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Florence Nightingale: The First Clinical Nurse Specialist

Whitehead, Phyllis PhD, APRN, ACHPN, RN-BC, FNAP

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doi: 10.1097/NUR.0000000000000548
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Opportunities come into your life when you least expect them. During a routine virtual meeting of the Virginia Association of Clinical Nurse Specialists, an affiliate organization of the National Association of Clinical Nurse Specialists, a member mentioned an exciting, upcoming series in The Online Journal of Issues in Nursing celebrating the life and work of Florence Nightingale and proposed writing a clinical nurse specialist (CNS) perspective on Nightingale. Her idea was quickly endorsed, and we created a writing group that included Dr Jennifer Matthews, Dr Cindy Ward, Ms Marion Kyner, Dr Terri Crowder, and me, Dr Phyllis Whitehead.

Using the recently published new edition of the National Association of Clinical Nurse Specialists’ CNS Core Competencies, we drafted an outline and began writing. My assignment was to review competencies and create a foundation for describing Nightingale as first CNS in spirit. As we explored the influence of Nightingale, the “Lady in Chief” healthcare reformer, none of us could have known the timeliness of our work as the COVID-19 was nonexistent in the summer of 2019. However, given the challenges of today’s pandemic, our discussion of Nightingale’s leadership in implementing infection control, basic hygiene, and overall health principles could not be more relevant to CNS practice.


Like Nightingale’s practice, the CNS role is independent and broad, influencing informed decision-making across changing environments, needs of populations, needs of organizations, budgetary appropriations, and regulatory mandates. Clinical nurse specialists are flexible and creative, adjusting their roles as Nightingale did when she leveraged her limited resources in the face of one crisis after another. And like today’s CNSs, Nightingale implemented changes in nursing practice and patient care and achieved improved outcomes while overcoming system barriers and bureaucratic resistance. The ultimate goal for CNSs is to optimize patient care and individualize care delivery in attaining health for men, women, children, and the family in the context of their communities, just as Nightingale role-modeled for nurses all those years ago.

Defined as clinical experts in a specialty area of nursing knowledge and practice, in the United States there are more than 70 000 CNSs practicing as advanced practice registered nurses.1 Clinical nurse specialists practice in every state using independent judgment to lead nursing and healthcare teams, translate evidence into practice, generate data and evaluate outcomes, and mentor and teach nurses and other healthcare professionals across clinical settings. Nightingale’s beliefs about nursing standards and practice, advocacy and training, and impact within systems of care delivery are reflected in the CNS practice across spheres of impact: direct patient care, nurses and nursing practice, and healthcare environment, systems, and organizations.

The influence of Nightingale’s analyses of gaps and her implementation of interventions to address deficiencies affecting the delivery of care in hospitals are evident in the CNS core practice competencies across the three spheres of practice. Clinical nurse specialists apply critical thinking skills to influence systems to enhance patient, family, and population care by developing collaborative relationships, coordinating care across all levels, directing quality improvement projects, and devising innovative workflows. Clinical nurse specialist clinical expertise competencies are ensured by the specialty standards of practice and care within the nurses and nursing practice sphere. As Nightingale advocated for robust education for nurses, CNS specialty directs specific knowledge, skill acquisition, and core and specialty competencies for in-depth clinical expertise and the ever-changing nursing practice and healthcare systems.


Nightingale worked independently and developed her unique role as well as the roles of her staff based on identified patient needs, directing interventions derived from meticulous analysis of observations involving patient responses, environmental factors, and clinical outcomes. Nightingale’s assessment of the patient’s needs was similar to today’s CNS patient direct care competences encompassing comprehensive health assessment including psychosocial, functional, physical, and environmental factors. Nightingale directed and delegated nursing care just as today’s CNS implements customized evidence-based interventions. Nightingale’s skills can be compared with CNS competencies of using advanced communication skills, evidence-based knowledge, mentoring, and leading systemic quality improvement and safety initiatives.

