Running head: THE CLINICAL NURSE SPECIALIST AS A FACILITATOR OF LEARNING
The Clinical Nurse Specialist as a Facilitator of Learning
Lauren Walker
Georgetown University
THE CLINCIAL NURSE SPECIALIST AS A FACILITATOR OF LEARNING
2
Today’s health care is continually changing with patient demands becoming more
complex. As these clinical situations become more demanding, it is necessary for health care
professionals to keep up with the patient needs by initiating standards of practice and model best
practice behaviors. The Clinical Nurse Specialist (CNS) is an excellent partner to help initiate,
educate, model and provide resources to fit the demands of complex patients. Zuzelo (2010),
states that the practice area for acute and critical care is defined not by the physical location but
by rather by the dynamic interaction between acute and critically ill patients and family, the
caregiver and the health care environment.
While adapting to a complicated health care system to fit the demands of its patients, new
graduate nurses are many times hired to help staff the hospital. They therefore increase the
complexity of the complicated orientation and educational needs of critical care staff. During
training, the nurse educator would be focused on general staff orientation, mandatory updates
and be a regulator for the requirements for education. The educational role of the CNS expands
the educator role and is the facilitator of educational experiences (Zuzelo, 2010). Facilitator of
learning is the ability of the CNS to use the self to facilitate patient’s learning (Curley, 1998).
The CNS recognizes that it is necessary to apply adult learning principles, which promotes the
value of lifelong learning and evidence based practice, enables a logical and relative experience
that is related to learner’s practice (Kesten, 2012). Through these principles of adult learning,
facilitated education by the CNS is relevant to the new graduate nurse as they build on previous
knowledge and experience and can readily apply new knowledge into practice. This knowledge
is in manageable increments and enables the new nurse to implement new knowledge and skill
into practice.
THE CLINCIAL NURSE SPECIALIST AS A FACILITATOR OF LEARNING
3
The use of case-studies as a learning tool by the CNS also helps to facilitate effective
critical thinking and problem solving skills and uses the adult learning principles. A trauma
fellowship was developed by the preceptor CNS and graduate student for a group of new
graduate nurses in the Trauma ICU. Six case studies were developed for the program in which
the nurses worked together to interpret, discuss, plan and implement care for the proposed
patient. The case study changes the focus of teaching to learning as the nurses were able to take
control of their learning and implement it into practice. With a need for a CNS intervention, the
CNS will develop expected outcomes for clinical practice, facilitates a plan, formal or informal,
according to specific learning styles, develop simulations and provide an opportunity for
evaluation.
The CNS, who possesses the skills and knowledge necessary to be an effective facilitator
of learning, encompasses the ability to facilitate learning for nursing staff, patients, physicians,
and other health care teams through formal and informal learning (Zuzelo, 2010). As a formal
expectation of the CNS, they are able to define level of current practice, desired level of current
practice, identify gaps within the system, determine interventions, and help to translate new
knowledge into practice. The CNS is always assessing learning needs and wants of the staff
through formal needs assessments, competency certification, as well as annual evaluations of
staff.
An informal role of the CNS is evident through the assessment of learning needs through
every CNS interaction at the bedside, role-modeling excellent care and service, precepting and
through direct patient care. For example, this semester the preceptor and graduate student make
daily rounds with patients and staff on the unit. A staff had approached the CNS regarding the
complications of a chest tube. Through a discussion and hands on teaching session, the CNS was
THE CLINCIAL NURSE SPECIALIST AS A FACILITATOR OF LEARNING
4
able to evaluate the knowledge and skill of the nurse as well as develop a plan to enhance her
level of skill and knowledge. Informally, the nurse therefore seeks out the CNS for need for a
nursing process, resource, and expert knowledge and skill. Zuzelo (2010), stated that
demonstrating applied clinical expert knowledge and problem-solving skills in real-time, greatly
impacts the development of staff. Through the process of reflective thinking, the nurse pauses
and thinks about the chest tube policy and management, interventions and role during care.
As a novice CNS, the graduate student must recognize that the CNS’s level of expertise
as a facilitator of learning develops overtime with experience, personal education, mentoring and
experimentation (Curley, 1998). Graduating with a Certificate in Nursing Education, the
graduate student has developed skills and practice of education with lectures, facilitation of
online programs, and the development of educational resources. This clinical experience and
background will help develop a smooth transition from education to clinical facilitation in the
novice position as a CNS. Orientation to the CNS role will also be effective by working with an
experienced peer. If there is another CNS within the organization, it is very beneficial to see
how they structure programs and practice as an Advance Practice Nurse as well as be able to turn
to them for help, advice and model behavior. It is also necessary for the novice CNS to become
involved in their professional organizations as well as have a heightened awareness of their unit
and their needs, but also be knowledgeable of resources to utilize within the organization as well
as appropriate resources to use outside the organization (Cohen et al., 2002).
