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Establishing the Clinical Nurse Specialist Identity by Transforming Structures, Processes, and Outcomes

Sanchez, Kimberly, MSN, RN, CCRN-K, ACCNS-AG; Winnie, Kathrine, DNP, RN, CCRN-K, AGCNS-BC; de Haas-Rowland, Natalie, MSN, RN, CCNS-CCRN-CSC-CMC

doi: 10.1097/NUR.0000000000000438
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Purpose: The purpose of this project was to delineate the clinical nurse specialist (CNS) from other nursing roles within this academic medical center with the goal of (1) aligning role responsibilities with core competencies, (2) categorizing role-specific activities using a productivity spreadsheet, and (3) disseminating role-sensitive outcomes.

Description of Project: The Donabedian model was used to evaluate the recently added CNS position and ensure the position aligned with professionally established role responsibilities and practice expectations. Using CNS competencies and standards of practice, the job description was restructured. A process for tracking productivity was developed, and outcomes reporting method was selected.

Outcome: Changes to the job description resulted in 88% of the job description being reflective of CNS competencies and standards of practice. With this new process, collective role-specific work increased from 36% to 95%. Outcomes were identified from 4 frequently performed role-specific activities.

Conclusion: The CNS role was successfully established and differentiated from other nursing roles by redesigning the job description, documenting role-specific activities, and capturing role-sensitive outcomes. Success was captured and disseminated using a year-end report, resulting in a positive response from hospital leadership and a recognized need for current and additional CNSs.

Author Affiliations: Clinical Nurse Specialists, Keck Hospital of USC, Los Angeles, California.

Correspondence: Kimberly Sanchez, MSN, RN, CCRN-K, ACCNS-AG, 630 N Coronado St, Los Angeles, CA 90026 (kimbsanc@gmail.com).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.cns-journal.com).

Clinical nurse specialists (CNSs) have been part of healthcare systems for over 60 years,1 yet CNS practice within organizations varies despite an established role definition. The CNS is an advanced practice registered nurse with expertise in nursing practice who contributes to the quality, safety, and cost-effectiveness of patient care through the integration of knowledge to support nursing practice and process improvement, evidence-based practice, and research efforts.1–3 The CNS community has worked to distinguish the CNS from other nursing roles,2,4 and those efforts should help promote understanding of the role to others; however, use of the role in healthcare systems is inconsistent and sometimes incorrectly utilized; CNSs are the only advanced practice registered nurses with advanced education and preparation in systems-level change.5 As a result, CNSs are necessary in order to obtain systems-level outcomes. The purpose of this project was to delineate the CNS from other nursing roles within this academic medical center, following the Donabedian model, with the goal of (1) aligning the CNS responsibilities with CNS core competencies, (2) categorizing CNS-specific activities using a productivity spreadsheet, and (3) disseminating CNS-sensitive outcomes. The CNSs at this facility outlined a systematic process for utilizing core competencies in job descriptions, compiling CNS hours on a multipurpose spreadsheet, and measuring and displaying CNS-sensitive outcomes.

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BACKGROUND

Healthcare systems have various nursing roles with differing role expectations as part of their care delivery model, including CNSs, nurse educators, nurse managers, and charge nurses. Clinical nurse specialists have expertise uniquely influencing all levels of the healthcare system.4 With the organization experiencing rapid growth, the care delivery model was changed to include CNSs, but there were incompatibilities between the limited scope of the CNS role, characterized by unit-based functions, and the intended role outcomes, improving quality housewide. Specifically, CNSs were responsible for unit audits of nursing actions instead of analysis and evaluation of system outcomes of care. Organizations should be equipped to align the various roles with their unique role responsibilities.

Additionally, nursing roles have set practice expectations.4 Practice expectations for the CNS should align with the established comprehensive set of core competencies,6 associated with the 3 spheres reflective of CNS practice: patient, nurse, and system.7 With the addition of the CNS role to the care delivery model, the practice expectations within the organization were focused on coaching activities within the nursing sphere and particularly unit-based education functions, limiting the scope of work to only a portion of the core competencies. Consequently, there was little difference in practice expectations between the CNS and nurse educator. In this organization, initial role delineation was attempted but unsuccessful because CNS scope of work was limited, whereas other nursing roles’ scope included work that should have been done by a CNS. For instance, nurses lacking education and preparation in evidence-based practice implementation attempted and often implemented practice changes using process improvement methodology. Distinguishing practice expectations is needed so roles align with those practice expectations.

