Download Observing the Work of the Clinical Nurse Specialist: A

Neuroscience nursing
Salla Seppänen, MNSc, Head of Health Department, Mikkeli University of
Applied Sciences
The aim of this article is to define the speciality of neuroscience nursing in the
field of professional nursing care and to discuss the different learning
pathways of neuroscience nursing. This article is based on the results of the
Neuroblend project, which promotes European level co-operation between
education and practice aiming to facilitate the development of neuroscience
nursing. The project is partly funded by the European Union through the
Leonardo da Vinci programme.
Neuroscience nursing has been recognised as an area of specialisation in nursing
science since the 1980s.
This means that neuroscience nursing needs to define specific roles, skills and task
areas as well as knowledge base, which are developed by scientific research.
The role of Neuro-nurse was defined through analysing the concept of
Clinical Nurse Specialist based on the review of 12 articles concerning the
roles, skills, tasks and education of Clinical Nurse Specialist.
Role of Clinical Nurse Specialist
The Clinical Nurse Specialist (CNS) is an advanced practice nurse (APN) with
graduate-level preparation as a clinical expert in evidence-based nursing
practice within a specialty area.1 The CNS uses clinical expertise to influence
patients/clients, nurses and nursing practice, and the organization/system with
a focus on providing high quality and cost-effective care. 2
The CNS role has evolved and described in the 1960s with 4 sub-roles: direct
patient care or clinician/practitioner, educator, consultant, and researcher.3
Some models added the fifth sub-role of administrator or manager/leader (or
change agent).4,5,6,7,8,9.
The United Kingdom RCN (1988) 10 reflects this ethos in their document
entitled ‘Specialities in Nursing 1988’ (cited in Wilson-Barnett & Beech 1994, p.
562). 11. This states that:
“Specialist practice involves a clinical and consultative role, teaching,
management, research and the application of relevant nursing research. Only if
a nurse is involved in all of these is he or she a specialist.” 11.
The first research project to address the concept of clinical nurse specialists in
the United Kingdom was undertaken by Castledine 1982. This descriptive study
showed that ‘to become a nurse specialist, a nurse must have practised
nursing, must continue to practise and must continue to evolve through
practising nursing’. 12.
In McGee et. Al’s (1996) study, specialist nurses were also expected to ‘adopt
a multifaceted role, incorporating elements of clinical practice, education,
consultancy, research and management’, (Mc Gee et. al 1996, p. 683) 8, as
outlined also in the existing literature.3,13,14,16. The results of the study
suggest that, with expert knowledge, nurse specialists can enhance patient
care and ensure patient satisfaction.
In 1998, the NACNS published its statement on CNS practice identifying that
the sub-role framework fostered role ambiguity. The NACNS highlighted a
practice statement outlining the core competencies and outcomes for CNS
practice. The NACNS conceptualised CNS practice within 3 spheres of influence
or practice domains that include patients/clients, nursing personnel, and the
organization/network. 15. The integration of the sub-role components to these
spheres provides both clinical and organizational expertise.
In 2004 the CNS practice statement was further developed toward a
conceptual model for CNS practice that included the elements of specialty,
focusing on clinical expertise, and three spheres of influence: patients/clients,
nurses and nursing practice, and the organization/system.2
Gawlinski and Kern (1994) stated that the CNS excels in practice, system
insight, and analysis. 16. Redekopp (1997) summarized the CNS focus as
encompassing direct and indirect nursing care and system analysis. 17. Collins
and Ferrario (1995) observed that CNSs are able to unite the sub-role
functions in "superordinate" roles, such as those needed for case management.
They also found that CNS’s use multifocal nursing strategies and identify and
implement system-level changes to enhance patient care. CNSs, therefore,
have a strength in the coordination and management of patient care. 18.
Beecroft (1995) also identified the ability of the CNS to facilitate patient care
through the components of the CNS role. 19. Facilitation of care by providing
physician liaison and patient advocate functions are extensions of the practice
and systems management abilities of the CNS. 20. In addition, Beecroft (1995)
observed that the multifaceted role gives the CNS the ability to respond to
rapid changes in the healthcare system.19. Gurka (
) observed that the
expert practitioner and role model attributes create the ability of the CNS to be
a transformer of care.21 Jury (1996) identified the components of theorybased practice, critical thinking, and research-based practice as unique
contributors to CNS practice.22
The CNS uses clinical expertise to improve clinical and economic outcomes
across all three spheres of influence. This framework represents a focus on
practice rather than roles.
