262 The Journal of Continuing Education in Nursing November/December 2007 Vol 38, No 6

The Role of the Clinical Nurse Specialist in

Promoting Evidence-Based Practice and
Effecting Positive Patient Outcomes
Cynthia Ann LaSala, MS, RN, CNS, Patricia M. Connors, RNC, MS, WHNP,
Jill Taylor Pedro, MSN, APRN-BC, ONC, and Marion Phipps, RN, MS, CRRN, FAAN
T
he role of the clinical nurse specialist is critical to im-
proving patient care and staff development and link-
ing professional practice to evidenced-based outcomes at
the patient, unit, and organizational levels. Today more
than ever, the role of the clinical nurse specialist is vital to
insuring the provision of quality patient care. As a mem-
ber of the leadership team, the clinical nurse specialist is
able to directly affect patient care by responding to the
needs of the patient, novice clinician, and expert practi-
tioner.
The purpose of this article is to describe the evolving
role of the clinical nurse specialist in a large urban hos-
pital and the effects this role has on patient outcomes.
In this acute setting, the clinical nurse specialist impacts
quality initiatives at the bedside, on a unit-based level,
and hospital wide. The expertise of the clinical nurse spe-
cialist is sought to assist, implement, and evaluate hos-
pital-wide quality initiatives and cost-effective patient
care practices. The impact of the clinical nurse specialist
enhances patient care and promotes professional nursing
practice. This article provides a historical view of the role
of the clinical nurse specialist, a description of clinical
nurse specialist practice at Massachusetts General Hos-
pital in Boston, and a discussion of opportunities and
potential threats to future growth of the clinical nurse
specialist role.
HISTORICAL OVERVIEW OF THE CLINICAL
NURSE SPECIALIST
In 1923, the Goldmark Committee identied a need
to include administration, teaching, and public health
content in the nursing curriculum. To include this con-
tent, clinical practice was de-emphasized and theory in-
put increased. As nursing moved into the university set-
ting, graduate programs in education and administration
were developed and an emphasis was placed on func-
tional role preparation. Professional advancement was
not clinically based (Riehl & McVay, 1973). Sills (1983)
noted the following reasons for this direction in nurs-
ing: the preparation of nursings early graduate leaders at
Teachers College, Columbia University; the post-World
War II increase in hospital care demands and nursings
subsequent shift from a private duty model to a super-
visory model within a hospitals bureaucratic structure;
Ms. LaSala is a Clinical Nurse Specialist in medicine, Ms. Connors
is a Clinical Nurse Specialist in obstetrics, Ms. Pedro is a Clinical Nurse
Specialist in orthopedics and urology, and Ms. Phipps is a Clinical Nurse
Specialist in neurology, Massachusetts General Hospital, Patient Care
Services, Boston, Massachusetts.
The authors gratefully acknowledge the expertise and support of the
Massachusetts General Hospital Clinical Nurse Specialist Research Task
Force, especially Ann T. Martin and Marian Jeffries, and the inspiration,
guidance, and mentorship of Dorothy Jones in the development of this
manuscript.
Address correspondence to Cynthia Ann LaSala, MS, RN, CNS,
Clinical Nurse Specialist, Massachusetts General Hospital, Patient Care
Services, Phillips 2009, 55 Fruit Street, Boston, MA 02114.
Clinical nurse specialists (CNSs) are vital members of the
healthcare delivery leadership team. The knowledge and ex-
pertise of the CNS is germane to the quality of care a patient
receives. More than 50 CNSs practice at Massachusetts Gen-
eral Hospital (the states rst Magnet hospital), where they
share their clinical skills, mentor staff through difcult situa-
tions, identify learning needs, and implement innovative ap-
proaches to patient care. This article presents a brief history
of the CNS role and describes how the CNS role is opera-
tionalized at Massachusetts General Hospital and its impact
on unit-based and organizational outcomes. In addition, sev-
eral programs and interventions identied by the CNSs in re-
sponse to results of the Staff Perception of the Professional
Practice Environment Survey are discussed. How the CNS
inuences the professional development of staff and potential
implications for the future role of the CNS are described. An
exemplar is included depicting a typical work day of a CNS on
an acute adult medical unit.
abstract
263 Clinical Nurse Specialist Role LaSala et al.
and the attendant issues associated with nursing being
predominantly a womans profession. All of these factors
created situations which were inimical to the growth of
clinical practice in nursing (Sills, 1983, p. 565).
In contrast to this approach to clinical nursing, the
1940s and 1950s articulated a need for nurses with spe-
cialized knowledge and skills. The growth of the health-
care industry and the lack of continuity across the patient
experience prompted a refocus on the patient experience.
