Something Old, Something New

The well-established role of clinical nurse specialist (CNS) and the emerging role of clinical nurse leader (CNL) both offer nurses an exceptional opportunity to make a real difference in improving minority.

The newly emerging role of clinical nurse leader (CNL) and the always evolving role of clinical nurse specialist (CNS) offer minority nurses two exciting career advancement opportunities at the graduate level. And because of their strong focus on improving patient outcomes and quality of care, both roles provide an ideal vantage point for addressing the crisis of racial and ethnic health disparities.

A new role introduced less than 10 years ago, the CNL is an advanced generalist prepared at the master’s level. CNLs serve as the central point of contact between the patient and other care providers, including physicians and nurse specialists. Although oversight responsibilities are associated with the role, the focus is on clinical leadership at the point of care.

The CNS, on the other hand, is a well-established nursing role that dates back to the 1950s. As the name implies, CNSs are specialists and are prepared at either the master’s, postmaster’s or doctoral level. The CNS is an expert in one or more specialty areas of nursing, such as a particular patient population, health care setting, type of care, type of problem or diagnostic systems subspecialty. For example, CNS specialty areas can include acute/critical care, adult health, community health, geriatrics,
health outcomes mental health, oncology and pediatrics.

Unlike CNLs, the CNS is an advanced practice nurse. In addition to direct patient care, CNSs engage in teaching, mentoring, consulting, research, management and systems improvement.

The CNL is an advanced generalist. The CNS is an expert in one or more specialty areas.

Although the clinical nurse leader and clinical nurse specialist have distinct responsibilities, there is some overlap between the two roles. But when both roles are implemented in a health care facility, they tend to be complementary.

CNL: Filling New Needs

The need to create a new advanced generalist nursing role arose in response to critical problems plaguing the nation’s health care delivery system in the 21st century, namely quality of care and patient safety, says Joan Stanley, senior director of education policy at the American Association of Colleges of Nursing (AACN), which spearheaded the development of the CNL role. The AACN convened a task force of nursing leaders and educators to determine the knowledge, competencies and educational preparation nurses would need to make the necessary changes and improvements in these areas. In May 2003 AACN’s board of directors approved the task force’s “Working Paper on the Role of the Clinical Nursing Leader” and the term CNL was born.

Currently, more than 430 nurses in the U.S. are CNL certified, according to AACN. More than 80 advanced generalist master’s degree programs to prepare CNLs are offered at nursing schools throughout the country. Approximately 100 nursing schools have partnered with more than 200 practice settings to implement the role.

One attractive feature of the CNL role, says Stanley, is that it provides nurses with a career advancement opportunity that lets them remain at the point of care as opposed to going into administration and management.

That is what appealed to Anjanetta Davis, MSN, RN, a clinical nurse leader/ clinical educator at Springhill Medical Center in Mobile, Alabama. “I noticed that [many] master’s prepared nurses move away from the bedside,” says Davis, who became CNL certified in 2008. “Being able to still take care of patients and also affect [improvements in] patient care and outcomes is what drew me to the role.”

Clinical nurse leaders oversee the lateral integration of care for a distinct group of patients and may actively provide direct patient care in complex situations, depending on the setting. They evaluate patient assess risks, and change care plans when necessary.

How does this role provide opportunities to address minority health issues? Cynthia Mundy, DNP, RN, NNP-BC, CNL, director of the clinical nurse leader program at the Medical College of Georgia (MCG) School of Nursing in Augusta, offers this example: A CNL overseeing the care of cardiac patients on a hospital unit may notice some discrepancies in outcomes. The CNL can evaluate the patients to see if there is a relationship between ethnicity-related issues and outcomes. Next, the CNL can check the literature to see if this clinical issue has been previously identified within this particular minority patient population. He or she can then develop and implement a plan of care to improve health outcomes for those patients.

Subama Mukherjee, who is currently a student in an accelerated BA-to-MSN/CNL program at MCG, says she wants to become a clinical nurse leader because it will allow her to combine population-based nursing with the experience and skills she has gained through her five years of work in the public health field. “I am drawn to nursing because I wanted to be involved [with direct patient care] in a way that public health does not enable me to be,” she explains. “Working with underserved populations is a huge passion of mine, which goes back to my own experience of growing up as an immigrant here in America.”

Increasing Demand

Who’s hiring clinical nurse leaders? Since its debut six years ago, the CNL role has been implemented across a wide variety of health care settings, including specialty clinics, emergency departments, hospital inpatient units, ICUs, rehabilitation units and ambulatory care clinics.

