Running head: THE CLINICAL NURSE SPECIALIST AND COLLABORATION
The Clinical Nurse Specialist and Collaboration
Lauren Walker
Georgetown University
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In the current health care system, patient’s increasing needs and outcomes drive the
advancement of nursing knowledge, skill, and goals. Within the health care system, the
Advanced Practice Nurse, is a key factor in the development of goals, education, and
priorities to help guide the health care team towards optimal patient outcomes. According
to Becker, Kaplow, Muenzen & Hartigan (2006), Advanced practice nursing is the application
of an expanded range of practical, theoretical, and research based therapeutics to phenomena
experienced by patients within a specialized clinical area of the larger discipline of nursing. The
Clinical Nurse Specialist (CNS) is an Advanced Practice Nurse who upholds many
characteristics that enhances practice and knowledge in the Acute and Critical Care setting.
The CNS is a registered nurse who holds a master’s or doctoral degree in nursing and has
expertise in a clinical nursing specialty. They are active through clinical practice and direct care
of patients, consultation, education, research, collaboration, and clinical leadership. The CNS
promotes excellence in nursing practice and serves as a role model as well as advocates for
nurses by providing leadership (McNamara, Lepage, & Boileau, 2011). The CNS practices
autonomously and integrates knowledge of disease and medical treatments into assessment,
diagnosis, and treatment of patient’s illness (Thompson, 2007). With in-depth knowledge, skills,
advanced judgment, and clinical experience, they assist in providing solutions for complex health
care issues at all levels. They are leaders in the development of clinical guidelines and protocols
and promote the use of evidence, provide expert support and consultation, and facilitate system
change (McNamara, Lepage, & Boileau, 2011). The CNS improves patient outcomes through
leading and interacting with nursing personnel, thereby improving nursing practice. They
provide leadership in advancing the practice of nursing to achieve quality and cost-effective
patient outcomes as well as provide leadership of multidisciplinary groups in designing and
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implementing innovative alternative solutions that address system problems and patient care
issues.
The Synergy Model drives the CNS’s actions and decisions as they are continually
challenged on the job. McKinley (2007), describes the core concept of the Synergy Model is the
needs or characteristics of patients and families influence and drive the characteristics of the
clinical unit or system. When patient characteristics and nurse competencies match, patient
outcomes are optimized. Patient characteristics include resiliency, vulnerability, stability,
complexity, resource availability, participation in care, participation in decision making, and
predictability. These characteristics are then matched with the nurse competencies including
advocacy and moral agency, caring practices, clinical inquiry, clinical judgment, collaboration,
facilitator of learning, response to diversity, systems thinking. The roles of the CNS are
currently described on the basis of three spheres of influence which include nurse to patients and
their families, nurse to nurse, and nurse to system. The Synergy Model aligns the eight patient
characteristics with the role of the CNS in the three spheres of influence (Becker, Kaplow,
Muenzen & Hartigan, 2006).
With the current complexity of the healthcare system, collaboration and communication
among healthcare professionals is increasingly important. Collaboration, a nursing characteristic,
is an important and valuable tool to use in the clinical setting and is critical for safe patient care
and pivotal to the success of the CNS role. According to McKinley (2007), collaboration is
working with others, including physicians, families, and other health care providers, in a way
that promotes and encourages each person’s contribution toward achieving optimal and realistic
patient goals. Collaboration leads to innovation through dividing responsibilities and new
activities between partners. The patient, family, and members of various health care disciplines
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work toward promoting the needs and requests of patients. Collaboration in the health care
setting is associated with a complementary learning process to draw on internal and external
expertise to support the learning process (McNamara, 2011). The CNS, along with the
interdisciplinary team, has the potential to provide problem-solving strategies beyond the
confines of each discipline’s perspective and expertise (Sievers & Wolf, 2006). According to the
Scope of Practice and Standards of Professional Performance for the Acute and Critical Care
Clinical Nurse Specialist, four measurement criteria guides the CNS in collaboration including
consultation and referral, interdisciplinary collaboration and coordination of patient care,
mentoring to nursing students and collaborating with nursing schools, and collaborating with
multiple disciplines in teaching, management, and research activities for quality patient
outcomes and healthy environment (McKinley, 2007). Skills used by the CNS, which are
necessary for effective collaboration, include clinical knowledge, social skills, communication,
negotiation and coordination.
The nurse to patient sphere in the Synergy Model is an important area for effective
collaboration by the CNS. McKinley (2007), states that clinical expertise, embedded in the
patient sphere of influence, is the foundation of CNS practice in the other two spheres of
influence. Within this sphere CNS is concerned for the functional status, behavioral changes,
satisfaction, comfort, and quality of life of the patient. They help note changes in physiological
status, presence or absence of complications, and the degree to which treatment objectives were
attained (Mckinley, 2007). The overall goal of care in this sphere is to directly affect the
accomplishment of cost-effective quality patient and family outcomes.