In 1943, Frances Reiter promoted the idea of the nurse
clinician role. This concept embodied three aspects of
clinical practice: (1) clinical competence in depth of un-
derstanding, range of function, and breadth of services;
(2) clinical expertise around the coordination of and re-
sponsibility for continuity of care; and (3) professional
maturity in collaboration with the medical profession
(Reiter, 1966). In 1947, oncology nursing was recognized
as a specialty, with the American Cancer Society and the
National Cancer Institute leading early efforts toward
graduate education in oncology nursing (Craytor, 1982).
Hildegarde Peplau described the clinical specialist as a
model of expertness. Peplau revised the general prac-
tice of nursing, developed the rst masters program in
psychiatric nursing at Rutgers University in 1954, and
helped introduce the rst clinical nurse specialist exami-
nation in psychiatric and mental health nursing (Hamric
& Spross, 1989).
In response to the shortage of primary care providers,
the Surgeon General recommended in 1963 that nurses be
educated to provide primary care in collaboration with
physicians, thus resulting in the advent of the nurse prac-
titioner (Steel, 1997). At the same time, expansion of the
Professional Nurse Traineeship Program to include clini-
cal nurse specialist education provided a major impetus
to develop graduate program content in advanced clini-
cal nursing. This expansion, together with a growth in the
number of baccalaureate-prepared nurses and the profes-
sions increasing interest in graduate education, led to the
rm establishment of education for clinical specialization
within graduate programs (Hamric & Spross, 1989).
The 1970s and 1980s saw both confusion and clarica-
tion by the American Nurses Association of the criteria
required to assume the title of clinical nurse specialist.
Between the early and mid 1990s, there was much discus-
sion about blending the clinical nurse specialist role and
the nurse practitioner role into one, creating an advanced
practice role. Precipitated in part by the loss of many
clinical nurse specialist positions as cost-cutting measures
within healthcare organizations and combined with the
subsequent growth of nurse practitioner programs, the
blended role appeared to be a way to make a multipur-
pose advanced practice nurse role marketable in a chang-
ing healthcare system. In 1990, the Council of Clinical
Nurse Specialists and the Council of Primary Nurse Prac-
titioners of the American Nurses Association merged, re-
ecting a transition to designation as nurses in advanced
practice (Hickey, 2000). Several clinical sites attempted to
develop the blended role in practice with varied results.
Over time, the clinical nurse specialist role has been
described, dissected, reframed, and retitled as clinical
nurse specialists and employing organizations struggled
to clarify role responsibilities and expectations (Sechrist
& Berlin, 1998). In an effort to eliminate the ambiguity
of clinical nurse specialist practice, the National Associa-
tion of Clinical Nurse Specialists issued a Statement on
Clinical Nurse Specialist Practice and Education in 1998.
The goals of the statement were fourfold: (1) to make ex-
plicit the contributions of the clinical nurse specialist to-
ward meeting societal healthcare needs; (2) to articulate
competencies for clinical nurse specialist practice and to
furnish outcome exemplars; (3) to provide a foundation
for a core clinical nurse specialist certication examina-
tion that could be coupled with specialty certication;
and (4) to provide a framework for the progressive evo-
lution of clinical nurse specialist education both at the
graduate level and through continuing education (Na-
tional Association of Clinical Nurse Specialists, 1998)
The authors have chosen to address the rst goal and
will describe how a group of clinical nurse specialists
in one institution have been able to implement the role
of the clinical nurse specialist in meeting the healthcare
needs of the population served in this setting.
THE CLINICAL NURSE SPECIALIST ROLE IN A
LARGE URBAN TEACHING HOSPITAL
The clinical nurse specialists presence is evident
throughout this 898-bed urban acute care hospital.
There are more than 50 clinical nurse specialists in the
institution, making a strong statement of organizational
support and commitment to the role. The clinical nurse
specialist is considered a leadership position in which
individuals are empowered to act as leaders, role mod-
els, practice experts, and supporters and participants of
research in their particular area of expertise. At a meet-
ing of clinical nurse specialists, the group was given a
questionnaire that asked the number of years of nursing
experience each person had; the total collective years of
experience in nursing was 848 years (Table 1). The ques-
tionnaire results also reected participation in 33 differ-
ent professional organizations (Table 2) with more than
30 certications and credentials (Table 3) held by the col-
lective group. Bereavement, ethics, qualitative and quan-
titative research, and wound care were a few of the areas
of expertise characterized by the group.
