Jun 01, 2012
By David McDonald

Who Is the Clinical Nurse Specialist

Valued for their knowledge, expertise and contributions to the team, clinical nurse specialists continue to struggle for role clarity.

Muxlow with other First Nations and Inuit Health staff in a planning session
Teckles Photography Inc.

They’ve been an important part of the Canadian health-care scene for half a century now, yet an element of mystery still surrounds their role. According to experts — including CNSs themselves — there are a number of reasons for this, including inconsistency in the use of their job title and lack of a common understanding about who they are and what they do.

The CNS role emerged in the 1960s in response to the increasing complexity of health-care delivery, and today CNSs are found mostly in the areas of medical-surgical care, gerontology and mental health. But they have also established a strong presence in critical care, community nursing, oncology, palliative care and neonatal care.

In 2009, CNA issued a position statement on the role of CNSs, acknowledging their “significant contribution to the health of Canadians within a primary health care framework.” In this statement, CNA defined the CNS as an RN with a master’s or doctoral degree in nursing who has advanced knowledge and clinical expertise in a nursing specialty, assists in providing solutions for complex health-care issues, provides leadership in the development of clinical guidelines and protocols, promotes the use of evidence, provides expert support and consultation and facilitates system change.

Shaw says, “As a CNS, I try to provide nurses with new ideas for familiar issues.”
Teckles Photography Inc.

“Having a clinical nurse specialist enhances expectations for nursing care and lends support to the nursing role,” says Maureen Shaw. “As a CNS, I try to provide nurses with new ideas for familiar issues.” A Calgary native with more than 40 years of nursing experience, Shaw has spent the last 20 as a CNS in gerontology, mostly at Vancouver General Hospital. A decade ago, she developed the country’s first acute care for elders (ACE) units, which have since been adopted in many other centres across Canada. ACE units are specialized geriatric wards dedicated to the recovery needs of older patients, with the goal of limiting the negative effects of hospitalization and maintaining the patients’ ability to function independently. The essence of her role, she says, lies in constantly stepping back to ask that most fundamental of institutional questions: “Does this approach really help the patient?”

Shaw has also been responsible for implementing a number of other innovative and widely adopted programs to improve the treatment of older patients in hospital settings, especially with regard to the use of restraints, feeding tubes and other potentially demeaning practices. Despite her workload, she manages to spend a third of her time with patients and their families — something she considers an indispensible part of the job.

Working directly with patients while also having a broader impact was a big draw for Doris Sawatzky-Dickson, a CNS in neonatal intensive care at Winnipeg’s Health Sciences Centre (HSC). In the late 1990s, Sawatzky-Dickson became the first CNS in her unit. It was the kind of job she had long imagined for herself: “I wanted to stay clinical; I wanted to stay near the bedside. But I also wanted to have a wider influence on the health of newborns and their mothers.”

A snapshot of CNSs in Canada

The first national survey of Canadian clinical nurse specialists, funded by CNA and Health Canada and carried out by a team of researchers led by nursing science professor Kelley Kilpatrick, reveals the practice patterns of 804 self-identified CNSs. Canadian Clinical Nurse Specialist Practice Patterns, a report of the results, was released last December. Here are the some of the findings:

  • 78% were trained at the graduate level; of these, more than 65% hold a master’s degree in nursing
  • 22% hold a baccalaureate degree as the highest level of education
  • Nearly 20% are currently enrolled in an education program
  • 53% are certified in their clinical specialty
  • 84% work on a full-time basis
  • When paid overtime is included in gross income, 77% of full-time CNSs earn between $70,000 and $99,000
  • 62% work in tertiary or community inpatient settings, 25% in tertiary or community outpatient settings, 20% in ambulatory care, 15% in long-term care, and 13% in home care
  • The top four areas of specialty are gerontology/rehabilitation (19%), medical/surgical (18%), emergency/critical care (12%), psychiatry/mental health (10%) and community health (9%)
  • 75% see patients in their practice
  • According to respondents, the top barriers affecting the full implementation of CNS roles include heavy workload (25%), lack of role clarity (17%), lack of nursing leadership at the level of the organization and nursing licensing body (13%), lack of teamwork (13%) and insufficient funding (8%)
  • According to respondents, the two greatest facilitators for implementing the CNS role are leadership at the level of the organization and nursing licensing body (26%) and team processes: communication, respect, teamwork, trust, collaboration (25%)