Role-sensitive outcomes result when practice expectations align with role responsibilities.6 When the CNS role was introduced, the initial intent of the organization was to improve quality and safety housewide. The organization’s introduction of a CNS with incorrect role responsibilities and narrow practice expectations limited the ability to demonstrate outcomes of CNS practice. Consequently, any outcomes were limited to coaching activities and unit-based education instead of quality and safety improvements housewide. In order to positively influence all levels of healthcare, improve organizational metrics, and demonstrate CNS-specific outcomes, a fundamental understanding and integration of the CNS role with corresponding practice expectations are essential.

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PROJECT DESIGN AND IMPLEMENTATION

Donabedian Model

The Donabedian model was used to examine the quality of care obtained by introducing the CNS. This examination included the 3 interrelated categories that make up the Donabedian model: structure, process, and outcomes.8 Donabedian8 indicates that components of structure include the characteristics of the environment where care is provided, including employee qualifications and organizational framework. Process is equated to the work performed, and outcomes are the result of the process.8 To systematically improve the CNS contributions to the organization, the group addressed the interrelated categories individually and collectively. Job descriptions are an account of employee responsibilities outlined by the organization, analogous with Donabedian’s structure. Although some organizationally assigned CNS responsibilities aligned with the CNS role, other responsibilities were inappropriate for the role, requiring revision of the job description. Productivity in the healthcare setting reflects the efficiency in generating services, reflective of “process” in the Donabedian model. Role-specific services needed to be evaluated and reassigned to ensure work performed aligned with CNS practice expectations. Outcomes are achieved when practice, or work performed, aligns with the role, or organizational framework. When these two are not addressed, CNS-specific outcomes may not be attained, potentially jeopardizing the future of the CNS within the organization. The Donabedian model allowed for an organized method for evaluating practice and developing change.

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Redesigning Job Descriptions: A Multistep Approach

Having a job description inclusive of core competencies establishes a foundation for CNS work and creates a structure for evaluating that work.9 Two organizations have contributed to the development of CNS core competencies. The National Association of Clinical Nurse Specialists identified role-specific7 and population-specific10 CNS competencies, and the American Association of Critical-Care Nurses (AACN) outlined the scope and standards of practice for acute care CNSs.11 Core competencies are entry-level expectations and behaviors for the CNS.7 A job description outlines role responsibilities, and the CNS job description should differentiate the role from that of other nursing professionals. The benefit of developing a job description based on core competencies is that the unique role of the CNS is structured appropriately.

The initial CNS job description was developed prior to implementing a new nursing care delivery model and based on the needs and preferences of the organization. Some job description statements reflected CNS core competencies; others outlined work normally performed by other nursing leaders, and several described general responsibilities that could be performed by any nursing role and did not require an advanced degree. Of particular concern to the CNS group was the lack of role delineation between the CNS and nurse educator. In some organizations, this role delineation is not as crucial because the CNS functions as both CNS and nurse educator. When an organization employs the CNS and the nurse educator as separate positions, the expectation of a CNS is to focus on all aspects of nursing practice, whereas the expectation of a nurse educator is to focus on assessing learning needs, providing educational offerings, and evaluating learning.4 For example, one way a CNS addresses nursing practice is by developing and updating policies to include the latest recommendations for practice. Among the nursing roles, the CNS is best prepared to perform this function because of his/her education and training. The preparation of a nurse educator qualifies him/her to perform activities focused on education and competency validation, including orientation and coordinating preceptor programs.4 In organizations with distinct positions, overlap of the roles is unnecessary and ineffective, considering the extent of role responsibilities of either. In this organization, the CNS role was ambiguous because the few core competencies selected by the organization focused on coaching activities within the nursing sphere that closely aligned with the nurse educator role.

