The role of the pediatric clinical nurse specialist (CNS) is grounded in the core curriculum and competencies outlined by the National Association of Clinical Nurse Specialists Statement on CNS Practice and Education and the certifying body (
National Association of Clinical Nurse Specialists, 2019
). As of 2019, there were over 70,000 practicing CNSs across the United States (National Association of Clinical Nurse Specialists, 2019
). The NACNS program directory outlines 12 CNS pediatric programs in eight states and over 60 adult programs across the country (National Association of Clinical Nurse Specialists, 2020
). While there are fewer pediatric programs, the 2020 NACNS census survey revealed that based on the CNS competencies and the Advanced Practice Registered Nurse (APRN) Consensus Model's certification for licensure, approximately 22.5% (n = 557) of CNS respondents practice in pediatrics. Care of the pediatric patient has become more complex and therefore a need for a pediatric CNS to support more complex care becomes even more apparent (Cohen et al., 2011
; Murphy and Ehritz, 2021
). The purpose of this article is to review ongoing pediatric CNS challenges, the value of the role, opportunities and outlining the journey of the CNS team at Seattle Children's (SC) in Seattle, Washington.Background
In 2014, the Washington state Nursing Care Quality Assurance Commission (NCQAC) sought to align with the APRN Consensus Model and as member of the National Council of State Boards of Nursing (NCSBN), to “promote uniformity in nursing regulation (
Washington State Department of Health, 2022
).” The NCQAC approved the rules in January 2016 and they became effective in April 2016, thus allowing the CNS to license as an Advanced Registered Nurse Practitioner (ARNP) in the state of Washington. The state rule changes also provided SC an opportunity to align with the state changes and the consensus model. Nursing executives supported the role of the CNS in the institution and subsequently provided the CNS team time to certify over the next few years. There was also a partnership formed with one of the local schools of nursing to support a post-master's certificate, as well as supporting future CNSs through the Doctor of Nursing Practice (DNP) pediatric CNS program. As the CNS team began to complete and certify as pediatric CNSs, there was energy to revisit the scope of the CNS at SC. This prompted further assessment and analysis of the current role against national standards, competencies, and the literature.Forming a team
There was a subset of clinical leaders from various areas that volunteered to assess the CNS role at SC. The team consisted of CNSs or registered nurses (RN) who were completing their CNS degree or certification. Areas represented included surgical, medical (including medically complex care), pediatric intensive care unit (PICU) and pediatric cardiac intensive care unit (PCICU). The team's effort was sponsored by the director of nursing practice and quality, which the CNS team had recently begun directly reporting to. Previously, a unit-based CNS reported to a unit's nursing director and after the reporting structure was centralized, a dotted line between those the two roles.
The team outlined fundamental actions needed to ensure consistency in the CNS role as an APRN using the Consensus Model, NACNS, and the American Association of Critical Care Nurses (AACN) CNS standards (
American Association of Critical Care Nurses, 2014
). The initial interventions included a review of core competencies, scope and standards alignment, role comparison to other advanced practice provider (APP) roles at the organization and longer terms practice goals, like prescriptive authority. One of the initial interventions was to require the CNS position to be certified as a CNS and hold an ARNP license. The next intervention focused on updating staff identification badges to align with APPs, rather than RNs. From March 2019 to March 2022, the team embarked on role comparison to the NP (where applicable), updating the job description and core competencies to align with the NACNS and AACN CNS scope of practice and standards, while identifying methods to be involved in more patient care and consultation in their respective units and across the system. One of the more time-consuming actions was the analysis of the role compared to the AACN pediatric CNS scope of practice and standards (American Association of Critical Care Nurses, 2014
). The team performed an analysis of the local CNS practice to the CNS scope of practice by outlining if there was no evidence, some evidence or strong evidence to guide opportunities for advancement / alignment. The 2014 AACN pediatric acute care CNS practice domains included assessment, diagnosis, outcomes, planning, implementation, and evaluation. Through the analysis of the domains to the CNS practice, the areas where there was some to no evidence of it being a part of the CNS practice became more apparent. The practice components where there was little to no evidence were primarily medical provider-based actions, like formulating a differential diagnosis or prescribing. The SC CNS team recommended prioritization of areas where there was some evidence of it in local practice, like initiating referrals and performing more formal consultations prior to pursuing elements that were not in place like prescribing.The effort to advance CNS practice and assess organizational readiness remains an ongoing effort. The team transitioned the work into the existing CNS monthly meetings to ensure continued participation and inclusion of all team members.
