A clinical nurse specialist (CNS) is a master's degree– or doctoral-prepared expert clinician with advanced training and education in a specialized area of clinical population focus who works in varied healthcare settings.1 A key facet of the role is the CNS impact on patient care, nursing practice, and healthcare organizational systems. However, CNSs have been referred to as invisible champions as the role continues to not be well understood in clinical settings and often missed for their major contributions to the delivery of safe, highly reliable, quality-driven, patient care based on best evidence.2 Healthcare organizations and graduate nursing schools must find novel ways to promote the role and “grow their own,” to bring the CNS role and its invaluable contributions to patients, the nursing profession, and healthcare systems from invisible champion, to center stage.
According to the US Department of Health and Human Services, “In the United States, CNSs comprise the second largest category of academically prepared advanced practice registered nurses (APRNs; nurse practitioner, 55.3%; CNS, 16.9%; dual nurse practitioner/CNS, 6.5%; nurse anesthetist, 13.6%; nurse midwife, 6.1%; dual nurse midwife/practitioner, 1.1%).”3 A large healthcare organization in the Midwest recognizes the value and contributions of the CNS and has developed a CNS intern role while completing their advanced practice clinical and academic requirements. The purpose of this article is to describe the CNS internship program and the strategies developed to equip the CNS graduate with the tools to overcome issues during role transition.
CNS INTERNSHIP PROGRAM
The CNS internship is a role transition experience that provides orientation to the CNS role through a mentored partnership with a primary CNS preceptor. The CNS intern is also nurtured for success by the experienced CNSs within the department for the entirety of the internship. Each potential intern completes an interview process after applying for the internship via a job posting. Prior to start date, evidence of acceptance into an MSN Clinical Nurse Specialist program of study is required. The internship varies from 1 to 3 years and is based on organizational need. Internship time ranges from part-time (32 hours a week) to full-time (40 hours a week) based on intern needs and organizational ability to accommodate the desired full-time equivalent. There is no formal didactic content provided in the internship program. However, because there is ready access to a group of mentors among the seasoned CNSs, there is opportunity to recognize challenges early and talk through countermeasures presented later in this article with CNS mentors/colleagues. There is a constant stream of support and resources for the CNS interns who reach out as needed. For the program, CNS internship role expectations include the following:
- completion of an accredited CNS program of study and certification within 3 to 5 years;
- maintains a high level of clinical expertise through graduate program education and completion of continuing education programs;
- provides expert consultation in the clinical population of focus within nursing and the professional community;
- collaborates in the management of a designated patient care population across the life course and facilitates best nursing practices;
- participates in department, institute, and organization committees;
- identifies educational needs across a continuum of population-focused patient care to facilitate the development of programs and materials for patients, families, and healthcare team members;
- serves as a role model and mentor to clinical nurses and assists nursing staff with integrating research findings into practice;
- evaluates practice outcomes through participation in quality initiatives and clinical research projects;
- disseminates knowledge through presentations or publications at local, regional, and national levels;
- practices excellence in interpersonal skills with patients, families, visitors, and peers and role models positive guest relations and collaborative practice; and
- participates in 45- and 90-day evaluation with ongoing annual evaluation of performance. Evaluations occur with the preceptor, the APRN clinical director, and the APRN clinical manager. Feedback is obtained for the evaluations from unit-based managers and includes interactions with unit staff and unit metrics such as infection rates and fall rates that the intern worked on.
EMOTIONAL AND CLINICAL CHALLENGES OF THE CNS INTERN AND COUNTERMEASURES
Transitioning from the role of clinical nurse to APRN is an emotionally and clinically challenging undertaking. Some of the major emotional hurdles that must be overcome include role identification, role ownership, imposter syndrome, and social isolation. Clinical challenges include translating academic theory to clinical practice, managing the variance between CNS clinical role competencies and the hiring organization's understanding and implementation of the role, and, lastly, balancing the responsibilities that accompany scope of practice and prescriptive authority.
The lived experience of the CNS internship promotes early recognition of the challenges and emotional hurdles that lie ahead and provides a protracted course for the development of countermeasures, resiliency, and practical solutions to overcome barriers to role transition. Tables 1 and 2 are a summarization of causes of emotional challenges and clinical challenges and the measures employed in the CNS internship to minimize the challenge.
The mystique of the CNS role that continues to exist within healthcare organizations and among healthcare providers adds to an already challenging role transition for the CNS student. In an effort to overcome these challenges and ease transition, healthcare organizations must consider creative and innovative ways to unveil the mystery and shine the light on CNS contributions to patient care, quality and safety initiatives, systems thinking, nursing practice, and population health management. Most recently, 4 CNS interns have completed the internship, and all 4 have successfully transitioned to the CNS role and remain employed within the organization. Sharing experiences and stories of success may be the catalyst that sets the CNS internship journey into motion for healthcare organizations that are bold enough to invest in a most valuable resource; we guarantee the return on investment will be well worth it!
1. National Association of Clinical Nurse Specialists. https://nacns.org
. Accessed September 12, 2019.
2. Mohr L, Chamblee T. Revitalizing pediatric and neonatal clinical nurse specialist roles. CNS pediatric and neonatal university programs are seeing a resurgence. ANCC Bold Voices
3. US Department of Health and Human Services, Health Resources and Services Administration The registered nurse population: initial findings from the 2008 National Sample Survey of Registered Nurses. https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/rnsurveyfinal.pdf
. Published 2010. Accessed September 16, 2019.