The initial job description did not incorporate job description statements that reflected the robust scope of the role, resulting in a systematic evaluation of the structure of the CNS at the organization as outlined in the job description. First, the job description statements were reviewed for portrayal of the role responsibilities and expectations of the CNS. Of the 60 statements within the document, 10% were core competencies and were accurately included. Another 15% were nurse educator duties, with more than half of those statements specific to the nurse educator role. Another 12% were nurse manager or administrative responsibilities. Organization-specific responsibilities made up 63% of the job description statements. Next, competency and standards of practice documents were reviewed. Similar statements from the various documents were grouped and considered for inclusion in the job description. The statements most inclusive of the CNS role responsibilities and expectations that also aligned with the desired outcomes of the organization were then included. At the conclusion of the review, 74 of 244 (30%) of competency and standards of practice statements were included in the job description. Lastly, existing job description responsibilities more appropriate for nurses in other roles, such as nurse educator or nurse manager, were identified for removal or replacement. Five of the 9 nurse educator duties and 6 of the 7 nurse manager duties assigned to the CNS were removed. Examples of nurse educator and nurse manager statements included in the CNS job description were as follows: assists in educational needs assessments, evaluates the effectiveness of education, and contributes to staff performance appraisal.

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Refocusing Efforts: A Guide for Practice

Clinical nurse specialists are organizational resources, and their productivity reflects the value of the services they provide. Value has been defined as attaining healthcare-related outcomes or obtaining organizational results per unit of cost.12,13 In a value-based model, the outcome is of importance, but so is the cost in attaining that outcome.12 Value then rises when quality is improved for the same unit cost.12 In order to improve value, appropriate organizational resources must be utilized or obtained. A business case provides an objective basis for use of organizational resources or a rationale for obtaining additional resources by presenting a total cost for resources associated with achieving a desired outcome.12 Although CNSs understand the purpose of making a business case using a cost-benefit, cost-effectiveness, or cost-avoidance analysis for organizational projects, CNSs may not see themselves as an organizational resource needing an objective basis for the role in the organization. Because there is supporting evidence that CNSs improve outcomes,14 CNSs are analogous to a service introduced to the organization or a patient care intervention being implemented. Therefore, CNS efficiency and value rise when their work performed improves outcomes per unit cost and productivity tracking allows for a quantifiable unit cost.

The initial tracking of productivity focused on hours, activities, and activity descriptions. Productivity was recorded using each CNS’s preferred method at his/her preferred frequency. One of those methods was the calendar. This required the CNS to ensure his/her calendar accurately accounted for his/her daily activities. The other method of tracking productivity was with an electronic application. This required the CNS to remember to capture the activity in the moment or later ensure his/her electronic application entries were accurate, similar to the calendar. Although information could be exported from both the calendar and the electronic application, it was not in the same format, making it difficult to collectively present the work of the group. The group was only able to show the work of each individual CNS using their preferred method of tracking productivity. To avoid having to reformat the various documents, productivity would need to be uniformly documented and continue to include hours, activities, and activity descriptions as initially intended.

This initial tracking of productivity showed CNS work frequently overlapped with that of nurse educators, failing to show the benefits of having both a CNS and a nurse educator. To reiterate, the CNS implements evidence-based practices,7 and the nurse educator focuses on improving nursing education.4 Upon further review of initial productivity, CNSs were still providing in-services despite the number of nurse educators, and a contributing factor was having in-services assigned to whoever was willing and available. This arbitrary assignment of work accounted for a lack of role delineation. The CNS was left with less opportunities to show their effect on patient, nurse, and system outcomes by having their unique contributions blurred with those of the nurse educator.

Ultimately, analyzing and reporting collective CNS data and contributions using a time-driven activity-based model were limited by the lack of an organized process. Three steps were followed for improving the process of gathering data and categorizing work in a multipurpose spreadsheet.

First, work to be performed by the CNS was visually linked to the newly compiled job description statements for development of the multipurpose spreadsheet. The competency statements, job description statements, and work were divided by patient, nurse, and system, the 3 spheres reflective of CNS practice (Figure 1).

