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Integrating Entrepreneurial Skills Into Clinical Nurse Specialist Education

The Need for Improved Marketing, Negotiation, and Conflict Resolution Skills


doi: 10.1097/NUR.0000000000000440
DEPARTMENTS: Educator’s Corner

Author Affiliations: Associate Professor and AP-CNS-DNP Program Track Coordinator, Johns Hopkins School of Nursing, Baltimore, Maryland.

The author reports no conflicts of interest.

Correspondence: Lola A. Coke, PhD, ACNS-BC, RN-BC, FAHA, FPCNA, FAAN, Johns Hopkins School of Nursing, 525 N Wolfe St, Baltimore, MD 21205 (

Executive leadership in hospitals and health systems is once again recognizing the importance of the clinical nurse specialist (CNS) as the key leadership role in effective process change and quality improvement initiatives. No one fills this role better than a specialty master’s degree–educated CNS, especially one with a doctoral degree. By definition, CNS practice “is consistently targeted toward achieving quality, cost-effective outcomes through patient/client care, by influencing the practice of other nurses and nursing personnel, and by influencing the healthcare organization to support nursing practice.”1 As a number of specialty master’s programs convert their CNS programs to the doctoral level, students obtain knowledge and skills in systems process change including how to identify a clinical problem, develop and implement a systems change project to address the problem, mitigate risk, and create an outcomes assessment and evaluation plan to determine the effectiveness of the project. Development of a cohesive project around a clinical problem becomes a key part of the CNS role. However, what seems to be missing from the doctor of nursing practice (DNP) educational preparation are important skills to equip the CNS to effectively market and communicate the value and importance of the CNS role and assertiveness and negotiation skills to influence key stakeholders as part of the process or quality change project work. In addition, CNSs need conflict management skills to manage emerging issues among workers with bullying and horizontal violence and workplace violence as patients and families become more aggressive.

As CNS program graduates enter the workforce, they will need assertiveness and negotiation skills to develop their new role job description as the CNS role has many facets. In an article that addressed CNS role transition after education was completed, Ares2 reported on the continuation of role ambiguity for the CNS because of “variation in responsibilities, overlapping competencies, and differing conceptualizations of the roles in the workplace.” Additionally, published CNS survey results indicated that 54.5% of current job descriptions were not based on the established nationally outlined CNS competencies.3 Both of these issues are important topics to be dealt with by the new CNS graduate as he/she considers role positions and how he/she may want to shape the role, especially at the time of hire. The new CNS graduate needs to consider himself/herself as entrepreneurial as he/she enters a new role and negotiates his/her role responsibilities with the leadership team. Additionally, there is an emergence of innovative and creative CNS roles being described in the literature as seasoned CNSs forge new areas of practice to meet the needs of today’s contemporary healthcare environments. These roles include, for example, using a business case framework to design best practice interventions,4 integration of the CNS and infection prevention professional roles,5 ambulatory care environments with realignment of the CNS in case or care management,6 and community-based transitions of care where CNSs improve heart failure outcomes.7 Therefore, CNS educational programs need to develop and teach content that challenges students to think with an entrepreneurial mindset and integrate the necessary business, marketing, and negotiating skills they need into didactic and clinical practice experiences.

In an integrative review that examined educational gaps of nurses who sought entrepreneurial roles, Arnaert and colleagues8 identified 4 essential categories of skill development needed for entrepreneurs. These include cognitive skills, interpersonal skills, business skills, and strategic skills. For specialty master’s programs that have become DNP programs, the business and strategic skills are often sufficiently developed. The 2 categories that are less developed are the cognitive and interpersonal skills, but yet vitally needed as part of the CNS role toolkit.

For the category of cognitive skills, there were 3 gaps identified: (1) self-regulation, (2) professional “know-how,” and (3) grasping the larger context.8 For self-regulation, the authors described the need for providing skills that develop work-life balance and ability to employ stress management techniques. Professional “know-how” includes having population-focused advanced practice knowledge that is obtained from clinical practicum experiences and theoretical content to ensure expertise is obtained. Lastly, in grasping the larger context, the authors described the need for educational programs to ensure there is understanding of the healthcare system. As DNP scholars, the CNS would have obtained a working knowledge of systems-level operations and change processes.

The second category, interpersonal skills, includes (1) networking and marketing of services, (2) dealing with contextual resistance, and (3) clear communication. Many educational environments today include interprofessional education and opportunities for multidisciplinary interaction; thus, there has been improvement in networking and understanding of various team roles. However, there still exists a gap in education to teach nurses how to market themselves. This includes how to promote the image of nursing overall, selling the importance of role responsibilities, and, lastly, promoting the nursing role at the organizational level. Providing opportunities to exchange ideas with more experienced role models including business coaches to learn negotiation skills and engaging in mentor-mentee relationships would be important ways to engage learners in how to market themselves.9 Additionally, Arnaert and colleagues8 found that nurses felt ill equipped to develop any marketing materials that would help to market their services to their patients or members of the healthcare team.

Contextual resistance includes the ability to manage and resolve conflict. If conflict is not managed well, there is a threat to successful teamwork. Conflict management was identified as a critical skill when interacting with others including colleagues and patients or family members.10 A study by Thompson et al11 demonstrated that poor conflict management on hospital units led to inferior patient care and increased stress. The CNS also needs to be equipped to address conflict that is manifested through an increase in bullying, horizontal violence, intergenerational differences, and differences between disciplines in the current healthcare environment.12

Lastly, communication is categorized into effective communication skills and developing assertiveness and confidence. The authors found that improvement in communication seems to develop as the nurse becomes more confident and learns to be more assertive. Integrating training programs, such as the American Organization of Nurse Executives, Nurse Manager Competencies Program,13 into the curriculum would help the CNS to learn essential, communication, negotiating, and conflict management skills, which would likely increase confidence. Many educational curricula also include development of written communication skills through writing courses and teach guidelines for poster development, which is important for dissemination of project findings at the institutional level and for dissemination to the nursing profession.

Certainly, some schools of nursing are beginning to revise their curriculum to address the educational gaps discussed, but there is still work to be done. These are important skills that are vital for today’s CNS to have as part of the professional toolkit in order to effectively navigate today’s changing healthcare environment and to be a key player at the table with the leadership team. It is a critical time for all CNS programs to teach the graduate how to negotiate role descriptions that solidify and standardize the CNS role based on the CNS competencies to reduce role ambiguity and to forge new roles for the CNS in nontraditional healthcare settings.

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