CNLs have a unique set of competencies and skills that are applicable to any health care setting, says Stanley. “Initially, the biggest need for them is in acute care settings to address gaps in care, [medical] errors and quality improvement efforts.” To that end, CNLs look at outcomes and apply evidence-based practice to ensure that patients benefit from the latest innovations distinct group of patients in care delivery.

Evidence that CNLs can make a real difference in improving patient safety and quality of care is already beginning to emerge. Preliminary results of a study conducted at the University of Central Florida (UCF) College of Nursing in Orlando show that after employing CNLs, a health care facility recorded more incident reports. The increase in reports is attributed to the CNLs recognizing and fixing problem areas, such as infection rates or patient falls, says study co-investigator Mary Lou Sole, PhD, RN, CCNS, CNL, FAAN, FCCM, Pegasus Professor at UCF.

The study also shows a trend toward improved patient communication and physician satisfaction, she adds. “The CNLs are providing continuity of care, so the physicians are coming on board.”

Rose O. Sherman, EdD, RN, NEABC, CNL, director of the Nursing Leadership Institute at Florida Atlantic University (FAU)’s Christine E. Lynn College of Nursing in Boca Raton, is seeing interest in the CNL role grow, particularly among acute care institutions. One reason for this, she believes, is that the scope of nurse managers’ responsibilities has become so broad that health care facilities need someone to address the clinical management of patient care, a critical piece of which is improving patient outcomes, especially in this era of pay for performance.

Another big area of demand for clinical nurse leaders is the Veterans Health Administration, which is the nation’s largest employer of registered nurses. The VHA plans to introduce the CNL role into all of its hospitals nationwide by 2016.

CNS: Changing with the Times

Although the clinical nurse specialist role is not new, it is constantly evolving as new nursing specialty areas, care settings, types of care, health needs and patient populations continue to emerge, says Christine Filipovich, MSN, RN, chief executive officer of the National Association of Clinical Nurse Specialists (NACNS). For example, before the AIDS virus was identified, there was no such thing as an HIV/AIDS CNS.

An advanced practice career as a CNS offer nurses a great deal of versatility. For example, CNSs can take a clinical career path, in which they treat patients; an administrative path, in which they teach nursing staff; or a research path, conducting qualitative as opposed to quantitative research.

“My role focuses on serving as an educator and consultant to nurses,” says Lourdes Januszewicz, MSN, RN, CNS, CCRN, a Hispanic nurse who works in the intensive care unit at Pomerado Hospital in Poway, California. With 11 recent hires, Januszewicz is busy getting the new nurses on board as well as helping current nursing staff enhance their education and competencies. She not only conducts the nursing rounds but also facilitates the multidisciplinary rounds with the medical director or his partners.

In contrast, Evangelina T. Villagomez,
PhD, APRN, CCRN, CDE, CS, FCCM, assistant professor of acute and continuing care at the University of Texas Health Science Center at Houston School of Nursing, is both a critical care and diabetes CNS who does research and teaching. “It’s the ultimate CNS role because I’m in an academic position, but I also practice and do research,” she says.

The Health Resources and Services Administration (HRSA) Division of Nursing estimates that there are currently 32,385 CNSs who have national certification and 27,379 who have state certification. More than 200 schools of nursing offer advanced practice master’s or doctoral degree programs that prepare nurses for CNS certification.

Because the CNS role is so well established, it has more than proven its ability to dramatically improve the clinical environment. CNSs influence outcomes by providing expert consultation in their specialty area(s) to all care providers and by implementing improvements in health care delivery systems. According to AACN, clinical nurse specialist practice has been linked to reduced hospital MSN, RN costs and lengths of stay, reduced frequency of emergency room visits, improved pain management practices, increased patient satisfaction with nursing care and fewer complications in hospitalized patients.

“CNSs are primarily change agents, both for health care systems and for patient populations within a given specialty who need more customized care to meet their needs,” says Judy Martin-Holland, PhD, RN, MPA, CNS, FNP, associate dean of academic programs and diversity initiatives at the University of California, San Francisco School of Nursing, which offers CNS preparation at the master’s and post-master’s levels. “It really does take a person who is very self-assured to embody the role and use it to empower and advocate for patients in the particular specialty chosen.”