FIGURE

FIGURE

Second, the actual multipurpose spreadsheet was developed and finalized from the drafted content (Supplemental Digital Content 1, http://links.lww.com/NUR/A18). A 1-page spreadsheet was developed to visually link the job description responsibilities and expectations with actual CNS activities. It was important to visually link professional accountabilities with actual CNS activities to help facilitate discussions about how work was categorized. It also provided guidance for newly hired CNSs by listing potential activities and resources for completion of those activities. The spreadsheet had all 52 weeks on the 1 page, and it auto-totaled the cost at year end. The sum feature quantified individual CNS productivity on a weekly and annual basis. An additional benefit was easily obtaining the total time spent on a project even if the group worked on the same activities in different capacities. Ease of use was important to sustain completion of the form as was expected.

Lastly, the collective productivity from individual CNS spreadsheets was compiled. The group used the spreadsheet for 1 month and then compared actual activities listed to see if all CNSs categorized them the same way. After several discussions, standing activities were added to the spreadsheet. Some of these activities included CNS rounds, patient/family rounds, clinical consultation for nurses, clinical consultation for patients/families, consultation at councils or committees, involvement in regulatory surveys, and other similar things that all CNSs would be doing in different capacities (SupplementalDigitalContent1,http://links.lww.com/NUR/A18). The template was standardized for ease of use and consistency in categorization of work. This productivity spreadsheet became the formal mechanism for tracking time and activities.

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Clarifying Measures of Success

Advanced practice nursing roles contribute to patient and organizational outcomes, and when CNSs are part of the care team, organizations have lower hospital length of stay, lower cost of care, and fewer complications.14 Although organizations routinely display their outcomes visually using scorecards or dashboards, disseminating CNS-sensitive outcomes in a meaningful, transparent, and quantifiable ways is less common. A scorecard has been used to demonstrate CNS contributions to the healthcare team and further to demonstrate the value of the CNS role by displaying performance initiatives and connecting those initiatives to organizational strategic goals.15 The use of scorecards has been shown to assist with prioritizing work and links contributions to patient and organizational outcomes.15

Clinical nurse specialists need to be accountable for their work and outcomes to avoid threats to the role when operating costs are being evaluated and positions are being cut.16 When individuals are held accountable for an outcome, it is more likely that they deem the outcome important and are more likely to monitor the outcome17 and its related process measures. In accordance with the Donabedian model, quality is a 3-part approach,8 and the CNS group knew the established structure with the redesigned job description and the established process with the productivity spreadsheet needed to be followed by outcomes. At this organization, CNSs and nurse educators had shared goals, mainly focused on education, with no process for identifying, measuring, or internally disseminating role-specific outcomes. The scorecard was the mechanism chosen to display the outcomes that resulted from CNS work and facilitated accountability among the CNS group, but its development required a systematic evaluation of the organizational priorities and nursing services goals.

First, the CNS group reviewed the organizational priorities, reflecting the mission and vision of the organization, and nursing services goals, focused on the 6 organizational priorities. Examples of the nursing services goals included interprofessional collaboration, reducing harm events, enhancing the patient experience, optimizing patient flow, and collaborating with business partners.

Next, the CNS group identified role-specific goals and corresponding activities to align with the organizational priorities and nursing services goals. The associated health and process outcome measures for identified goals and activities were then selected, including outcomes known to be influenced by CNS practice, including length of stay, cost of care, and complication rates.14 Because CNSs focus on quality and safety, the group began to lead or consult at committees related to nursing quality indicators. With CNSs serving as nursing practice experts, the CNS group led the efforts to write and revise nursing and clinical practice policies to ensure all policies are supported by evidence. Additionally, the CNS group established a 5-month evidence-based practice mentorship program where staff nurses are paired with a CNS to review current evidence, plan, and lead implementation of a new practice. Because CNSs are responsible for integrating knowledge to support nursing practice, the CNSs led rounding with patients, family, and nursing staff.

