nursing and other disciplines.
2. Demonstrates knowledge of qualitative and quantitative research methods.
3. Communicates the importance of nursing research to clinical practice and theory development.
4. Disseminates recent innovations and research findings relevant to nursing practice and client outcomes.
5. Demonstrates and promotes critical thinking which leads to the formulation of research questions and hypotheses.
6. May develop collaborative research proposals in his/her clinical nursing specialty, as a primary investigator or co-investigator.
7. May participate in research projects.
8. Assures ethical and legal practices in the conduction of research.
9. Stimulates others to read and interpret research findings in health care literature.
10. Demonstrates ability to function as an external reviewer for research proposals.
11. Demonstrates the ability and knowledge to participate on research committees.

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Domain of Leadership

Clinical Nurse Specialists work within complex systems. Leadership is required to advance nursing practice and to promote quality client care. The CNS’s leadership subrole may take place in a number of different ways in different systems. The leadership occurs at multiple systems levels. CNSs provide leadership for other nurses, clinical programs, research programs, and client care. The CNS provides linkages between systems and transcends traditional boundaries. The Clinical Nurse Specialist facilitates the empowerment of clients related to public policy issues.

Performance Standards

1. Demonstrates advanced understanding and synthesis of the role of the CNS within the nursing profession and the health care system.
2. Influences the quality of nursing practice.
3. Share knowledge of client’s perspectives during policy development and planning.
4. Critically analyzes socio/political issues and contributes to the political process to influence health outcomes.
5. Evaluates outcomes of policy decisions and communicates findings.
6. Participates and provides leadership on internal and external committees relating to care delivery, policy and procedure development, research, education and professional development.
7. Participates in employee recruitment, selection, career development and performance appraisal.
8. Collaborates in the development of nursing roles within a changing health care system.
9. Anticipates future changes (needs, technology, changing system, professional development) and recommends appropriate changes/implications.
10. Demonstrates advanced knowledge and synthesis of negotiation and conflict resolution.
11. Identifies human, material and organizational system needs.
12. Demonstrates knowledge and skills in managing organizations and environments.
13. Collaborates in the development of strategic and program planning and evaluation to foster innovation.
14. May be appointed or cross-appointed to a university or college.
15. Maintains membership in provincial, federal and/or international professional associations.

Outcome

1. Progressive change is evident within the CNS’s domain of responsibility.
2. Policy planning and development demonstrates intersectorial representation.
3. Human, material and organizational resources are positively influenced.
4. Internal/external committees benefit from CNS representation.

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Environmental Supports

Environmental supports involve elements that are generally a joint responsibility of the CNS and administration. Regardless of where the CNS works, it is always in context of work with others. In the case of private/independent practice, the CNS may be responsible for both domains of practice and environmental support.

The CNS can advocate for environmental supports but it is an administrative responsibility to provide them. The environmental supports required for optimal enactment of each domain of practice are listed below:

Environmental Support for Advanced Practice

1. The employing agency/system supports the identification and referral of clients with complex needs.
2. The employing agency/system supports the advanced practice of the CNS by promoting flexible time arrangements and protected time for the provision of direct care.
3. The employing agency/system ensures that mechanisms are in place for documentation and communication.
4. The employing agency/system shares accountability for inter- and intra-professional communication and planning for optimal health care.

Environmental Support for Consultation

1. Administrative structure facilitates consultation to the CNS by nursing staff, other health professionals, clients, families, and communities.
2. The organizational placement and position description of the CNS facilitates formal and informal consultations.
3. Systems exist for the CNS to receive formal and informal consultations.
4. A system exists for the documentation and communication of CNS consultations.
5. The consultee demonstrates an enhanced understanding of the issues.
6. The consultee is able to generalize and apply the new knowledge to other situations.

Environmental Support for Education

1. The employing system supports the identification of nurses’ learning needs
2. The practice setting promotes ongoing learning of nurses.
3. The employing system allows flexibility of work hours for both learners and educators to meet the learning needs of staff on varying work schedules.
4. Resources are available and accessible to education which recognizes variability of learning styles.

Environmental Support for Research

1. Employing systems facilitate research activities including material and non-material support.
2. CNS role descriptions include research activity.
3. Mechanisms exist for communication and documentation of research activity.
4. Nursing knowledge is validated or generated.
5. Client care is evidenced and reflects current knowledge.
6. Practice within the CNS’s domain of responsibility is positively influenced by research findings.
7. The quality of nursing care and/or worklife is evaluated and improved by the CNS’s research activities.