This semester, the CNS preceptor actively participates in the nurse to patient sphere by
creating evidence-based programs of care developed for specific patient populations and
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diagnosis. In the Neuroscience Intensive Care Unit (NSICU), the preceptor recognized a need
for standardized admission orders specific to the diagnosis of the patent. She took her clinical
knowledge and skill, researched the recent evidence and collaborated with the attending
physician and pharmacist to create admission order sets for patients diagnosed with a
Subarachnoid hemorrhage and intracerebral hemorrhage. The development of these orders
initiated quick intervention of the medical team to impact the outcomes of the patients through
evidence-based practice. The preceptor also demonstrated collaboration as an expert by
discussing, validating, and prioritizes diagnoses in collaboration with patients and family
members. Many days, the CNS will approach the patient and families in the Intensive Care Unit
(ICU) to introduce herself and role on the unit. Often, patients ask questions regarding their
diagnosis, prognosis and medical therapy. The preceptor will sit with the patient and their
families to have a discussion regarding progress, need for interventions and clarify questions and
concerns while supporting and validating the decisions of the medical and nursing team.
Lastly, the preceptor demonstrates collaboration in the nurse to patient sphere by
providing consultation and initiate referrals to other members of the multidisciplinary team to
facilitate optimal care. The preceptor recognizes that the nurse and physicians prioritize their
actions and decisions on the unit according to the needs of the patient and often other tasks are
overlooked. With the knowledge of progressive mobility and mobilization on the overall impact
of the patient, she will continue to demonstrate to her team how the maneuver is performed and
include early therapy consults for mobility to work towards optimal patient outcomes.
The second sphere of the Synergy Model is the nurse to nurse sphere where the nurse
uses their knowledge, skill and expertise to model and impact other nurses and clinical outcomes.
Collaboration in this sphere is demonstrated through mentoring nursing students in the area of
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CNS preparation and collaborate with other disciplines in teaching, consultation, management,
and research activities to improve outcomes in nursing practice and enhance the health care
environment (McKinley, 2007). This semester, the preceptor collaborates with Georgetown
University and The University of Phoenix to guide two Graduate Nursing Students in their
graduate education. The preceptor collaborates with the two universities to develop a plan of
study, establish goals and set priorities for the students. The preceptor then individualizes the
clinical experience for the students according to their personal goals and objectives. ]
The use of research and evidence based care influences the CNS actions on the unit. The
preceptor and graduate students collaborated with the nursing team to develop a standardized
method of documentation for sedated procedures. Through the use of the recent evidence,
JAHCO requirements and the hospital policy, the staff was presented and educated with the
updated sedated procedure form. Credentialing for the administration of moderate sedation was
also redeveloped by the graduate student and preceptor for physicians and nurses according to
the recent Anesthesiology guidelines, hospital policy and evidence based literature. The nursing
staff was then in-serviced and educated through discussions and a PowerPoint on their roles and
responsibility during the moderate sedation procedure.
The Nurse to System sphere is impacted significantly through CNS collaboration. The
CNS uses collaboration to improve the delivery of care and outcomes within the system. Within
the system the CNS upholds the mission, culture, and resources to implement change (McKinley,
2007). Through collaboration, they develop criteria for and evaluate the quality and
effectiveness of nursing practice and systems, participate in interdisciplinary efforts to address
costs, duplication, and barriers to goal attainment based on Quality Improvement data obtained
(McKinley, 2007). The CNS participates in and disseminates research to enhance practice as
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well as collaborate with senior investigators and members of the interdisciplinary team in
conducting research relevant to practice. The CNS is also seen collaborating with nurse leaders,
managers, educators, senior nursing staff.
The use of the collaboration by the CNS in the nurse to system sphere is evident to the
graduate student this semester. The preceptor became involved and included the graduate
student in a research study in the Neurosciences ICU. The study aim is to determine if the use of
hypothermic cooling for patients after a hemicraniectomy and increased intracranial pressure
improves outcomes compared to patients who remain normothermic after a hemicraniectomy and
increased intracranial pressures. To develop this study, the CNS first discussed the goals,
objectives and study aims with the attending physicians organizing the study. After IRB
approval was obtained, the preceptor and graduate student collaborated with medical records to
obtain patient records, a nursing colleague to understand the computer software used to store
data, as well as continue to work with the physicians for clarification and guidance during the
data collection. The outcomes of this study can have the potential to influence the care,
interventions and outcomes of patients in the future.
The hospital in which the preceptor works is currently constructing a new tower building
for the critical units and step-down critical care units. The preceptor is involved with planning
for the transition this upcoming fall. For the transition, the system has developed several
committees to help plan, train and safely move into the new units. The preceptor is a member of
the Training and Orientation team responsible for developing and delegating a system wide plan
for training staff on new equipment, flow of the units as well as system and unit based changes.
Members of this team include the Critical Care CNS, Patient Care Directors from Critical Care,
Short Stay Dialysis, and Step-Down Medicine, Human Resource representative as well as a
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consultant from Gilbane to help facilitate the upcoming move. Collaboration within this group is
essential to incorporate the knowledge from each participant to determine the greatest needs for
the units and develop a priority list for training for the transition.