Before the CNS role was introduced at HSC, quality improvement initiatives were considered the joint responsibility of the nurse educator and the clinical resource nurses. But their time, says Sawatzky-Dickson, was usually consumed by other duties. “We weren’t doing research. We weren’t doing a lot of proactive, or even reactive, quality improvement,” she recalls. “Things just weren’t getting done. Now they are.” And, she contends, the work — now carried out by the CNSs — is paying big dividends for both the patient and the health-care system.

After more than 35 years’ experience delivering nursing care, Trinidadian-born Josephine Muxlow finds her current role working as a CNS in adult mental health for First Nations and Inuit Health, Atlantic Region, Health Canada, as fresh and stimulating as ever. Muxlow, who started her nursing career as a midwife in England, is also an adjunct professor in the Dalhousie University school of nursing.

“The CNS role covers a broad range of topics, and you have to keep on top of the current information,” she explains. “You have to incorporate evidence-based research, and you have to be able to address complex issues for the client — whether that’s an individual or a community.”

In her job, Muxlow works with health service providers in First Nation communities to help build capacity in areas such as crisis intervention and community stabilization, emotional trauma and mental health promotion. She also works with district health authorities to increase the communities’ access to care. It’s a big job, both thematically and geographically, and it makes full use of her skills as a CNS. The role, she says, is intensely challenging, as well as intensely rewarding.

After a decade and a half on the job, Sawatzky-Dickson remains an unabashed booster of the CNS role. “When you see a unit that’s proactive about quality — rather than just reactive because someone’s made an error — you’ll probably find a clinical nurse specialist in there somewhere,” she says.

And the research bears that out. Kelley Kilpatrick, a nursing science professor at the Université du Québec en Outaouais in Saint-Jérôme, says that although there are strong findings on how effective CNSs are at providing quality patient care, there is not a good understanding of the CNS role.

Role confusion
Kilpatrick was the lead investigator on a recently published groundbreaking study that examined the practice patterns of CNSs in this country (see sidebar). “We found that the lack of understanding of the CNS role applies to a lot of stakeholders,” says Kelley.

Beverley McIsaac agrees. “I have found that even CNSs were challenged to tell me what they did,” says the past-president of the Canadian Association of Advanced Practice Nurses (CAAPN).

A separate issue is that the CNS title is being used by nurses with different educational backgrounds working in many different settings and roles. “It creates confusion among policy-makers and employers,” says Muxlow. “That’s been the issue all along, and until we have role clarity and consistency nationwide, we are not going to be able to move forward.”

The problem is compounded by the lack of reliable data on how many CNSs there are in Canada; there is simply no official list. In fact, to carry out their research, Kilpatrick and her co-investigators had to rely on CNSs to identify themselves. Although her data indicate there are around 2,400 CNSs in Canada, Kilpatrick can’t be sure of the real number because there is no regulation of the title.

As CAAPN president — her tenure ended in September 2011 — McIsaac went looking for answers to that same quantitative question. “I’ve gone to all of the jurisdictions in Canada and said, ‘Tell me how many clinical nurse specialists you have practising here.’ And most can’t,” says McIsaac, who is an NP by training and now a consultant on advanced nursing practice and regulatory services for the Association of Registered Nurses of Newfoundland and Labrador.

