Clinical nurse specialist

Advanced practice nurse
the journal
A clinical nurse specialist (CNS) is an advanced practice nurse who can provide advice related to specific conditions or treatment pathways. According to the International Council of Nurses (ICN), an Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. Clinical Nurse Specialists are registered nurses who have had graduate level nursing preparation at the master's or doctoral level as a CNS. They are clinical experts in evidence based nursing practice within a specialty area, treating and managing the health concerns of patients and populations. The CNS specialty may be focused on individuals, populations, settings, type of care, type of problem, or diagnostic systems subspecialty. CNSs practice autonomously and integrate knowledge of disease and medical treatments into the assessment, diagnosis, and treatment of patients' illnesses. These nurses design, implement, and evaluate both patient–specific and population based programs of care. CNSs provide leadership in the advanced practice of nursing to achieve quality and cost effective patient outcomes as well as provide leadership of multidisciplinary groups in designing and implementing innovative alternative solutions that address system problems and/or patient care issues. In many jurisdictions, CNSs, as direct care providers, perform comprehensive health assessments, develop differential diagnoses, and may have prescriptive authority. Prescriptive authority allows them to provide pharmacologic and nonpharmacologic treatments and order diagnostic and laboratory tests in addressing and managing specialty health problems of patients and populations. CNSs serve as patient advocates, consultants, and researchers in various settings.

In the United States, a CNS is an advanced practice registered nurse (APRN) with graduate preparation (earned master's or doctorate) from a program that prepares CNSs. The National Association of Clinical Nurse Specialists (NACNS) announced in July 2015 its endorsement of proposals for the Doctor of Nursing Practice (DNP) as the required degree for CNS entry into practice by 2030. According to the Consensus Model for APRN Regulation (2008), "The CNS has a unique APRN role to integrate care across the continuum and through three spheres of influence: patient, nurse, system. The three spheres are overlapping and interrelated, but each sphere possesses a distinctive focus. In each of the spheres of influence, the primary goal of the CNS is continuous improvement of patient outcomes and nursing care. Key elements of CNS practice are to create environments through mentoring and (p. 8) system changes that empower nurses to develop caring, evidence based practices to alleviate patient distress, facilitate ethical decision making, and respond to diversity. The CNS is responsible and accountable for diagnosis and treatment of health/illness states, disease management, health promotion, and prevention of illness and risk behaviors among individuals, families, groups, and communities." (p. 9). CNSs are clinical experts in a specialized area of nursing practice and in the delivery of evidence based nursing interventions. A systematic review published in 2011 identified 11 studies from the US (four RCTs and seven observational) that had looked at the possible effect of having CNS as part of the healthcare team. The reviewers found some evidence of reduced length of stay and costs of care for teams that included a CNS.

CNSs work with other nurses to advance their nursing practices, improve outcomes, and provide clinical expertise to effect system wide changes to improve programs of care. CNSs work in specialties that are defined by one of the following categories:
Population (e. g. pediatrics, geriatrics, women's health)
Setting (e. g. critical care, emergency department, long term care)
Disease or medical subspecialty (e. g. diabetes, oncology, palliative)
Type of care (e. g. psychiatric, rehabilitation)
Type of problem (e. g. pain, wounds, palliative)

Historically, in North America, the CNS role developed within the acute care (hospital) setting. Currently, in addition to the traditional acute care setting, CNSs practice in a variety of non acute care settings. In the Australian health system, however, a clinical nurse specialist refers to a promotional position, rather than a qualification.