There are some studies concerning CNS roles. For example Loftus & Mc Dowell
(2000) studied in the United Kingdom clinical nurse specialist in oncology (n =
8 oncology CNSs). They found patient care activities from information-giving,
client education, psychological support, and advocacy.23. Another United
Kingdom study (n = 25 CNSs) described additional activities of the CNS as a
consultant and care coordinator. 24. Research in Scotland (n = 3 CNSs) also
emphasized coordination of care as an important CNS activity. 25. Skills and
role functions of case managers are outlined by Hamric. 26.
A study in China (n = 3 CNSs) describes the CNS as a "care engineer" who
collaborates with the healthcare team to initiate new services and programs,
redesign work roles, and implement new care pathways. 27. In the United
States, expert practitioner and consultation activities by the CNS included
assessing, diagnosing, and evaluating responses to health problems, providing
care to patients and families with complex problems, interdisciplinary
collaboration on the healthcare team, introducing new skills and technology,
and providing leadership in developing and implementing policies and
procedures, standards of care, protocols, and critical pathways. 28. The
grounded theory research in advanced nursing practice in adult critical care
was conducted in 5 countries. The study identified three strategic activities of
the advanced nurse that included improving patient care, patient education,
and promoting continuity of care.29.
According to Sue Miller (1995) the following components will make up the role
of the clinical nurse specialist:
1 Clinical Expert: In order to be credible and acceptable to a work
environment filled with 'specialists' this is essential. To be a clinical expert the
nurse will need to have worked within the neurological care environment and
to have much experience, preferably in a managerial post, and have relevant
post-registration qualifications. The neurological care environment can be a
highly competitive one and if this component of the role is not obvious the CNS
may start and fail here. As a clinical leader and expert, the CNS has the
potential to advocate for patients, to mentor and support nursing staff, and to
implement system changes that promote evidence-based practice.7
2 Resource/Consultant: In this role the CNS would be available to the unit
as well as hospital staff. They would be able to consult her concerning
problems with patients, relatives, staff and equipment. To carry out this
component the CNS would have to be familiar with the problem solving
process. She would be aware of current research concerning nursing practice,
as well as hospital and health policies. Consultations may originate from
individuals or groups from the multidisciplinary team or administration.7
Nurses have become an integral part of the multidisciplinary team in planning
the care of patients and, some would argue, work very similarly to doctors.
Many nurses are leaders within their own specialities, initiating care and
making treatment decisions.7
3 Educator: Patient teaching should be an inherent part of the role of CNS. A
CNS may help develop existing teaching skills present in unit staff, enabling
constructive learning to carry on in her absence, as well as working with junior
staff and post-registration nursing students. The CNS would also be able to
teach staff who do not wish to undertake further study. 7
4 Change Agent: In this field, clinical nurse specialists can be leaders, they
can plan for and initiate change. They will need planning, organizational,
directing, co-ordinating, controlling and evaluation skills, as well as an
understanding of change theories. A CNS can provide the link between
administration and nursing and help to direct change so that both
administration and nursing retain the right staff.7.
5 Researcher: The clinical nurse specialist has a key role in linking research
and practice. This is perhaps an often overlooked aspect as not only do they
need to become researchers and analyse other research, but actually put these
findings into practice. It is also important for the CNS to publish her own
research findings and articles so that a broader sphere of nurses may learn of
her role and changes in practice. This is important for the general
dissemination of knowledge.7.
6 Advocate: The role of the CNS as advocate is not widely documented, but
we all need advocates: both staff and patients. Clay (1987) states that it is up
to nurses to say when staffing levels are inadequate and how health service
cuts will and are affecting the care that a patient has a right to expect and
receive; in this way, if not in others, we become the patient’s advocate.30.
Advocacy for staff is perhaps the pinnacle of achievement for the CNS. In the
long-term this will help to retain much needed skilled professionals, as
opposed to watching them leaving nursing disenchanted, only to use their
managerial and communication skills in other professions. The CNS will only
achieve this if she/he can successfully fulfil all her/his other roles; then she/he
may truly profess to offer advocacy.7
Sub-roles were defined as direct patient carer, educator, consultant,
researcher; beside these roles the roles case manager, developer/ change
promoter were described also in the articles. The results of analysis of the
articles were compared to Patricia Benner’s theory and the European
Function Profile of a neuroscience nurse. By this process the roles of Neuronurses were defined as follows:.
