Many registered nurses (RNs) in Canada pursue advanced education to become the experts, leaders and change agents needed in the Canadian healthcare system. Referred to as advanced practice nurses (APNs), these master- and doctorate-educated professionals are taking on additional responsibilities in direct and indirect care.
The Canadian Nurse Association (CNA) (2019) identifies two advanced practice nursing roles in Canada: a nurse practitioner (NP) and a clinical nurse specialist (CNS). NPs are registered nurses with graduate level education and experience who autonomously diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals and perform specific procedures. NPs work in all settings and with all patient populations, including primary care, hospital settings, home care and palliative care, and often work with vulnerable patients and in locations with limited access to health care, such as rural and remote areas. A CNS is a registered nurse who holds a master's or doctoral degree in nursing, alongside an expertise in a clinical nursing specialty. The CNS is an agent of change who brings value to patients, practice settings and organisations and helps to improve safety, promote positive health outcomes and reduce costs. This article will focus on the role of the CNS using the Pan-Canadian Core Competencies for the CNS published by the CNA (2014), which in Canada, denote the CNS as an advanced practice role.
The clinical nurse specialist
The CNA (2016) describes the CNS role as responsive to the dynamic needs of the patients, practice settings and organisation. Despite variation in practice, the primary focus of the CNS role is to improve patient, population and health system outcomes by integrating their knowledge, skills and expertise in the domains of clinical care, system level work, advancing nursing practice, and evaluation and research.
Within the domain of clinical care, CNSs do not have the legislative authority to diagnose, order tests and prescribe medications or treatments. Instead, the CNS brings a high level of expert specialist knowledge, skills and abilities, in conjunction with their graduate level education to enable them to autonomously provide consultation on complex patient needs at the individual, population and system level of healthcare.
With a focus on continuous quality improvement, CNSs engage in system level work involving individuals across the spectrum of the healthcare system, including direct care staff, educators, policy makers, administrators, regulators and other health care professionals. Often, a complex individual patient consultation by a CNS that results in immediate clinical therapeutic interventions, is followed by an exploration of the practice context and contributing factors. When system level issues are identified, the CNS manages change and political processes to influence the improvement of care through clinical practice.
Advancing nursing practice is a core function the CNS engages in through continuous learning, modelling professionalism and accountability, and self reflection of their contributions to the healthcare team. CNSs act as mentors to all nurses and team members to promote their ongoing development of quality improvement, specialty knowledge and pursuit of additional education.
Actively engaging in research and evaluation underpins all domains of practice. When gaps in care are identified and when designing the delivery of care, CNSs will use all available research and knowledge to promote safe, effective and reliable care. They lead and participate in research initiatives to facilitate new evidence where needed, with evaluation embedded in all quality improvement initiatives.
Evaluation of the CNS role is essential to ensure the long-term stability of the role. Despite the presence of CNSs within the Canadian healthcare system for over 50 years, the understanding of the role varies among healthcare decision makers. To address this, in 2014, the Participatory, Evidence-based, Patient-focused Process for APN (PEPPA) framework was introduced (Bryant-Lukosius and DiCenso, 2004). The PEPPA framework supports the development of various APN roles and is shaped by the underlying principles and values consistent with APN, namely addressing health needs through the delivery of coordinated care and collaborative relationships among care providers and systems. It included three main stages: development, implementation and evaluation.
As an APN with highly specialised clinical expertise and graduate level education, CNSs are extremely valuable members of the team, responsive to changing healthcare contexts. In the current era of healthcare workforce and population challenges, CNSs will play a critical role in modelling, mentoring and supporting nurses. The Pan-Canadian Core Competencies for the CNS provide a framework for understanding the CNS role, and the PEPPA framework provides a scaffolding for implementing and evaluating the role in various practice settings. As an agent of change, the CNS brings value across health care to improve safety, promote positive health outcomes and reduce costs (CNA, 2019). When the potential influence of support provided by a CNS in a clinical practice area is understood and they are appropriately positioned as part of the policy and decision-making team, their effectiveness within the system of healthcare is maximised.