264 The Journal of Continuing Education in Nursing November/December 2007 Vol 38, No 6
The hospital developed a leadership triad model
in which the clinical nurse specialist collaborates with
a nurse director and an operations coordinator in ad-
vancing quality care. The Triad Team works together
to provide leadership for the units that they are respon-
sible for. This model continues to support the team ap-
proach to the management of the unit. The main focus
of the clinical nurse specialist is to inuence practice
on the unit and throughout the organization through
direct care in both acute inpatient settings and outpa-
tient areas. The clinical nurse specialist reports directly
to the nurse director.
TABLE 1
PROFILE OF CLINICAL NURSE SPECIALISTS IN HOSPITAL
Demographic Data
Number of collective years in nursing 848
Number of collective years at hospital 420.5
Number of collective years in the clinical nurse specialist role 238.5
Number of professional organizations in which clinical nurse specialists are members 96
Collective number of hospital committees clinical nurse specialists serve on 205
Collective number of presentations given by clinical nurse specialists in 2003 319
Collective number of conferences/educational offerings attended by clinical nurse specialists in 2003 152
Clinical Areas of Expertise
Bereavement (Pediatric), Burns, Cardiology (Adult and Pediatric), Cardiac Surgery (Adult and Pediatric), Clinical Research, Critical
Care (Adult, Pediatric, Neonatal), Emergency, Ethics, Family Practice, General Medicine, Geriatrics, Neurology, Obstetrics, Occupa-
tional Health, Oncology, Oncology Symptom Management, Ophthalmology, Orthopedics, Palliative Care, Patient Education, Post-
anesthesia/Perioperative, Psychiatry, Quantitative Research, Precision and Accuracy of Biophysical Measures, Rehabilitation Nurs-
ing, Research Methods and Implementation, Respiratory, Thoracic Surgery, Transplantation (Adult and Pediatric), Trauma, Urology
TABLE 2
PROFESSIONAL ORGANIZATIONS REPRESENTED
American Academy of Nursing (AAN) Association of Womens Health, Obstetric and Neonatal Nursing
(AWHONN)
American Association of Critical Care Nurses (AACN) Boston Area Nursing Informatics and Consortium (BANIC)
American Association of Neuroscience Nurses (AANN) Council of Armenian American Nurses (CAAN)
American Association of Nurse Practitioners (AANP) Eastern Nursing Research Society
American Association of Occupational Health Nurses (AAOHN) Emergency Nurses Association (ENA)
American Heart Association European Society of Cardiology, Workgroup on Cardiovascular
Nursing
American Nephrology Nurses Association (ANNA) Massachusetts Association of Registered Nurses (MARN)
American Nurses Association (ANA) Massachusetts Coalition of Nurse Practitioners (MCNP)
American Nurses Credentialing Center (ANCC) National Association of Clinical Nurse Specialists (NACNS)
American Nursing Informatics Association (ANIA) National Association of Orthopedic Nurses (NAON)
American Psychiatric Nurses Association (APNA) Oncology Nursing Society (ONS)
American Public Health Association (APHA) Sigma Theta Tau-International
American Society of Bioethics and Humanities (ASBH) Society for Vascular Nursing (SVN)
American Society of Perianesthesia Nurses (ASPAN) Society of Critical Care Medicine (SCCM)
Association for the Advancement of Wound Care (AAWC) Society of Pediatric Nurses (SPN)
Association of Operating Room Nurses (AORN) Wound Healing Society (WHS)
Association of Rehabilitation Nurses (ARN) Wound Ostomy Continence Nurses Society (WOCN)
265 Clinical Nurse Specialist Role LaSala et al.
Clinical Nurse Specialist Planning and
Collaboration
The clinical nurse specialists meet twice a month as a
group. During these meetings, agenda items have included
the development of new guidelines for the management of
patient pain, the development of standards for unit-based
orientation, the implementation of an alcohol withdrawal
pathway in the hospitalized patient, the treatment of the
patient with delirium, the creation of a program to increase
use of lowmolecular-weight heparin, the implementation
and education of policies regarding safe transport of pa-
tients to and from diagnostic testing, the introduction of a
falls prevention program, and approaches to improve doc-
umentation. The clinical nurse specialists were involved
in the development of these projects, which were created
directly in response to common patient problems identi-
ed by staff, and the resources required to address these
issues. These activities help articulate the clinical nurse
specialists role in supporting the ability of Massachusetts
General Hospital to respond to a constantly changing
healthcare environment and how the clinical nurse spe-
cialist is instrumental in contributions toward meeting
organizational goals.
