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Once again this year, the journal is pleased to include the abstracts from the 2003 Annual Conference of the National Association of Clinical Nurse Specialists (NACNS). Last year was the first time the abstracts were published, and the feedback was overwhelmingly positive. For example, one clinical nurse specialist (CNS) reported that although she and many of her CNS colleagues practiced in large healthcare systems where they interface with several different departments and providers, the abstracts are evidence of the breath and depth of CNS practice. Another CNS commented that the abstracts demonstrated the flexibility of CNS practice: through CNS practice, specialty knowledge and skills are adapted to meet focused cultural, regional, and community health needs. Several CNSs noted that publishing the work of others helped them network with other CNS with similar interests. Publishing the abstracts ensures that that CNS practice is described in the literature, where it will be available to CNSs, students, the nursing community, healthcare administrators, and other disciplines.


Again this year, you will find innovative new ideas for nursing interventions and an old theme. The new ideas are varied; the old theme is consistent across the 50 or so years that CNSs have been in practice-improving and advancing nursing practice and nurse-sensitive outcomes. You will also find an emerging clarity about CNS practice. NACNS's notion of CNS practice as an integration of specialty knowledge and skill across 3 spheres of influence is replacing previous ideas about CNS practice defined by subroles.


NACNS's contemporary conceptualization of CNS practice is an integration of specialty knowledge, clinical expertise, and professional attributes across 3 spheres of influence-clients (patients, families, and communities), nurses/nursing practice, and healthcare systems/organizations. An example of integrated CNS practice across the three spheres can be seen in Clinical Nurse Specialists: Poised and Positioned to Promote Protocols and Pathways to Achieve Practice Excellence. In this abstract, Benson describes how a CNS refined a pathway for patients undergoing coronary artery bypass graft by incorporating best practices for management of atrial fibrillation and regulation of insulin/blood sugar levels. The outcomes of the change were monitored using a variance tracking method; the data demonstrated a reduction in both time to extubation and incidence of sternal wound infections. A similar pathway modification for patients with pneumonia resulted in reducing the hospital length of stay by 1 day. To achieve these outcomes, the CNS had to apply several competencies, including specialty knowledge, expert clinical skills, collaboration, education, and leadership. Change at the level described in the abstract means working with nursing staff, medical staff, and unit administration. Outcomes of the change impacted individual patient care, modified the staff's standard of care, and saved dollars for the organization's bottom line-CNS practice integrated across 3 spheres of influence.


Other abstracts are examples of CNS practice that focuses on only one sphere. The client sphere includes direct care activities. Examples include Powers and Daniels'Back to the Basics: What Does the Evidence Say? in which the authors presented a reminder of the profound effects of basic nursing care on patients in the intensive care unit. Hepburn-Smith described a family-centered care program for patients with chronic respiratory disease and their families. Evans described a public awareness and education program focusing on type 2 diabetes in children. Together, these 3 abstracts are evidence of the direct care aspects of CNS practice. These abstracts also provide the evidence that the CNS's patient can be individuals, families, or communities.


There are many abstracts that demonstrate the influence of CNS practice on the nurses/nursing practice and systems/organization spheres of influence. In the nurses/nursing practice sphere, Conley and Zolck discussed the benefits of mentoring staff to apply principles of geriatric assessment, McFarlane and D'Antuono presented the results of a educational initiative to improve performance in code blue events, and Conley and Coughlin presented a creative program for developing preceptors to enhance relationship-building and connectedness of newly hired nurses. The effect of CNS practice on the system is evident in Gegaris's description of developing a chest pain observation and treatment unit and Daniels, Haughan, Boilenger, and Rust's description of building an infrastructure for pediatric pain management.


The notion of spheres of influence was first introduced by NACNS in the 1998 Statement on CNS Practice and Education, 1 has steadily gained popularity, and is emerging as the new perspective of CNS practice. CNS practice has evolved for the past 50 plus years and will continue to do so to meet the needs of the patients, nurses, and organizations we serve. Before the notion of spheres of influence, CNS practice was viewed as subroles-clinician, educator, researcher, consultant, and administrator. Arriving at the subroles was quite a step forward in bringing clarity to CNS role. In 1970, Lewis 2 edited the American Journal of Nursing Company's publication Clinical Nurse Specialist, a compilation of articles selected and reprinted from the American Journal of Nursing, Nursing Research, and Nursing Outlook. The publication was one of several in the company's contemporary nursing series. It included 35 articles predominately written in the 1960s. In the preface, Lewis noted that among the articles, authors varied in their notions of CNS concept, function, and responsibilities. Even the terminology used to describe the CNS was inconsistent and included terms such as nurse-clinician, clinical associate, and liaison nurse. By the 1980s, these variations coalesced into the subroles. The subroles, however, proved to be inadequate, primarily because the competencies of the subroles overlap. The subroles miss the integrative nature of CNS practice and fail to note the effect of CNS practice on outcomes.


Moving to a conceptualization of CNS practice as an integrative whole across spheres of influence has implications for educational programs, competency validation, and other initiatives. Evidence suggests that at present, more than 50% of all CNS educational programs are using NACNS's statement to as a curriculum guide. As this percentage is expected to increase, the core curricula of CNS programs will begin to look more alike than different. Second, NACNS is releasing guidelines for CNS educational programs based on the statement. These guidelines will help to decrease the variability among CNS educational programs and entrench the notion of CNS practice across spheres of influence. Third, existing and emerging methods for validating CNS competencies beyond the master's degree, such as psychometric certification examinations and portfolio requirements, will need to attend to the spheres of influence as an organizing framework for these initiatives.


It needs to be noted, however, that throughout the long journey to conceptualize, define, educate, and support the CNS that was first visualized by early nurse leaders, one thing has remained consistent: In that 1970 publication, Lewis 2 observed that, despite the differences, a common thread ran through all the articles-a concern for development of expert clinically focused nurses in various specialty fields in the interest of improving the quality of nursing practice and patient care. It's clear that CNSs' mission has not wavered during the 50-year journey. The abstracts provide ample evidence.




1. National Association of Clinical Nurse Specialists. Statement on Clinical Nurse Specialist Practice and Education. Glenview, Ill: National Association of Clinical Nurse Specialists; 1998. [Context Link]


2. Lewis EP. Preface. In: Lewis EP. Clinical Nurse Specialist. New York: American Journal of Nursing Company; 1970. [Context Link]