Lastly, an outcomes report was adapted from a scorecard found in literature15 and included organizational priorities, nursing services goals, CNS activities, and outcome data. The health and process outcome data were collected via 2 sources, an electronic form, developed and used during CNS-led patient and family rounds, and existing audit reports for health and process outcomes measures already monitored and disseminated throughout the organization. Data from these sources were tracked quarterly to facilitate accountability among the CNS group in attaining the identified outcomes.

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Marketing the CNS

Following this structure, process, outcome approach, the CNS group solidified its own identity and established the CNS identity among a small group of colleagues, but there were opportunities for awareness throughout the organization. Promoting the CNS allowed for a broader group to understand the advantages of having CNSs and the value of services offered by a CNS. In this organization, marketing of the CNS occurred through use of a brochure, scorecard, and year-end report. A simple, easy-to-read brochure helped explain role responsibilities and introduce the CNS group to others (Supplemental Digital Content 2, http://links.lww.com/NUR/A19). The scorecard helped outline activities and metrics to a limited audience interested in CNS-sensitive outcomes. At year end, the CNS role, activities, and outcomes were summarized in a report and assisted with internal dissemination of achievements (Supplemental Digital Content 3, http://links.lww.com/NUR/A20). These materials were distributed during CNS week, unit rounding, and networking events. These marketing strategies increased recognition of the CNS group and facilitated interprofessional collaboration within the organization.

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Outcomes

The final job description was relevant to and reflective of CNS practice, collective and individual CNS-specific work increased, and health and process outcomes were identified from CNS group activities. Of the 51 job description statements, 88% were reflective of competencies and standards, and the remaining 12% of the job description statements could not be updated because of the needs of the organization. Of the competency and standards selected, 28% were national core competencies, 56% were population-specific core competencies, 29% were AACN’s standards of clinical practice, and 15% were AACN’s standards of professional performance. With this new process, collective CNS-specific work increased from 36% to 95%, individual CNS-specific work increased similarly, and the group now had 1 aggregate of CNS productivity. The outcomes identified from 4 frequently performed group activities included 17 health outcomes and 48 process outcomes. The electronic rounding form captured 79% of the process outcomes, and the remainder were collected from the existing organizational reports.

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DISCUSSION

Previous literature on CNS role,9 practice,17,18 and outcomes6,17,18 has emphasized 1 or more of Donabedian’s interrelated categories of structure, process, and outcome, but these have not been addressed collectively. The value of the CNS has clearly been demonstrated; however, the use of CNSs in limited ways has potentially decreased opportunities to show CNS-specific outcomes. The value of the CNS is diminished when time is spent performing work that does not require the specialized clinical knowledge of the CNS and may even be incorrectly attributed to another nurse or healthcare professionals. In order for the CNS to be recognized as an irreplaceable team member, it is necessary for the CNS to ensure their work is appropriate for the role. This may require reestablishing the CNS role and work to align with the definition/scope of CNS work identified in literature, rather than to be what is assigned by the organization. Job descriptions must be written to align with what is expected from CNSs throughout the country, and this can be ensured by utilizing competency statements developed for the role. Clinical nurse specialist work must be purposefully selected to attain CNS-sensitive outcomes and should align with the prioritized needs of the organization. Visually displaying these outcomes further disseminates the value of the CNS. In summary, positive CNS outcomes will subsequently occur when the role is correctly defined and the appropriate work is performed.

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CONCLUSIONS

This project followed the Donabedian model to delineate the CNS role within an academic medical center. An accurate job description that used core competencies ensured the role was structured appropriately in the organization. Establishing a job description inclusive of CNS competencies and standards of practice may guide and gauge CNS work. A multipurpose spreadsheet that compiled CNS hours established a process for documenting CNS activities and assisted with making a business case for the CNS role. Objectively capturing productivity supported the CNS’s contribution to the organization in attaining CNS-sensitive outcomes. A reporting method that linked CNS work with organizational priorities allowed for dissemination of outcomes. Accountability for role-sensitive outcomes may facilitate monitoring and prioritization of outcomes. This project outlined how to evaluate the structure of the CNS at the organization as outlined in the job description, develop a process for gathering and categorizing CNS work, and display and disseminate outcomes using a scorecard. Although this project may be replicated as outlined, future efforts may focus on developing a universal electronic repository of possible job description statements from competencies and standards that populate associated CNS work and CNS-sensitive outcomes to streamline the process for organizations introducing the CNS role into their organizations or CNSs choosing to evaluate their role in their organization. Success was captured with and disseminated through a comprehensive year-end report, resulting in a positive response from hospital leadership and a recognized need for current and additional CNSs.