The clinical nurse specialist meeting is one of the ve-
hicles for dissemination of clinical practice information
to nurses throughout the hospital. The meeting agenda is
driven by the needs of the clinical unit, department, and
organization. In 2005, the clinical nurse specialist mem-
bership held two retreats. The areas of leadership and
professional development of the clinical nurse specialist
role were identied as priorities. In subsequent planning
sessions, the clinical nurse specialist role denition at
Massachusetts General Hospital was examined, expand-
ed, and rewritten. A plan was formulated to improve
the process for interviewing new clinical nurse special-
ist candidates, selection of candidates, and orientation of
the newly hired clinical nurse specialist into the clinical
practice environment. Following this retreat, the clini-
cal nurse specialist Professional Development Series was
created and implemented.
Staff Perception of the Professional Practice
Environment Survey
On a yearly basis, the nursing staff is asked to com-
plete a survey regarding their perception of the profes-
sional practice environment and the common patient
care problems they encounter in daily clinical practice.
Nurses are asked to rate and report the frequency of
common patient problems in their daily practice, nurs-
ing diagnoses or problems that occur on their respective
units, and their perceived preparedness to manage each
problem or diagnosis. The common nursing problems
are obtained from a list provided and validated by clini-
cal experts, such as members of the clinical nurse special-
ist group.
Numerous programs and interventions have been
identied by the clinical nurse specialists in relation to
the ndings in past surveys. Examples include the de-
velopment of wound care programs and unit-based in-
formation to assist staff in preventing and treating skin
breakdown. In this instance, a clinical nurse specialist,
who is a unit-based wound specialist, is recognized and
TABLE 3
CERTIFICATIONS AND CREDENTIALS HELD BY HOSPITAL CLINICAL NURSE SPECIALISTS
Acute Care Nurse Practitioner (ACNP) Critical Care Registered Nurse (CCRN)
Adult Nurse Practitioner (APRN) Emergency Medical Technician-Basic (EMT-B)
Adult Health Clinical Nurse Specialist (APRN-BC) Emergency Nursing Pediatric Course (ENPC)
Advanced Cardiac Life Support (ACLS) Family Nurse Practitioner (FNP)
Advanced Oncology Certied Nurse (AOCN) Fellow of Critical Care Medicine (FCCM)
Certicate of Advanced Study in Primary Care (Post Masters)
Certication in Inpatient Obstetrics (RNC)
Fellow of the American Academy of Nurses (FAAN)
Certication in Legal Nurse Consulting (CLNC) Fellow of the American Heart Association (FAHA)
Certied Clinical Nurse Specialist (CCNS) Gerontological Nurse Practitioner (GNP)
Certied Critical Care Nurse (CCRN) Oncology Certied Nurse (OCN)
Certied Neuroscience Registered Nurse (CNRN) Orthopedic Nurse Certied (ONC)
Certied Occupational Health Nurse Specialist (COHN-S) Pediatric Advanced Life Support (PALS)
Certied Operating Room Nurse (CNOR) Trauma Nursing Core Course (TNCC)
Certied Specialist (CS) Womens Health Nurse Practitioner (WHNP)
266 The Journal of Continuing Education in Nursing November/December 2007 Vol 38, No 6
consulted by members of the interdisciplinary team.
Programs have also been developed regarding airway
management, risk for injury, confusion, falls, substance
abuse, ethical dilemmas, violence, and end-of-life issues.
These programs have had a positive impact on the abil-
ity of staff to care for acutely ill patients. Staff now feel
better prepared to anticipate and provide for the needs of
these patients. These positive outcomes have led to the
retention and satisfaction of staff, which promotes posi-
tive quality outcomes. New graduates feel supported on
units where clinical nurse specialists impact care. Some
examples of these initiatives are described further.
Example 1. One of the common patient problems staff
identied as being the least prepared to deal with was
violence. Violence rarely presents without contributing
factors (i.e., anger, family conict, substance abuse, and
decisional conict). The sum of these problems moved
violence into the forefront on one inpatient trauma unit.
Staff were concerned about a cluster of angry and violent
incidents that occurred on the unit. They felt unsafe in the
workplace and were anxious to see changes implemented.
Verbalization from discontent to fear led some to share
that they were considering leaving the organization.
A graduate student working with the unit-based clini-
cal nurse specialist assisted in gathering stories and data
to identify priority issues and concerns. When the data
collected were analyzed, the following themes emerged:
risk of violence directed at the patient/victim, fear of
violence directed at the nurse/caregiver, reaction to the
violence/patients ability to cope, lack of environmental
support for patients, and staff safety.