Nightingale was no doubt an expert negotiator and collaborator seeking improvements in the environment through on-site practices and changes in legislative, regulatory, and fiscal policies. Like today’s CNS, the scope of her influence was broad, but her focus was always on the patients she served. She was instrumental in validating the need for improving sanitation, nutrition, and ventilation of the wards. and her on-site sanitary reforms dropped the hospital’s mortality from an unprecedented rate to 2.2% from 42.7%.2–4 Today’s CNSs use a more exacting scientific approach and evaluate the impact of nursing interventions on patient outcomes, yet the rationale of improved outcomes is exactly the same as Nightingale’s. Nightingale’s actions and writings demonstrated that she considered housing, social supports, access to healthcare, employment, and education all to be crucial and interrelated to a person’s health and well-being. Similarly, social determinants of health are important aspect of CNS practice.


Education and mentoring are interwoven in CNS practice competencies and mirror Nightingale’s framework for formal nurse training in the principles of care provision. She trained orderlies and after the Crimean War advocated for the Army Medical Department to train military orderlies in the personal care of soldiers. An original champion of home care, Nightingale understood the value of a trained/educated care provider. Today’s CNSs are similarly dedicated to advancing the education and training of nurses and nursing staff, serving as bedside consultants, clinical teachers, mentors to nurses, and other providers. By developing protocols, advancing innovative practices, and leading clinical care improvements, CNSs are following in the footsteps of Nightingale in ensuring a well-prepared, competent nursing workforce.

In Notes on Nursing, Nightingale contemplated what nursing is and what it is not. Ultimately, she believed nursing was a science and an art developed by practice and discipline, adamant that the nurse was not just an assistant to the physician and that training embodied teaching the nurse to help the patient live well. Nightingale’s legacy as the first modern nurse educator is the one she is most identified with. Her model for formal education (as opposed to on-the-job volunteerism) laid the foundation for nursing schools with identified curriculum and supervision of training.4


Nightingale collected vast amounts of data that she analyzed and used to set new directions for care delivery practice and healthcare environments. Clinical nurse specialist practice competencies include evaluation of system-level needs for care programs and structural modifications to achieve outcomes by removing barriers and facilitating practices that support nursing’s unique contributions to advancing health to organizations, community, public, and policy makers. Clinical nurse specialist leaders cultivate power and influence cumulatively from their attributes, intentionality, supportive relationships, communication skills, coalition building, and rational persuasion, just as Nightingale did. Clinical nurse specialists gain respect and often become the most trusted team professional for accomplishing the strategic goals of the organization. An organization’s achievement of Magnet designation, a peer-reviewed affirmation of excellence, has been attributed to CNSs’ leadership, and the power to create interprofessional collaboration supports nurses and nurse practices in the quest for direct patient care through the organization. Across all variety of settings, CNSs use expert knowledge and skills to influence nursing practice and clinical outcomes.

Clinical nurse specialists demonstrate impact on systems of care delivery, which resonates with Nightingale’s vision of nursing practice. Just as Nightingale’s aspirations were to always strive toward improvement and perfection and to make nursing a “high art,” CNSs endeavor to meet the nursing challenges of our patients, organizations, society, and profession.

If you would like to read our entire manuscript, it is available at The Online Journal of Issues in Nursing,4 Matthews J, Ward C, Kyner M, Crowder T, Whitehead P, “Florence Nightingale: Visionary for the Role of Clinical Nurse Specialist,” released on May 31, 2020.


1. National Association of Clinical Nurse Specialists. Statement on Clinical Nurse Specialist Practice and Education. 3rd ed. 2019. Accessed June 25, 2020.
2. Miracle VA. The life and impact of Florence Nightingale. Dimens Crit Care Nurs. 2008;27(1):21–23.
3. Neuhauser D. Florence Nightingale gets no respect: as a statistician that is. Qual Saf Health Care. 2003;12(4):317.
4. Matthews JH, Whitehead PB, Ward C, Kyner M, Crowder T. Florence Nightingale: visionary for the role of clinical nurse specialist. Online J Issues Nurs. 2020.
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