Specializing in Closing the Gap

Because clinical nurse specialists are able to focus on specific populations, health care settings and diseases, the CNS role offers nurses an exceptional opportunity to help close the gap of racial and ethnic minority health disparities, says transcultural nursing expert Josepha Campinha-Bacote, PhD, MAR, PMHCNS-BC, CTN, FAAN, president of Transcultural C.A.R.E. Associates in Cincinnati. For example, she continues, a transcultural CNS can work in the emergency room, which is the main point of entry into the health care system for many minority patients. A diabetes CNS working with Native American or Hispanic patients can use his or her expertise to address dietary issues in a culturally specific way.

Sally Brosz Hardin, PhD, RN, FAAN, dean and professor at the University of San Diego’s Hahn School of Nursing and Health Science, says nursing students in the school’s CNS program—28% of whom are students of color—frequently study problems related to health disparities affecting their own racial and ethnic groups.

The fact that CNSs are advanced practice nurses is also an advantage. “An advanced role not only puts you in different settings, but puts you in different roles,” Campinha-Bacote explains. “This versatility allows a CNS to address health care disparities in a multifaceted way.” For instance, some African Americans are reluctant to participate in clinical research studies because of a mistrust of the medical system dating back generations. “But if you’re a [CNS] providing patient care and education who switches to a research role, you already have that rapport with the patients.”

For the CNS, an important part of addressing a patient or population’s specific health needs is looking at all the different factors that can impact their care, including the social structure and environment, says Beverly Patchell, RN, MS, CNS, co-director of the Center for Cultural Competency and Health Care Excellence at the University of Oklahoma Health Sciences Center College of Nursing in Oklahoma City and past president of the National Alaska Native American Indian Nurses Association (NANAINA).

“The CNS’ role is not just to provide excellent care to the individual with cardiovascular disease, for example, but to see the individual in [the larger context of] his or her family group and community,” Filipovich adds. “The CNS can often help families understand not only the [patient’s] disease, but also the implications for the rest of the family. The CNS can help the family make changes at home that can lead that person to a healthier lifestyle.”

Working Together

What exactly is the relationship between the established clinical nurse specialist role and the new clinical nurse leader role? Does one role make the other redundant? Or do medical facilities need to have both CNSs and CNLs on board if they want to deliver the safest and highest quality patient care in today’s challenging health care environment?

Although Filipovich acknowledges that there has been some confusion surrounding the CNS and CNL roles, she points out that their educational pathways and competencies are very different.

In its 2006 “Statement of Support for Clinical Nurse Specialists,” AACN emphasizes that “CNSs play an important role in the provision of nursing care that does not duplicate the emerging role of the clinical nurse leader. CNLs are educated as generalists, while CNSs are prepared for specialty practice. The CNL operates primarily on the clinical microsystem level involving small, functional frontline units, while the CNS is engaged not only within the microsystem but also at the systems levels within three spheres of influence: patient, personnel and organizational systems. The CNL coordinates and implements patient care, while the CNS designs and evaluates patient-specific and population-based programs. The CNL evaluates and implements evidence-based practice, while the CNS has the added responsibility of generating new evidence.”

The key is to clearly define the job descriptions for both roles. In most cases, these distinct roles complement each other when they coexist within the same health care facility. In fact, AACN’s Stanley knows of one health care system in which the need for CNSs increased when it implemented the new CNL role. “That’s because the CNL, who is more focused on the unit or microsystem level, knows when to bring in the advanced specialty knowledge of the CNS,” she explains.

As part of her Robert Wood Johnson Foundation Executive Nurse Fellowship project, FAU’s Sherman interviewed CNLs nationwide about their transition into the role, including their relationship with CNSs. “If you look at the literature, it might lead you to believe that there is some friction between the two, but I did not find that at all in my [preliminary research findings],” she says. “I found, at least from the CNL viewpoint, that they clearly understood that the CNS role is a specialty role. Where CNLs and CNSs were working together, they appropriately consulted with each other back and forth.”

Whether you want to have a broader general focus on quality and patient care as a CNL or to focus on a particular area of specialty as a CNS, both roles are excellent opportunities for minority nurses, says Patchell. “One way [current] CNSs and CNLs can help minority nurses progress [in their education and careers] is to take an active part in mentoring and recruiting them [into these leadership roles] and letting them know they can do it,” she adds.

Even minority nurses who are students in CNL or CNS programs can inspire others to follow their lead. Angelina Bean, RN, who is completing her CNL program at UCF College of Nursing, feels that she is a role model for other nursing students of color. “So many minority students feel that they can’t pursue a master’s degree,” she says. “I feel like I give them a piece of hope that they can.”