An interdisciplinary team that included nurses, police
and security, management, unit-based clinical nurse spe-
cialists, psychiatric clinical nurse specialists, ethics clini-
cal nurse specialists, and social services was organized.
A plan was implemented that included group sessions
for discussion, workplace safety sessions, provision of
education related to dealing with difcult patients, pol-
icy changes, and a lock-down of the unit to maximize
environmental safety for patients, visitors, and staff. Is-
sues related to patients being detained by police without
a police detail on-site were also brought to the attention
of the security management team. Community polic-
ing was introduced, which promoted development of
positive collaborative working relationships between se-
curity and nursing staff. As a result, there was a decrease
in staffs verbalization of fear and a desire to leave the
work setting. The lock-down of the unit provided for
the physical alteration of the environment that decreased
risk to staff, patients, and visitors, and resources and in-
terventions were identied to assist patients and staff in
effectively managing threatening behavior.
Example 2. In response to an audit of documented
emergency pages and cardiac arrest calls (Code Blue),
a course was designed by two respiratory clinical nurse
specialists and a respiratory therapist to address basic
respiratory care principles of patients in the adult and
pediatric general care units. Data obtained showed that a
Code Blue tended to be called while the emergency was
more of a respiratory situation or a failure to rescue
the patient from becoming further compromised.
All Massachusetts General Hospital registered nurses
now receive a packet during their hospital orientation
that includes information about the anatomy and physi-
ology of the respiratory system, airway assessment,
oxygen delivery devices, oxygen monitoring principles,
emergency response to respiratory distress, suctioning,
chest tubes, and tracheostomy care. After completion
of the Basic Respiratory Care of Patients packet and su-
pervised clinical experience, the nurse is expected to be
able to demonstrate a respiratory assessment and sterile
suctioning technique, identify and select various types
of articial airways and appropriate oxygen delivery de-
vices, describe the principles of pulse oximetry monitor-
ing, and identify and prioritize the needs of a patient in
respiratory distress.
A test is taken after completion of the packet and a
score of 85% or better is needed to pass. A score below
85% requires the nurse to attend a 4-hour respiratory
care workshop, which is offered bimonthly. Most clinical
nurse specialists and nurse directors choose to send their
staff to the class anyway for the hands-on experience.
Since the advent of this method, there has been a bet-
ter response to respiratory distress issues with a decrease
in respiratory code calls. Nurses have demonstrated a
greater knowledge of what they need to do to prevent
intubation of the patient by using their critical-thinking
skills and appropriate resources.
Example 3. The clinical nurse specialist is recognized
as the unit-based wound care specialist and is consulted
by both nursing and physician staff. The clinical nurse
specialist is also consulted for the assessment and selec-
tion of the appropriate therapeutic pressure relieving sur-
faces. Centralized and unit-based educational programs
and resource materials have been developed and imple-
mented by members of the clinical nurse specialist group
to assist staff in preventing and treating skin breakdown.
Examples include the development of a wound care
guide for staging and product selection. The reference
is a double-sided laminated visual reference located on
all inpatient units and included in practice manuals that
identies wounds in various stages of healing with treat-
ment objectives, a plan of care, and available resources
within the hospital.
267 Clinical Nurse Specialist Role LaSala et al.
An existing 1-day wound care workshop was re-
cently revised by the Clinical Nurse Specialist Wound
Care Task Force and expanded into a 2-day program to
further address the educational needs of staff and pro-
mote a standardized approach to wound assessment and
management on all units. The primary goal of the pro-
gram is to update the nurses contemporary knowledge
of evidence-based wound care practice, products, and
skills. The clinical nurse specialists have developed some
guidelines for assessing wounds that are now part of a
newly developed patient care bedside ow sheet to im-
prove and standardize wound documentation. The clini-
cal nurse specialists also collect data annually related to
prevalence and incidence of pressure ulcers. An analysis
of past data has demonstrated prevalence and incidence
rates less than the national average when compared to
hospitals of similar size and acuity.
The Staff Perception of the Professional Practice En-
vironment Survey results were distributed to nursing
leadership and examined to evaluate current reality and
assist in prioritizing response to systematic organization-
al changes needed related to orientation and the develop-
ment of educational offerings. Unit-based results were
also distributed to the nursing leadership triad covering
each unit to develop appropriate unit-based priorities
specic to the units needs. The clinical nurse specialist
is able to use this summary of identied problems and
issues to develop a plan to educate staff and prepare them
to anticipate patient and family needs while promoting
quality evidence-based care.
