The Clinical Nurse Leader (CNL) and the Clinical Nurse Specialist (CNS): How Similar in Scope and Competencies? The National Association of Clinical Nurse Specialists (NACNS) For ANA Organizational Affiliates June 8, 2005

NACNS Mission: To enhance and promote the unique, high value contribution of the clinical nurse specialist to the health and well-being of individuals, families, groups and communities, and to promote and advance the practice of nursing.

Beginnings…50 years ago The first CNS program was initiated at Rutgers in 1954. It represented a fundamental shift in the vision of education for nurses to university-based knowledge development and application of that knowledge through expertise (Mick & Ackerman, 2002).

Expert nurse! The CNS was initially conceptualized as an expert nurse at the bedside, providing specialized nursing care directly to patients, and indirectly improving care by focusing on nursing staff education and system analysis (Boyd, et al, 1991; Fenton & Brykczynski, 1993; Page and Arena, 1994).

CNSs advance nursing practice… Over the years, CNSs continued as expert nurses while expanding their activities to influence other nurses and nursing practice, as well as the structure, processes and outcomes of nursing care, thereby advancing the practice of nursing.

Value of CNS Practice -Examples The value of CNS practice was demonstrated by an extensive research review published in 1993 (Naylor & Brooten) which examined CNS effects on low birth weight infants, children with chronic illnesses, acutely ill adults, and hospitalized elderly. More recent 2005 publication of research and other articles about CNS outcomes of care

Early 1990s--Healthcare system problems resulting from cost-cutting and diminished CNS influence in nursing and system spheres Increasing errors in patient care Lack of resource people for education and coaching for staff Limited mentoring for inexperienced nurses Short staff in the acute care setting & increased use of unlicensed assistive personnel Resulted in a re-evaluation of the value of CNS practice

Today, there is a strong, renewed interest in CNS practice to improve patient outcomes There is a national shortage of available CNSs. Organizations are offering large sign-on bonuses. Having CNSs on staff is a published desirable characteristic for Magnet Hospital status.

Today… CNSs are in high demand to advance the practice of nursing in a variety of settings and are recognized as valuable contributors to the health care delivery system. At the recent AONE meeting, 25+ states had requests for CNSs. CNSs number over 67,000 (US Dept.HHS, 2003). 40 new or re-opened CNS education programs in the past 3–5 years.(Walker, Gerard, et al, 2002).

NACNS Standards (AONE, NLN-AC endorsed) NACNS Statement on CNS Practice and Education, 2nd edition (2004) includes core competencies and clinical leadership characteristics. *2003 Survey reports >50% of CNS programs using NACNS educational Recommendations.

Leadership Competencies in 3 spheres of influence (NACNS, 1998; 2004): CNS practice is conceptualized as clinical expertise expressed in three domains (spheres of influence)— patient/client, nurses and nursing practice, and organizations/systems. Leadership skills encompass communication, disciplined inquiry, systems-level thinking, and shared decision-making.

Specialty Practice Patient/Client Specialty Knowledge Nurses & Nursing Practice Organizations & Systems Specialty Standards of Practice Specialty Skills/Competencies © J.S. Fulton 2003 Clinical nurse specialist practice conceptualized as core competencies in three interacting spheres actualized in specialty practice and guided by specialty knowledge and specialty standards.

Themes of CNS practice (NACNS, 1998; 2004): how similar is the CNL role to these themes? Evidence-based practice Innovation in clinical care Quality nurse-sensitive outcomes Patient safety Empowering nurses Interdisciplinary collaboration; and Nursing practice-delivery system interface.

CNL? Bottom line concern:too much overlap between the roles and titles • We were assured by AACN (Rossiter memo) that the title CNL was simply a “placeholder” and a new title would be sought to avoid confusion and overlap with the CNS title. • Then told too late to change it. • Potential exists for confusion to public (patients, families, legislators), profession, other health care providers. • CNSs have provided health care for 50 years and the issue of trademarking the established title was never considered necessary.

Who picked the CNL title and why? CNS-CNL-CNS-CNL-CNS…

How is “microsystem level by CNL” differentiated from CNS “delimited area”? CNSs specialize in a delimited area of practice and typically, the specialty can be identified in terms of the following (ANA, 2004; NACNS, 1998; NACNS, 2004): Population (e.g. pediatrics, geriatrics) Type of problem (e.g. pain, wound) Setting (e.g. critical care, ED) Type of care (e.g. rehab, end-of-life) Disease/pathology/med specialty (e.g. oncology, diabetes, cardiovascular)

Nurse executives (Erickson & Dittomasi, 2005) have argued that the CNL will add further role confusion about nurses for the public. They articulately provide support for the CNS practice in saying: “What is it about this role (CNL) that will catapult the nursing profession to a new level that could not occur by advancing the professional development of clinical nurses, reinstituting the CNS role throughout the United States, showcasing and adopting best practices in care delivery and role implementation, and most strategically, coming to consensus about entry into professional nursing practice at the baccalaureate level?” (March 2005 Journal of Nursing Education, p. 100).

CNL as entry into practice? Appears this was an original goal of CNL role. One of our main concerns--the potential demise of the baccalaureate nurse and baccalaureate programs at this time of a nursing shortage. Other leading nursing organizations (AONE, NLN, STT) have recently concurred with ANA and NACNS regarding the need to support the baccalaureate degree as the entry into practice and published/circulated statements in support.

AONE Statement, April 18, 2005 AONE: “The educational preparation of the nurse of the future should be at the baccalaureate level”. AONE: “Given that the role in the future will be different, it is assumed that the baccalaureate curriculum will be re-framed”.

Stanley, et al (2004) paper comparing scope for CNSs and CNLs Includes 3 main areas of discussion: one column describes characteristics of the CNL, one describes characteristics of the CNS, and the third is titled “Shared Role Characteristics” and clearly identifies areas of overlap. We remained concerned about several areas in particular that are hallmarks of CNS practice, including: integrating evidence-based practice into health care, designing and developing innovative nursing interventions and programs of care, and providing leadership and education to nurses and nursing practice (NACNS, 1998; 2004).

Examples of the overlap between the CNS and the CNL roles…. 1. “Both the CNL and CNS translate nursing research findings into clinical practice” (Stanley, et al, 2004, p. 3). 2. “The CNL and CNS use knowledge of health organizations, systems, policy leadership and change to develop and implement/coordinate evidenced-based standards, policies and procedures”. (Stanley, et al.,2004, p. 3).

More overlap? 3. “Although both the CNL and CNS work with multidisciplinary care teams, the sphere of influence and focus may differ” (Stanley, et al,2004, p 4). 4. “The CNL and CNS design and provide health promotion and risk reduction services for patients”. (Stanley, et al, 2004, p. 3).

CNL Implementation concerns Institutional and/or employers reassignment of CNS and NP to the CNL title described at recent VA meeting in Tennessee. No control over how role or scope of practice is implemented. Curricula very different. Fear that duplicity in roles will harm CNSs- no clear practice outcomes for CNL that are different from CNS.

Conclusions Concern about the impact of the CNL on the CNS role continues to be an issue, given the overlap in some of the key competencies. Continued clarification of the differences between CNSs and CNLs is critical. NACNS and AACN should partner in this initiative. Influence against institutional/employer reassignment of CNSs (and NPs) to CNL role is needed. Outcomes research of the CNL “pilot project” will be evaluated thoughtfully.

Thank you to ANA and our Organizational Affiliate colleagues ANA: for their continued support of CNSs and NACNS ANA: for their willingness to dialogue with stakeholders about this important issue OA colleagues: for support of CNS contributions.