Review of literature
A review of literature was conducted on the role of the pediatric clinical nurse specialist (CNS) in supporting patient care, nursing practice and system improvement and limited to the past five years. The results were expanded to include non-pediatric CNS focused articles, as the search results yielded three pediatric CNS authored articles. The updated search criteria returned eleven articles which were reviewed and selected for inclusion. Subsequently, the presentation of the challenges, opportunities, value of the role and opportunities are broadened for to the overall CNS role.
Challenges and opportunities
Several articles focused on ensuring alignment in the foundation and core competencies of a CNS to improve role clarity (
Fischer-Cartlidge, Houlihan and Browne, 2019
; Mayo, Ray, Chamblee, Urden and Moody, 2017
; Sanchez, Winnie and de Haas-Rowland, 2019
). Without alignment to national standards, there may be a risk confusion with other nursing, non-APRN roles, such as the nurse educator or clinical nurse leader (CNL) (Mayo, Ray, Chamblee, Urden and Moody, 2017
). Equally, improved role clarity may also help redistribute some responsibilities to more appropriate team members like the nurse educator or nurse manager (Sanchez, Winnie and de Haas-Rowland, 2019
). Strategies are also needed to support recruitment and ensuring candidates meet national standards upon hire (Fischer-Cartlidge, Houlihan and Browne, 2019
).There are also recommendations to improve supporting the CNS role, like improved visibility of the structure, process and outcomes for CNS led activities. There may also be a benefit to centralizing the role and developing tools that connect the CNSs practice to the organizational goals and outcomes (
Fischer-Cartlidge, Houlihan and Browne, 2019
; Sanchez, Winnie and de Haas-Rowland, 2019
). With more than 92% of CNSs report not billing for their services, identifying how CNS led interventions help reduce cost may assist with connecting CNS practice to institutional financial stewardship (National Association of Clinical Nurse Specialists, 2020
). Foster and Flanders identified this may support ongoing funding of the CNS role during organizational cost reduction, by demonstrating ties to improved outcomes and reduce cost to a hospital system/organization (as cited in Sanchez, Winnie and de Haas-Rowland, 2019
).Value of the CNS role
Clinical Nurse Specialists influence three spheres of influence: patient, nurse/nursing practice, and system. Supporting a patient care and outcomes, CNSs provide patients with medical complexity increased continuity throughout their admission and help reduce the risk of patient harm. Clinical Nurse Specialists in a neonatal intensive care unit (NICU) and a complex care unit (CCU) partnered together to support children with medical complexity (CMC) and support safe and effective care between care areas (Murphy & Ehritz, 2020). The CNS team was able to achieve this by designing a strategy that individualized care plans, facilitated in multidisciplinary collaboration, provided staff education, and promoted safe transitions (Murphy & Ehritz, 2020).