AN EXEMPLAR OF THE ROLE OF A CLINICAL
NURSE SPECIALIST
Practicing in general medicine presents its own set of
unique challenges and learning opportunities. New nurs-
ing graduates often seek initial employment on medical
and surgical units in major acute care medical centers to
begin building a skills set and a level of competence that
will form the basis for continued professional develop-
ment throughout their careers. The clinical nurse special-
ist is in a position to impact care and achieve outcomes
by inuencing individuals to act in ways that yield posi-
tive outcomes.
Boyle (1996) identied patient-focused instruction
as the primary characteristic that distinguishes the
clinical nurse specialist in the educator role compared
with nurses functioning as educators in staff develop-
ment or academic roles. Teaching may be formal or in-
formal, occurring in the classroom or at the bedside,
which is where staff nurses are concerned. Collabora-
tive patient care planning and learning are optimized
through collective discussion of the patients problems,
patient specic assessment, and shared decision making
(Boyle, 1996).
As a role model, the clinical nurse specialist facilitates
situations that empower staff to intervene independently
in the future. The clinical nurse specialist also mentors
staff by creating an environment that encourages them
to develop to their full potential and to envision mistakes
as opportunities for learning, developing critical-think-
ing skills, and growing professionally and personally. As
a mentor, the clinical nurse specialist listens attentively,
acknowledges the mentees insight, and afrms that it
makes a difference. To function effectively as a consul-
tant, the clinical nurse specialist must be readily avail-
able, be nonjudgmental, possess excellent interpersonal
communication skills, and be sensitive to boundary
and territorial issues. In the mentoring role, the clinical
nurse specialist focuses on the individualized needs of
the mentee, promoting a caring, supportive relationship.
The clinical nurse specialist teaches in ways that moti-
vate others to learn.
As clinical expert, collaborator, consultant, and edu-
cator, the clinical nurse specialist has a unique opportu-
nity to positively inuence patient care outcomes, conti-
nuity of care, and the professional development of staff
through role modeling, mentoring, coaching, and direct
care activities. The clinical nurse specialist promotes a
sense of clinical inquiry and critical thinking through re-
search use and evidence-based practice.
The following narrative offers practical examples of
ways a clinical nurse specialist can promote the profes-
sional development of staff and positively inuence pa-
tient outcomes.
A Day in the Life of a Clinical Nurse Specialist
As someone with less than 2 years of experience as a
clinical nurse specialist but more than 30 years of varied
nursing experience, working beside professional nurses
who are new to practice is both a humbling and privi-
leged place in which to be. In my role as clinical nurse
specialist on a 25-bed general adult medical unit, it is an
awesome but energizing challenge to know that I have
the ability to signicantly impact future nursing prac-
tice by assisting these novice nurses in the acquisition of
clinical competence and leadership skills that will help
move our profession forward.
Morning report begins at 7:00 a.m. As I come onto
the unit, a member of the registered nurse staff who has
worked the night shift shares how frustrated she was car-
ing for a patient who has been admitted in acute alcohol
withdrawal. Although the patients medical issues have
resolved, his verbally abusive statements and manipula-
tive behavior challenge not only the nursing staff, but
268 The Journal of Continuing Education in Nursing November/December 2007 Vol 38, No 6
also other members of the interdisciplinary healthcare
team.
A second registered nurse consults with me about an
elderly patient with a history of congestive heart failure
and a tracheostomy who is 2 days post-transfer from the
Medical Intensive Care Unit and dropped his oxygen
saturation and became hypotensive overnight. The pa-
tient has had several setbacks since initially being hos-
pitalized approximately 2 months ago. He has an angry
disposition and an emotionally needy family. I check on
him later that morning and spend time with the family
addressing some of their questions and concerns.
I am told of the re-admission of a chronically ane-
mic, morbidly obese woman with a serious depressive
disorder and a hematocrit level of 16 whose behavior of-
ten regresses to that of a child. I hear her crying and de-
manding that someone medicate her for pain. The nurse
assigned to her care and I discuss the plan of care and
identify the need to consult with the Clinical Nurse Spe-
cialist Psychiatric Consultation Liaison Service to assist
in the management of this patients behavior.
It is now 7:40 a.m. and I have 20 minutes to prepare
for my weekly meeting with the nurse director, check
my e-mails for any urgent messages, and speak with the
resource nurse of the day shift to assess other hot spots
on the unit and stafng coverage.