• Care provider:
• Case manager:
• Planner/ practice developer:
• Coach/ teacher/ supervisor:
These roles were chosen because, they cover the work of neuroscience
nurses and these roles are important also in the perspective of care of neuropatients and their relatives.
The role of care provider focuses on the direct care of a Neuro patient. This
means that the nurse works with professional standards and norms within the
care environment. A nurse meets the needs of patient and relatives and can
handle conflicts that may arise between the professional standards and the
wishes of patients and their relatives.
The role of case manager focuses on assessing, planning and guiding the
care of a Neuro patient. The aim of case managing is to make sure that all
care providers work in co-operation being committed to the shared aims of
the care. Continuity of care is thus the key issue in the case manager’s role,
which extends to the multidisciplinary team work.
The role of planner/ practice developer has a productive task, focusing on
effectiveness and efficiency of care. The planner or practice developer has a
key role in linking research and practice and thus promotes the changes in
policy as well as in clinical practice of care.
The role of coach, teacher, and supervisor aims to stimulate and motivate
other team members by giving advice, pointing out key issues and giving and
receiving feedback. They will try to find solutions when problems occur. The
coach / teacher / supervisor provides competence-based training to other
members of the care team and stimulates (or motivates?) them to learn.
The roles were also defined in the professional levels, which were
adopted from Benner´s theory from novice to expert. In this project
were taken three levels that were described by Benner
Competent
Proficient
Expert
 The competent nurse has 2-3 years experience in neuroscience
nursing. The nurse follows rules and applies an organising perspective
to decide which elements of the problem are relevant. The decision
making is based on systematic analysis of the situation, a search of the
knowledge, and reasoning.
 The proficient nurse has 3-5 years experience in neuroscience nursing.
The nurse bases her decision-making on the holistic picture of the
situation. Along with the theory and facts, an expert nurse is able to
also use intuitive knowledge to realize what is happening. A nurse can
quickly assess the situation and decision-making is then quicker.
 The expert nurse has 5 or more years experience in neuroscience
nursing. She or he understands the whole situation immediately and
thus knows how to approach the situation. Analysis of the situation is
not done just based on explicit observations or remarks, thus the
wholeness of the situation is known by total integration of intuitive,
theoretical and practical knowledge.
The next phase of the project was to define the core competences of
neuroscience nurses. The base for this work was already done and published
in the European Function Profile of a neuroscience nurse. The function profile
in this project was translated to the competences. But the biggest question at
the beginning of the work was - What is competence?
The European Union and the Bologna process have turned the concept of
learning objectives from tasks toward competences.
EUROPEAN QUALIFICATION FRAMEWORK (EQF) produced
RECOMMENDED DEFINITION (5.9.2006) for concept competence
KNOWLEDGE means the outcome of assimilation of information through
learning. Knowledge is the body of facts, principles, theories and practises
that is related to a field of study or work. In the EQF, knowledge is described
as theoretical and/or factual.
SKILLS means the ability to apply knowledge and use know-how to complete
tasks and solve problems. In the EQF, skills are described as cognitive (use
of logical, intuitive and creative thinking) and practical (involving manual
dexterity and the use of, methods, materials, tools and instruments).
COMPETENCE means the proven ability to use knowledge, skills and
personal, social and/or methodological abilities, in work or study situations
and in professional and/or personal development. In the EQF, competence is
described in terms of responsibility and autonomy.
In Neuroblend there are definitions of A CORE COMPETENCE AND A
SUPPORTIVE COMPETENCE.
A core competence is the ability to do a particular activity to a prescribed
standard i. e. meeting certain criteria, FORMULATED IN A BROAD WAY,
OFTEN OCCURING AS A COMPLEX SET OF SKILLS, KNOWLEDGE AND
ATTITUDES, COVERING A COHERENT SET OF PROSFESSIONAL
TASKS.
A SUPPORTIVE COMPETENCE IS A NARROW, MORE ATOMISTIC
CONCEPT USED TO LABEL PARTICULAR ABILITIES; A SET OF SKILLS
OR EPISODES CONNECTED TO ONE PROFESSIONAL TASK.