CNSs also provide value in developing the structure and ongoing improvement to nursing practice through evidence-based practice (EBP) (
Patterson, Mason and Duncan, 2017
). A CNS can be a mentor to staff throughout the EBP review process and help teams reach outcomes (Patterson, Mason and Duncan, 2017
). With the use of tools like the Specific, Measurable, Attainable, Realistic and Timely (SMART) model, a CNS team may be better able to connect research implications to patient care outcomes (as cited in Mason, 2021
). With the use of this approach, one center reported that 80% of their nursing research studies (n = 13) resulted in a change in patient care practices (Mason, 2021
). There was both improvement to patient safety and estimated cost savings between $50,000 to $248,000 (USD) by implementing practice changes that reduced patient falls. Clinical nurse specialists are also key to responding to external issues, such as the COVID-19 pandemic when there is autonomy in the role (Ladak, Lee and Sasinski, 2021
). By having more autonomy, a CNS may be better able to update standard operating procedures to meet rapidly changing practice needs (Ladak, Lee and Sasinski, 2021
).Opportunities for the future
As clinical leaders, pediatric CNSs and CNSs at large may help energize teams around issues and support project(s) through each cycle of improvement (
Fulton, Mayo, Walker and Urden, 2019
). Coaching and mentoring may also support staff's knowledge in the use of quality improvement, EBP, and research methods. This may result in more staff being involved in improvement work supporting clinical practice and patient care (Fulton, Mayo, Walker and Urden, 2019
). Strategies to support the three spheres of influence include engaging stakeholders, providing feedback, interfacing with the system and dissemination of findings (Fulton, Mayo, Walker and Urden, 2019
). These methods also appear to build trust among the teams and support outcomes (Fulton, Mayo, Walker and Urden, 2019
). One example involved a CNS team that collaborated to reduce the length of the nursing admission assessment by 25% (Slivinski, Phillips, Bollinger and Hooper, 2020
). This intervention saved approximately 624 h of nursing time annually, allowing for more time for a nurse to care for their patient(s) (Slivinski, Phillips, Bollinger and Hooper, 2020
).Future opportunities for the CNS are not only in the expansion of knowledge and improvements to clinical practice, but also with role advocacy. When there is advocacy for the role, it may allow the CNS to support patient care and nursing practice more comprehensively (
Tracy et al., 2020
). In 2017, the Department of Veteran's Affairs (VA) allowed and expanded CNSs practice, along with other APPs, to provide full title protection. Title protection, along with CMS reimbursement for APRNs, allowed the CNS to support patient care and their role as APRNs (as cited in Tracy et al., 2020
).Despite the contributions and history of the CNS as an APRN role, there remain systemic opportunities. The Bureau of Labor and Statistics (BLS) currently classifies the CNS under the RN role. In a written response from the BLS (2022):
Multiple dockets requested a new detailed occupation for “Clinical Nurse Specialists.” The [Standard Occupational Classification Policy Committee] SOCPC did not accept this recommendation, based on Classification Principle 1 which states that occupations are assigned to only one occupational category and Classification Principle 2 which states that occupations are classified based on work performed. Clinical Nurse Specialists are distinguished from Registered Nurses based on their educational background, and the SOC classification is task-based.
The BLS stated that the next opportunity for reclassification would likely be in 2028 and there would be time for public comment as early as 2024 (BLS, personal communication, June 6, 2022).
A recent peer-reviewed article also recommended that CNSs apply for a National Provider Identifier (NPI) to improve the national recognition it provides and embedding it into the onboarding process, which may help establish the CNS as an APRN role with the BLS (
Reed, Arbet and Staubli, 2021
). Coupled with full APRN practice and prescriptive authority, a NPI may help count the CNS as an APRN role, establish what location and type of work CNSs are practicing within the healthcare system (Reed, Arbet and Staubli, 2021
). Through collaboration and self-agency, the CNS is well positioned to meet this and future needs to support the three spheres of influence: patient, nurse, and system.Discussion
There are fewer articles on pediatric CNSs in the past five years and additional evidence is needed to understand the influence of a pediatric CNS on patient, nurse, and system outcomes. The articles published in the past five years do articulate methods to improve role clarity, practice implications, systematic role advocacy, and when coupled with strategic initiatives like the one described at one children's hospital, CNSs and organization may achieve some of those objectives. Role flexibility remains a strength of the CNS and CNSs may leverage their unique position as clinical APRN leaders to support the patients, nurses, and the system(s) they lead.
Conclusion
The CNS role has decades of history in supporting patient care, nursing practice, and system improvement. There remain challenges and opportunities to CNS practice, which may be mitigated through alignment with national standards in the foundation and core competencies of the role. Consistency in the CNS role may provide teams the support needed to meet healthcare targets through the application of scientific, nursing, and quality improvement methods. While role ambiguity remains a threat, establishing an organized and methodical approach to lessen it may improve overall CNS practice. Clinical nurse specialists remain an integral part of the healthcare system and are uniquely positioned as an APRN to meet today and tomorrow's healthcare needs.
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Published online: August 18, 2022
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© 2022 Published by Elsevier Inc.