In one region, McIsaac received estimates ranging from 500 to 900 CNSs. But when she tallied up those who met the educational requirement according to the CNA definition, she found fewer than 50. “I was amazed at the lack of consistency and clarity around the role,” she says. “Maybe we understand in theory what CNSs are doing, but we really don’t understand who is using the title in practice or whether they have met the CNA definition.”

Clinical nurse specialists have no legal or regulatory title protection. Nor are there any specific educational standards attached to the title. Kilpatrick, who worked as a CNS at the Montreal Heart Institute for a year and a half, believes that many in Canada would like to see CNSs be mandated to have a master’s degree, as they are in the U.S. Her research suggests that about one in five who identify as a CNS have a bachelor’s degree as their highest level of education — and that estimate, she says, may be drastically low.

All five interviewees would agree there is a layer of fog surrounding the CNS role. But where does the responsibility for dispersing the fog lie? “We need to find a way to get all the stakeholders — the educators, regulators and administrators — together to do some consensus work,” says Kilpatrick. “That would be the next logical step.”

Muxlow adds that she would like to see CNSs receive title protection much like NPs have in Canada today. Others don’t see the need. Shaw points out that there is nothing in the CNS’s work that requires that type of legislation. “CNSs have advanced training and skills,” adds McIsaac, “but there is no identified scope of practice issue. NPs have a protected title because of their prescriptive authority.”

Muxlow believes universities could play an important role in solidifying the CNS position in the system by establishing dedicated CNS graduate programs. She herself went to the U.S. to take a master’s of science in nursing with a specialty in psychiatric mental health nursing (CNS track) and believes it was worth the investment. “From my perspective, graduate preparation in a dedicated CNS program fully prepares you to go out and work as a CNS. And because many Canadian universities do not offer these programs, it makes it very difficult to ensure consistent use of the CNS title.”

Employers, too, tend to contribute to the lack of clarity by continuing to hire nurses without graduate degrees to fill CNS positions.

“Really, it’s leadership we should target so that employers and managers have a true appreciation and understanding of the role; they’re the ones who have control of the jobs,” says Sawatzky-Dickson. “We need to be verbal about it. We want every manager to say, ‘I want a clinical nurse specialist of my own.’”

And then there’s the part CNSs play in keeping themselves out of the spotlight. To the charge of not having done a very good job of creating a distinct professional brand, many would have to plead guilty.

“Clinical nurse specialists tend to get buried in their programs, so their work is not as visible,” says Shaw. “And the role itself is not about raising their own profilebut facilitating the ability of the nurses in their unit to provide services to the patient. I think the facilitating role is their greatest strength, but perhaps their weakness as well.”

Sawatzky-Dickson adds that nurses in general are reluctant to draw attention to their work, opting instead to credit the team effort for successes. That reticence, she says, is compounded in CNSs because of their tendency to identify more with their particular area of expertise than with their common experience as CNSs. “For example, when I’m considering some kind of professional development, am I going to go to an advanced nursing practice conference, or am I going to go to a neonatal conference?” Sawatzky-Dickson asks. “Me, I’m going to the neonatal conference.”

Shaw admits such a tactic does little to amplify “the collective voice” of CNSs, but says she, too, would opt for a conference pertaining to her specialty, gerontology.

Still, says Muxlow, CNSs do need to promote themselves. “If we don’t articulate our role and what we bring to a team, then it’s very difficult for people to have an appreciation for what we do.”

Despite the uncertainties surrounding their role in the health-care system, CNSs appear to be a happy lot; the majority of nurses surveyed by Kilpatrick indicated that they were satisfied with their job and not seeking new employment.

“I’ve been a nurse educator, a charge nurse, a resource nurse and a staff nurse, and I think this is the best nursing role in the business. I see it as a perfect job,” Sawatzky-Dickson says. “I think the clinical nurse specialist could be a cornerstone of nursing. Somebody just needs to hold the strings of all the balloons, see the big picture and keep us moving forward.”

David McDonald an Ottawa Writer and Filmmaker.
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