During our meeting, the nurse director and I discuss
our progress with implementing a resource nurse ori-
entation program on the unit. We involve one of our
experienced registered nurses in the discussion regard-
ing some of our observations and staff feedback relative
to the learning needs and progress of the 12 recently
hired registered nurses, who are new graduates. Spross
(1989) identied three components necessary for suc-
cessful collaboration: unity of purpose or a common
vision regarding organizational goals and philosophy,
professional recognition of one anothers skills and
contributions, and effective communication. In an ef-
fort to incorporate these elements, the nurse director
and I nalize our approach for the rst of several meet-
ings between a representative number of registered
nurse and patient care associate staff to improve work-
ing relationships between the two groups, advance the
concept of teambuilding on the unit, and promote bet-
ter patient care outcomes.
After the meeting, I follow up with the registered nurse
assigned to the patient in acute alcohol withdrawal to dis-
cuss his needs and treatment plan. The Clinical Nurse
Specialist Psychiatric Consultation Liaison Service and
the psychiatric clinical nurse specialist are in the process
of completing their assessments. The registered nurse ap-
propriately identies the need to contact the social work-
er to assist in dealing with family and discharge planning
issues. We collaborate with the social worker, registered
nurse case manager, physician team, and local shelters to
arrange for discharge over the next few days. I reinforce
with staff the importance of limit setting and using the
hospital police and security and the nursing supervisor if
additional people are needed to help manage this patient
in the absence of the nurse director and myself.
Another part of my role as a clinical nurse specialist
is to serve as an expert resource. Sparacino and Cooper
(1990) referred to expert practice as the prime mecha-
nism by which the clinical nurse specialist gains entry
into patient situations and sustains that activity (p. 15).
One of our new registered nurse graduates approaches
me after having inserted a Foley catheter in a morbidly
obese male patient for whom she is caring. The patient
has been complaining of pain and pressure at the site.
There is also a clinical nurse specialist wound care con-
sult from the physician team. Following a brief look
at the patients chart, the nurse and I assess the patient
together. Manually ushing and repositioning the cath-
eter relieves the patients discomfort and results in good
urinary drainage. I contact our specialty bed vendor and
obtain a bariatric bed for the patient for comfort and
pressure relief as a preventive measure. I discuss my rec-
ommendations with both the nurse and physician team
for wound care of a small Stage I wound the patient has
in his mid-lumbar area. I conrm plans with one of the
oncology clinical nurse specialists and unit pharmacist li-
aison for some upcoming in-service sessions on implant-
ed venous access devices and anticoagulation therapy for
patients with heparin-induced thrombocytopenia.
I nish lunch in time to meet with the psychiatric
clinical nurse specialist regarding the chronically anemic,
morbidly obese, depressive patient who is well known
to her and our Psychiatry Service. We initially visit the
patient together. The psychiatric clinical nurse specialist
continues with her own evaluation and then communi-
cates with me and a member of the physician team and
nursing staff regarding some recommendations for be-
haviorally managing this patient.
I proceed to check on two other patients admitted
with chronic obstructive pulmonary disease and pneu-
monia who have required bi-level positive airway pres-
sure as part of their medical management. In reviewing
their clinical status with the nursing staff, questions
emerge about what bi-level positive airway pressure is
and what it does. One of the patients is extremely agi-
tated and short of breath, with suboptimal oxygen satu-
rations. Both the resource nurse and the registered nurse
assigned to care for the patient are frustrated in working
with the physician team; they believe that the patient is
269 Clinical Nurse Specialist Role LaSala et al.
being inadequately medicated. I consult with one of the
physicians at the bedside with both nurses present and
recommend that we try some intravenous morphine. Al-
though initially hesitant regarding my recommendation,
the physician agrees. Within minutes of receiving a dose,
the patient is resting more comfortably, his oxygen satu-
ration stabilizes, and he is able to tolerate and maintain
the bi-level positive airway pressure more effectively. I
place some literature on noninvasive positive pressure
ventilation in the bedside charts of both patients as an
educational resource for staff.
I return to my ofce to follow up with some e-mail
correspondence regarding our Nursing Grand Rounds
program, which I and another clinical nurse specialist
colleague coordinate. I am interrupted by a member of
our biomedical engineering staff who needs to check and
review some information with me related to a second
central monitoring station and bedside monitors that
were installed the previous week. It is now close to 4:30
p.m. I check in with the evening staff. There is another
skin care consult on a patient with multiple sclerosis and
a request by the family of another patient, a frail, 93-
year-old elder with a C2 fracture, to discuss her ongoing
management and care.
Although fatigued by a to-do-list longer than it was
the day before, I leave for the day at approximately 5:45
p.m. feeling fullled knowing what I was able to do to
support and enhance professional practice and the qual-
ity of care for our patients today.