Environmental Support for Leadership

1. Timely access to relevant clinical and system information.
2. Opportunity for participating in key clinical and nursing decisions.
3. Placement in organization systems at level appropriate to impact across individual programs/units/sectors.
4. Flexibility in job description to capitalize on opportunities for leadership.
5. Expectation of collaborative relationships with nurse leaders and others.

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Glossary

Advanced Practice - the practice of nursing at a level which requires in depth theoretical knowledge at a graduate level in nursing. The competencies of the specialist include the ability to assess, conceptualize, and analyze complex problems related to health, and make appropriate recommendations and/or complement a plan of care (Adapted from National Council of State Board of Nursing, Inc., 1986). The scope of advanced practice nursing is distinguished by autonomy to practice at the edges of the expanding boundaries of nursings’ scope of practice (ANA,1995).

Advanced Practitioner - one who exhibits in-depth expert competency and in-depth knowledge of nursing and related sciences to provide quality nursing care to individuals, families, groups and community.

Advocate - an agent who acts on behalf of vulnerable people.

Change Agent – an individual who facilitates in problem-solving, strategic planning, and change projects (Kaplan, 1990).

Client – an individual, group, family, or community who receives the services of another who is qualified to provide this service.

Clinical Nurse Specialist – an expert advanced practitioner who provides direct care to clients and services as a role model and consultant to practicing nurses and others. The nurse participates in research to improve the quality of nursing care and communicates and uses research findings. The practice of the clinical nurse specialist is based on in-depth knowledge of nursing and behavioural and biological sciences. The role of the clinical nurse specialist includes the following components: practitioner, leader, consultant, educator and researcher. A clinical nurse specialist is a registered nurse who holds at least a masters degree in nursing and has expertise in a clinical nursing specialty (Canadian Nurses Association, 1986).

Criteria – a standard or principle by which a thing is judged.

Domains of Practice – (advanced practice, consultation, education, research, and leadership) are an organizing framework for the description of clinical nurse specialist performance.

Performance Standards – authoritative statements with measurement criteria which describe a competent level of behaviour in the clinical nurse specialist role regardless of specialty or practice setting. The standards enable the quality of advanced practice, consultation, education, research and leadership to be judged.

Primary Care – the first level of contact and maintenance within the health care system. It implies the delivery of a complex set of services and the assumption of responsibility for obtaining special services as required by the patient, in a manner that is responsive to patients’ needs and cultural values (Smith, Forchuk, & martin, 1985). For example, client services received from a family practice agency or public health service.

Quadertiary Care – a highly complex health care available only in a few centres. For example, transplant units.

Role Model – The demonstration of the behaviour associated with a particular position or profession that serves as an example for others.

Secondary Care – involves preventing complications of disease conditions. Secondary care include (1) the treatment of temporary dysfunctions that requires hospitalization but not highly skilled services and high risk interventions. (2) the evaluation of long-term illness that requires hospitalization to determine any needed change in treatment. (3) the provision of counseling and therapy that can not be provided in a primary care centre (Aydelotte, 1983). For example, a low risk birthing centre in a community hospital, or a short term psychiatric unit in a general hospital or community-based ambulatory care centre.

Specialty – a defined area of clinical or functional nursing practice requiring a narrowed focus and in-depth knowledge and skills to meet the full range of client needs in that area of nursing (College of Nurses of Ontario, 1987).

Tertiary Care – complex health care available only in specialized health care agencies.

Theory – A theory is a set of statements that tentatively describe, explain, or predict relationships between concepts that have been systematically selected and organized as an abstract representation of some phenomenon.

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References

American Nurses Association (1995). Nursing’s Social Policy Statement. Washington, D.C.: Author.

Aydelotte, M.K. (1983). The future health care delivery system in the United States. In N.I. Chaska, The Nursing Profession: A Time to Speak. New York: McGraw Hill.

College of Nurses of Ontario (1987). The Regulation on Advanced Nursing Practice. College of Nurses of Ontario.

Canadian Nurses Association (1986). Position Paper on the Clinical Nurse Specialist. Ottawa: Canadian Nurses Association.

Canadian Nurses Association (1994). Certification Program: An Information Booklet. Ottawa: Canadian Nurses Association.

Kaplan, S.M. (1990). The nurse as change agent. Pediatric Nursing, 16(6), 603-618.

National Council of State Board of Nursing, Inc. (1986). Position Paper on Advanced Clinical Nursing Practice. Chicago: National Council of State Board of Nursing, Inc.

Powers, B.A., & Knapp, T.R. (1990). The Dictionary of Nursing Theory and Research. Newbury Park, Califoria: Sage Publications Inc.

Smith, R.H., Forchuk, C., & Martin, M-L. (1985). Primary What? International Nursing Review, 32 (6), 175-176, 180.

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