From European Function profile.
The Core competences for neuroscience nurses are
• To provide professional neuroscience nursing care, based on
independent responsibility
• To co-ordinate an integral and coherent package of neuroscience
nursing care with one goal - continuity of care in the complete care
chain
• To set a good example ( role model) for (new) neuroscience nurses and
to teach and coach team members in functioning as care provider/ case
manager and develop individuals as well as the whole organisation
toward evidence based practice
• To design and develop a policy concerning nursing, care programs and
/or guidelines and protocols for neuro-patients, aimed at care
innovations and improvement of quality of care and to play a renewing
role in neuroscience nursing
• To advise on or to design and develop a policy concerning organisation
of care, ward management and institution policy and to become the
neuro patient’s advocate in organisation and management.
The aim for the project was to link roles and professional levels to
competences. In the next slide you can see how this was done.
Core competences 1-2 are linked to all levels and core competences 3-5
only to levels of proficient and expert. The role of care provider is
linked to all professional levels but only to key competence 1; thus the
role of case manager is also linked to all professional levels but only to
key competence 2. The role of Coach, teacher and supervisor is linked
to professional levels proficient and expert, but only to key competence
3. The role of planner/ practice developer is linked to professional levels
proficient and expert and to the key competences 4- 5.
This model gives a good tool for educators and planners to develop
education or neuroscience nursing courses. In addition, the model
facilitates individual nurses to assess their own professional
competence in neuroscience nursing and plan their own development
and education in the future.
The Neuroblend project also aims to develop the learning paths from a
competent neuro nurse toward an expert in neuroscience nursing. This path
toward expertise may vary a lot between the professionals and there is no
right or wrong way to achieve expertise. Formal education and experience in
practice is one possibility; but also the models which facilitate self directed
learning are needed, because to reach the level of an expert in neuroscience
nursing requires learning and reflection on own personal skills, knowledge
and competences. Learning means that you can develop your knowledge,
critical understanding and skills in neuroscience nursing. You should have an
ability to reflect critically on the knowledge base of the neuroscience
speciality and to use concepts and theoretical models. In addition, you should
train your ability to look at the problem from many different perspectives. To
be a successful expert, you have to be able to discuss your ideas with other
professionals, ask questions and communicate clearly about the issue under
consideration.
Expertise in neuroscience nursing
 is learnt by professional situations
 integrates education and practice
 is strengthening your motivation and career
 promotes critical thinking and problem solving skills
 can be achieved by blended learning paths and also by using virtual,
e-learning facilities
As the conclusion of this challenging project working I want to point issues for the future:
The professional expertise in neuroscience nursing goes through the steps
from novice to expert. A Clinical Nurse Specialist in Neuroscience Nursing is
an advanced practice nurse (APN) with graduate-level preparation as a
clinical expert in evidence-based nursing practice within a neuroscience
nursing. The CNS uses clinical expertise to influence patients/clients, nurses
and nursing practice, and the organization/system with a focus on providing
high quality and cost-effective care.
The challenges for neuroscience nursing in the future are:
- Ensuring appropriate access to neurological care for all patients.
- Advancing the art and science of neurology and nursing and thereby
promoting the best possible care for patients with neurological
disorders.
- Supporting and advocating for an environment which ensures ethical,
high quality neurological care.
- Providing excellence in professional education by offering a variety of
programs in both the clinical and nursing aspects of neurology, (add
neurosurgery?)and the basic neurosciences to other nurses and allied
health professionals
- Supporting clinical and basic research in the neuroscience nursing and
related fields.
- Developing evidence based care for neuro patients.
- Last but not least is to develop the model and tools how competences
of neuroscience nursing are recognised, assessed .and practised
The nursing profession must be developed as a career pathway, where the
specialities are recognised and the practice is evidence based. Neuroscience
nursing should be one of the specialities and career options for nurses and
that is why the role, competence and education of neuroscience nurses need
to be studied, discussed and defined among the nursing and the other health
professionals.
1. American Nurses Association. (2004) Nursing: Scope and Standards of Practice.
Washington, DC: Nursesbooks.org .
2. National Association of Clinical Nurse Specialists. (2004) Statement on Clinical
Nurse Specialist Practice and Education. 2nd ed. Pennsylvania: NACNS.