FUTURE OF THE CLINICAL NURSE SPECIALIST
ROLE
The presence of clinical nurse specialists is one of the
forces that maintains stability in the often chaotic envi-
ronment of the modern American hospital. The adage
that patients are now sicker and move through the health-
care system more quickly does not adequately describe
the actual experience of the patient, family, and clinical
staff in this setting. Patients and families come as strang-
ers to the clinical unit, often after spending hours in the
emergency department or the recovery room after sur-
gery. They are frightened, tired, in pain, and, if they have
been delayed for a long time in the emergency depart-
ment, frustrated and angry. The nurse is the rst member
of the healthcare team to greet the patient when he or she
arrives on a clinical unit. In the brief period of time after
the patient arrives, the nurse needs to assess the patient
and get to know him or her well enough to monitor sta-
bility and be vigilant for potential unwanted changes. In
this rst encounter, the nurse forms the foundation of a
connection that establishes a safe and healing place for
the patient and his or her family. It is the environment of
the clinical unit and the clinical comfort of the nurse that
allows this connection to occur.
A clinical unit is a community. The presence of a strong
leadership team, forged between the nurse director and
the clinical nurse specialist, helps dene the nature of the
unit community. Within this denition, expectations of
those caring for patients are clearly delineated, clinical
knowledge and wisdom are shared, support is provided
in difcult situations, and staff behaviors that lead to
discord and loss of team spirit are addressed and moni-
tored. The clinical nurse specialist is present to support
the new practitioner on the unit, identify learning needs
of all staff, assess care of patients, monitor quality, and
introduce innovative approaches to care of the popula-
tion of patients housed on respective units.
There are many factors in our healthcare system that
will increase the need for the expertise of the clinical
nurse specialist to be as close to the delivery of patient
care as possible. Advances in technology require the
skilled understanding of the application and interpreta-
tion of the latest developments in patient care equipment
and evaluative procedures. The increasing percentage of
the elderly in our society will require the development
of innovative approaches for the care of elders. As tech-
nology and patient populations change, there will be an
increased need for quality initiatives and the adoption
of more evidence-based practice initiatives. Additional
forces driving nursing practice will include the need for
disease prevention and close monitoring of those with
chronic disease and care of the poor and uninsured. The
clinical nurse specialist, prepared as an expert practitio-
key points
Clinical Nurse Specialist Role
LaSala, C. A., Connors, P. M., Pedro, J. T., Phipps, M. (2007). The
Role of the Clinical Nurse Specialist in Promoting Evidence-
Based Practice and Effecting Positive Patient Outcomes. The
Journal of Continuing Education in Nursing, 38(6), 262-270.
1
The clinical nurse specialist is able to directly impact patient
care by responding to the needs of the patient, novice clini-
cian, and expert practitioner.
2
The clinical nurse specialist inuences unit-based and orga-
nizational practice through direct care in both acute inpatient
settings and outpatient areas.
3
The clinical nurse specialist has utilized survey data to de-
velop a plan to educate staff and prepare them to anticipate
patient and family needs while promoting quality evidence-
based care.
270 The Journal of Continuing Education in Nursing November/December 2007 Vol 38, No 6
ner, will play an important role in preparing healthcare
systems for the future.
CONCLUSION
Prevost (2002) encourages all clinical nurse specialists to
be prepared to describe exactly what we do as clinical nurse
specialists, how the role differs from other nurses and phy-
sician extenders, and the important contributions we make.
Honing excellent communication skills is critical to mar-
keting our expertise so that our unique contributions to the
organization are apparent. We must continue to acknowl-
edge our own expertise and have a rm belief that no other
member of the healthcare team has this specic expertise.
The clinical nurse specialist must remain vigilant against
cost-containing endeavors and those who are inclined to
view the retention of the clinical nurse specialist as a lux-
ury. We must be proactive in making our hospitals listen
to the evidence that institutions continuing to support the
clinical nurse specialist role report improved documenta-
tion, better patient outcomes, decreased use of institution-
al resources, less staff burnout, decreased fragmentation
of services, and greater overall savings (Jones, 1993). The
authors believe that the continued support of the entire
clinical nurse specialist group by the nursing leadership at
Massachusetts General Hospital has been an integral part
in the success of the examples cited in this article. Their
support and guidance has allowed these endeavors to be-
come a reality and promote evidence-based practice with
an impact on effective positive patient outcomes.
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CE QUIZ ANSWERS
1. A 2. D 3. B 4. C
5. D 6. D 7. B 8. C
9. A 10. B