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References

1. What is a CNS? National Association of Clinical Nurse Specialists. https://nacns.org/about-us/what-is-a-cns/. Accessed January 29, 2019.
2. Mayo AM, Mercer M, Chamblee TB, Urden LD, Moody R. The advanced practice clinical nurse specialist. Nurs Adm Q. 2017;41(1):70–76.
3. Fulton JS, Baldwin K. An annotated bibliography reflecting CNS practice and outcomes. Clin Nurse Spec. 2004;18(1):21–39.
4. Mohr LD, Coke LA. Distinguishing the clinical nurse specialist from other graduate nursing roles. Clin Nurse Spec. 2018;32(3):139–151.
5. Response to the Institute of Medicine’s Future of Nursing Report. National Association of Clinical Nurse Specialists. https://nacns.org/advocacy-policy/position-statements/response-to-the-institute-of-medicines-future-of-nursing-report/. Accessed January 29, 2019.
6. Fulton JS. Improving outcomes reporting. Clin Nurse Spec. 2018;32(5):219–220.
7. Clinical Nurse Specialist Competencies: Executive Summary 2006-2008. Philadelphia, PA: National Association of Clinical Nurse Specialists (NACNS) Competency Taskforce; 2010. https://nacns.org/wp-content/uploads/2016/11/CNSCoreCompetenciesBroch.pdf. Accessed January 29, 2019.
8. Donabedian A. The quality of care: how can it be assessed? JAMA. 1988;260(12):1743–1748.
9. Baldwin KM, Clark AP, Fulton J, Mayo A. National validation of the NACNS clinical nurse specialist core competencies. J Nurs Scholarsh. 2009;41(2):193–201.
10. Adult-Gerontology Clinical Nurse Specialist Competencies. Washington, DC: American Association of Colleges of Nursing; 2010. http://nacns.org/wp-content/uploads/2016/11/adultgeroCNScomp.pdf. Accessed January 29, 2019.
11. AACN Scope and Standards for Acute Care Clinical Nurse Specialist Practice. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2014. https://www.aacn.org/~/media/aacn-website/certification/advanced-practice/128101cnsstds2010.pdf?la=en. Accessed January 29, 2019.
12. Bartlett ERJ, Embree JL, Ellis KG. A business case framework for planning clinical nurse specialist-led interventions. Clin Nurse Spec. 2015;29(6):338–347.
13. Olsen LA, Goolsby WA, McGinnis JM. Leadership Commitments to Improve Value in Healthcare: Toward Common Ground: Workshop Summary. Washington, DC: The National Academies Press; 2009. https://www.ncbi.nlm.nih.gov/books/NBK52851/pdf/Bookshelf_NBK52851.pdf. Accessed January 29, 2019.
14. Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ. 2011;29(5):230–250.
15. Jepsen S. Using a scorecard to demonstrate clinical nurse specialists’ contributions. AACN Adv Crit Care. 2015;26(1):43–49.
16. Foster J, Flanders S. Challenges in CNS practice and education. Online J Issues Nurs. 2014;19(2):Manuscript 1.
17. Fulton JS, Mayo AM, Walker JA, Urden LD. Core practice outcomes for clinical nurse specialists: a revalidation study. J Prof Nur. 2016;32(4):271–282.
18. Statement on Clinical Nurse Specialist Practice and Education. 2nd ed. Philadelphia, PA: National Association of Clinical Nurse Specialists (NACNS); 2004. http://nacns.org/wp-content/uploads/2016/11/NACNS-Statement.pdf. Accessed January 29, 2019.
Keywords:

advanced practice nurse; clinical nurse specialist; outcomes; practice; role

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