3. Snyder M, Mirr MP, Lindeke L, Fagerlund K, Avery M, Tseng Y. (1994) Advanced
practice nursing: an overview. In: Snyder M, Mirr M, eds. Advanced Practice Nursing:
A Guide to Professional Development. 2nd ed. New York: Springer; 1999:1-24.
4. Page NE, Arena DM. (1994). Rethinking the merger of the Clinical Nurse Specialist
and the Nurse Practitioner roles. Image J Nurs Scholarsh. 26:315-318.
5. Wells N, Erickson S, Spinella J. (1996). Role transition from Clinical Nurse Specialist
to Clinical Nurse Specialist/Case Manager. J Nurs Adm.;26:23-28.
6. Bullen M. (1995) The role of the specialist nurse in palliative care. Professional
Nurse 10(12), 755–756.
7. Miller S. (1995) The clinical nurse specialist: a way forward? Journal of Advanced
Nursing 22, 494–501.
8. McGee P., Castledine G. & Brown R. (1996). A survey of specialist and advanced
nursing practice in England. British Journal of Nursing 5(11), 682–686
9. Dunn L. (1997). A literature review of advanced clinical nursing practice in the
United States of America. Journal of Advanced Nursing 25, 814–819.
10. Royal College of Nursing (1988). Specialists in Nursing. RCN, London.
11. Wilson-Barnett J. & Beech S. (1994). Evaluating the clinical nurse specialist. A
review. International Journal of Nursing Studies 31(6), 561–571
12. Castledine G. (1982) The role and function of clinical nurse specialists in England
and Wales. Unpublished MSc dissertation. University of Manchester, Manchester.
13. Hamric A., Spross J. (1989). The Clinical Nurse Specialist in Theory and Practice.
Philadelphia. WB Saunders Company.
14. Hamric A., Spross J., Hanson C. (1996). Advanced Nursing Practice. An
Integrative Approach. Philadelphia: WB Saunders Company.
15. National Association of Clinical Nurse Specialists. (1998). Statement on Clinical
Nurse Specialist Practice and Education. Illinois: NACNS.
16. Gawlinski A, Kern LS, (19949) eds. The Clinical Nurse Specialist in Critical Care.
Philadelphia: Saunders;
17. Redekopp MA. (1997). Clinical nurse specialist role confusion: the need for
identity. Clin Nurse Specialist;11 (2):87-91.
18. Collins MS, Ferrario JA (1995). Role differentiation of the clinical nurse specialist
and nurse practitioner: its history, function, and future. In: Role Differentiation of the
Nurse Practitioner and Clinical Nurse Specialist: Reaching Toward Consensus.
Washington, DC: American Association of Colleges of Nursing;51-57.
19. Beecroft PC. (19959). The future arrives. Clinical Nurse Specialist 9 (1):1-7.
20. Cram E, Alpen M, Burger M, et al. (19969 Restructuring the clinical nurse
specialist position to a unit-based role. J Nurs Admininistration 26 (4):33-38.
21. Gurka AM. Transformational leadership: Qualities and strategies for the CNS. Clin
Nurse Specialist 1995;9 (3):169-174
22. Jury DL. Leading the change. Clin Nurse Specialist 1996;10 (5):215.
23. Loftus LA, McDowell J. (2000).The lived experience of the oncology clinical nurse
specialist. Int J Nurs Stud.37:513-521.
24. Gibson F, Bamford O. (2001). Focus group interviews to examine the role and
development of the clinical nurse specialist. J Nurs Manage. 9:331-342.
25. Hamric AB. (1992). Creating our future: challenges and opportunities for the
clinical nurse specialist. Oncol Nurs Forum 19(suppl 1):11-15.
26. Armstrong S, Tolson D, West B. Role development of acute nursing in Scotland.
Nurs Stand. 2002;16(17):33-38
27. Wong FKY. ( 2001). Senior Clinical Nurse Specialist pilot position in Hong Kong.
Clin Nurse Spec;15:169-176
28. Scott RA. (19999 A description of the roles, activities, and skills of Clinical Nurse
Specialists in the United States. Clin Nurse Spec.13:183-190
29. Ball C, Cox CL. (2003). Part One: Restoring patients to health-outcomes and
indicators of advanced nursing practice in adult critical care. Int J Nurs Pract.9:356367.
30. Clay T. (1987) Nurses: Power and Politics 1st edn. Heinemann Nursing, London.