The CNS also collaborates with nursing personnel and other health care providers to
identify needed changes in equipment or other products to enhance clinical outcomes and costeffectiveness. The NSICU is updating their ICU Bolt Monitoring device with an updated
catheter to monitor ICP. When the CNS was faced with ordering new cords for the current
system, she determined that the Hummingbird ICP device was the current best equipment to
detect and measure ICP. She evaluated the cost it would be to purchase the equipment as well as
compare it to the cost to order new cords and equipment for the current system. After the
evaluation, the costs for the new system were close to the cost of current equipment. To bring
this equipment into the NSICU, the preceptor collaborated with the physicians, Nurse
Practitioners and Physician Assistance to determine if this equipment was appropriate for the
care of their patients. After their approval the preceptor worked with Materials Management for
system approval of the equipment. After system approval, she organized a meeting with the
medical consultant from the company selling the Hummingbird. At this meeting, nurses who
would be using the device, nurse practitioners and physician assistants placing the device as well
as the CNS and Nurse Manager came together to learn about the equipment. The team was
educated on the device and then the preceptor, with the team, created a plan for education for the
staff and medical team. The team collaborated together to make a positive and effective system
change.
Collaboration is formally executed by the preceptor through organizations of meetings
with the multidisciplinary health care team as well as other members of the health care system.
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The meetings formally establish plans for outcomes, equipment, research opportunities, planning
for new units to open, and develop new policies, procedures and standards. Multidisciplinary
bedside rounding enables the CNS, physicians, nurses, respiratory therapist, pharmacists, and
students to meet with the patients and their family for an updated plan of care and medical
interventions. Informally, collaboration is seen through daily interactions. It is seen in the senior
nurse leader calling the preceptor for guidance regarding ACLS certification standards for all
telemetry nurses, or the preceptor calling a colleague to ask for help regarding a software
question. Simple and quick conversations of the CNS with other health care members or patients
help to guide the CNS decision making process to impact outcomes.
As a novice CNS it is imperative to use collaboration from the start to enhance outcomes.
According to McKinley (2007) the novice CNS needs to be willing to be taught, coached and
mentored by expert and competent CNSs through collaboration. The novice CNS should
participate in team meetings and discussions regarding patient care and practice issues as well as
open to various team members’ contributions. After the new CNS becomes more comfortable
with collaboration, they should seek opportunities to be taught, coached and mentored, elicit
others advice and perspectives, initiate and participate in tem meetings and discussions regarding
patient care and practice, and recognize and suggest various team participation. Although all
eight competencies are essential for contemporary nursing practice, each assumes more or less
importance depending on patient characteristics (Curley, 1998). While clinical judgment forms
the foundation upon which the other characteristics are built, it helps to drive the other CNS
characteristics (Gurzick & Kesten, 2010). Participating in collaboration is an essential step when
working with other health care members to expand knowledge, skill, and experience to improve
the system and optimize outcomes. Outcomes from collaboration within the system are seen
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through quality improvement standards, infection control rates, and patient satisfaction. Without
proper collaboration, and working together to combine thoughts and ideas, many components of
the Synergy Model would be impaired.
There are many barriers to the characteristic of collaboration. Since collaboration relies
heavily on the participation of all team members, it is imperative that everyone recognizes their
purpose for being included and responsibilities within the group. Otherwise, the group will not
benefit from all members that can impact change within the system. This semester, the graduate
student worked with the preceptor to educate the staff regarding a new ICP monitoring device.
When recognizing that the OR staff needed to be educated on the device, the preceptor first
attempted to contact the OR Educator. The OR Educator appeared offended and did not
welcome or give attention to the new piece of equipment on initial presentation. The graduate
student learned later that the OR Educator was recently turned down by the NSICU team
regarding a piece of equipment and her attitude was therefore negative towards other equipment.
Negative attitudes are a major barrier towards collaboration and working towards positive patient
outcomes.
Attitudes can certainly shape the outcomes of collaboration. When health care members
have a positive attitude towards a patient condition, an intervention, research, or implementation
of evidence based practice or equipment, it can stimulate and excite others within the group.
Individual supports include having a prearranged schedule, open communication, flexibility, and
respect for others (Sievers & Wolf, 2006). Support from the leadership team can also enhance
outcomes of collaboration. Recently the graduate student participated in a meeting of nurses,
managers and patient care directors tasked with redeveloping and standardizing the care of
central line catheters. The nurse manager excited the team by telling them that this is the time
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that the senior leadership is giving them the opportunity to change and impact how nurses
practice within the hospital. The team realized that they were being fully supported by the
system to impact practice and patient care. Collaboration is a necessary characteristic in which
the CNS can impact patients, nurses and the system through working with others to promote and
encourage each person’s contributions toward achieving optimal and realistic patient goals.
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References
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Curley, M. (1998). Patient-nurse synergy: Optimizing patient's outcomes. American Journal of
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Ecklind, M., & Stamps, D. (2002). The synergy model in practice, promoting synergy in
progressive care. Critical Care Nurse, 22(4), 60-66.
Gurzick, M., & Kesten, K. (2010). The impact of clinical nurse specialists on clinical pathways
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