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Clinical nurse specialists improve practice and outcomes.

Advanced practice registered nurses (APRNs) have been making positive contributions to the complex health care system for many years. There are four categories of advanced practice nurses: nurse practitioner (NP), certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), and clinical nurse specialist (CNS). While most nurses in Montana are familiar with NP, CNM, and CRNA practice, some confusion exists about the CNS role. The purpose of this article is to provide an overview of CNS practice and outcomes.

The CNS role was created to meet the multifaceted needs of patients, nursing staff, and entire health care organizations. A CNS is prepared with a masters or doctoral degree in nursing and is considered a clinical expert in an area of specialization (e.g., critical care, medical-surgical, oncology, community health, etc.). The function of the CNS is to improve the overall quality of care by providing direct patient care, by providing education and support to bedside nurses, or by improving systems and processes that ultimately affect the patient directly. The National Association of Clinical Nurse Specialists (NACNS) has conceptualized CNS practice as having three distinct, but overlapping spheres of influence. These spheres include the patient/client sphere, the nurses/nursing practice sphere, and the organization/ systems sphere. Additionally, the CNS executes various roles to influence outcomes within the spheres of influence. These roles traditionally include expert clinician, educator, consultant, change agent, and researcher.

Consider the following scenarios:

* A patient with a chest tube is admitted to your orthopedic unit because no other beds are available. Although you are an expert in orthopedic patient management, you know little about chest tubes. So you call the critical care CNS, who provides an on-the-spot inservice on proper care and management of these tubes.

* A care provider in a small town thinks there may be an increase in sexually transmitted diseases among the youth. The community health CNS develops a comprehensive plan to assess and address the problem.

* Your surgical unit is experiencing a high percentage of bariatric surgical patients who are exceeding the expected length of stay (LOS), resulting in financial losses to the hospital. The medical-surgical CNS assesses the nature of the problem and develops a comprehensive plan to get LOS in line with national norms, thus returning the service line to financial viability.

In the past, CNSs have had difficulty tangibly demonstrating their worth to organizations and this likely contributed to decreased reliance on CNS practice for a period of time. More recently, however, there has been renewed emphasis on creating mechanisms by which to demonstrate the positive impact of CNS practice. Indeed, there have been a multitude of studies which have demonstrated that CNS practice can improve patient outcomes and reduce costs in a variety of settings and with a variety of patient populations (Fulton & Baldwin, 2004).

Regulation of CNS practice varies by state. Some states require no extra licensure, some require special endorsement, and others require a second license as an advanced practice nurse. Like other APRNs, CNSs are eligible for Medicare reimbursement. Prescriptive authority is also available in some states. Montana requires an individual wishing to practice as a CNS to obtain an endorsement on the registered nurse license that recognizes the advanced practice. Additionally, in Montana the CNS title is protected and may only be used if 1) masters or doctoral level preparation from a CNS program has been completed, and 2) certification from an appropriate certifying body has been obtained. Currently, only psychiatric CNSs may seek prescriptive authority in Montana.

CNS practice is highly rewarding, especially if you want to influence patient care on a broader level. Nurses seeking to become clinical nurse specialists have the opportunity to do so right here in Montana. Montana State University-Bozeman recently began offering a Clinical Nurse Specialist Option as part of its graduate program. The Community/Public Health track prepares students for CNS practice in community and public health, while the Adult Health track prepares students to work with adults with complex acute and chronic health needs. More information about these options may be obtained from the College of Nursing website at: http:// or by contacting Ms. Lynn Taylor, the Graduate Administrative Assistant, at 406-994-3500 or


Fulton, J. & Baldwin, K. (2004). An annotated bibliography reflecting CNS practice and outcomes. Clinical Nurse Specialist, 18(1), 21-39.

Susan Luparell, PhD, APRN, BC, CCRN & Charlene Winters, DNSc, APRN, BC
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Title Annotation:Education Under the Big Sky
Author:Luparell, Susan; Winters, Charlene
Publication:The Pulse
Geographic Code:1USA
Date:Apr 1, 2005
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