The CNS is described as an expert clinician, consultant, educator and researcher. They
intervene on an individual patient and family level, a nurse-nurse level and a system level. The
Synergy Model was introduced as a way of linking certified practice to patient’s outcomes as
well as serve as a framework for CNS responsibilities. The model describes how nurses practice
THE CLINCIAL NURSE SPECIALIST AS A FACILITATOR OF LEARNING
5
on the basis of the needs and characteristics of patients and the demands of the healthcare
environment predicted for the future. Patient characteristics drive the nurse competencies and
when the characteristics of a patient and the competencies of a nurse match and synergize,
patient’s outcomes are optimized (Cohen et al, 2002). Because of the CNS spheres of influence
have evolved, so too must our conceptualization of its role dimensions (Maloney-Harmon,
1999). To fully implement the role of facilitator of learning, it is imperative to utilize the
Synergy model and its three spheres of influence to ensure the unique contributions of the CNS
to provide cost effective outcomes (Gurzick & Kesten, 2010). The facilitator of learning will be
utilized within the spheres of the Synergy Model from nurse to nurse, nurse to patient and nurse
to system by the CNS.
As educational needs are recognized, the CNS determines if the needs are related to a
specific unit or a more global span of the hospital (Cohen et al., 2002). The CNS must have
expert knowledge and skill in the assessment, differential diagnosis, and treatment of illness and
disseminate this knowledge to their medical team. As stated by Zuzelo (2010), clinical expertise,
embedded in the patient and client sphere of influence, is the foundation of CNS practice in the
other two spheres. The overall goal of care within this sphere is to directly affect the
accomplishment of cost-effective quality patient and family outcomes (Zuzelo, 2010). Kesten
(2012), states that education is to increase the competence and confidence of clients for self
management and patient education enhances quality of life, anxiety, and independence. To
model facilitator of learning in the nurse to patient sphere, the preceptor engages herself in her
patients. Daily, she visits patients and participates in their care. Many times the CNS is a
friendly face offering support and making sure needs and concerns are addressed. She also helps
THE CLINCIAL NURSE SPECIALIST AS A FACILITATOR OF LEARNING
6
to connect and provide patients and their families with proper resources and education according
to their individual needs.
To facilitate this patient awareness and support as a new CNS, the graduate student will
help with accurate patient diagnosis based on multiple sources of data, develop measurable
outcomes with interventions, work towards prevention, alleviation, and/or reduction of
symptoms, work towards prevention of unintentional consequences, develop, implement, and
evaluate innovative educational programs for patients, families, and group, and disseminate
knowledge of new data and information through interventions and presentations. The preceptor
this semester continues to emphasize the importance of being a facilitator with the new graduate
nurses during their orientation period. Many times, she wants to fully utilize the primary new
graduate preceptor to build their nursing skills and critical thinking. As a CNS, she approaches
each preceptor and new graduate as a resource to help clarify questions, concerns, and model
good nursing practice.
In the nurse to nurse sphere, the CNS bridges the gap between clinical practice and
research and my translating research findings into practice (Gurzick & Kesten, 2010). In the
nurse to nurse sphere the CNS also works to advance the practice of nursing and improve patient
outcomes through updating standards of care and developing best practice models of care that
direct the actions of nurses and nursing practice (Curley, 1998). The CNS will provide
leadership and consultation expertise to nursing staff and other health professionals in the
implementation of evidence-based practice. While working with the nursing staff, it is also
important for the CNS to practice honesty, communication skills, positive self-regard,
confidence, and willingness to take risks (Zuzelo, 2010).
THE CLINCIAL NURSE SPECIALIST AS A FACILITATOR OF LEARNING
7
Outcomes of effective CNS practice in the nurse to nurse sphere of influence includes
identifying knowledge and skill development needs of nurses, using and disseminating evidencebased practices, nursing care interventions and knowledge that have an evidence base, nurses
who can articulate their unique contributions to nurse-sensitive outcomes and patient care, nurses
who are empowered to solve patient care problems, as well as engaging nursing in learning
experiences that enhance competence and providing educational programs that advance the
practice of nursing (Zuzelo, 2010). Through the nurse to nurse sphere, the novice CNS will use
the nursing process to assess, plan, implement and evaluate (Kesten, 2012). Through this
process, a needs assessment will be used to determine how to best support the staff as well as
implement needed changes in equipment to enhance outcomes.
The CNS exemplifies facilitator of learning through the nurse to nurse sphere on a
continual basis. During a conversation with the graduate student, she explained that a majority
of her role is being “the nurse’s nurse”. Through this statement, the CNS demonstrates her
support of her nurses by making daily bedside rounds with the staff to provide an extra hand with
difficult interventions and patient conditions or help guide her nurses through a code situation.
She will also make herself available to clarify clinical questions and concerns. A nurse came to
the CNS with a question regarding the use of a specific monitor. Not only did the CNS go to the
bedside to demonstrate proper usage of the monitor, but she also did an online review of the
recent evidence based practice standards of the monitor use and indications for use in the clinical
setting to provide and discuss with the nurse.
The last sphere of influence in the Synergy Model is the nurse to system influence where
the CNS will help to function as a change agent. The CNS will contribute to and advance the
knowledge base of the healthcare community through presentations, publications and
THE CLINCIAL NURSE SPECIALIST AS A FACILITATOR OF LEARNING
8
involvement in professional organizations (Maloney-Harmon, 1999). The outcomes of CNS
work in the nurse to system sphere includes articulation of clinical problems within the context
of the organization mission, culture, policies, and resources, providing a patient care process that
reflects continuous improvements that benefit the system, implement changes to strategies that
benefit the system, develop policies that enhance the practice of nurses within the context of
multidisciplinary teams, use evidence based practice medicine for the development of the system
as well as implement patient care programs that are aligned with system mission, goals and
priorities (Zuzelo, 2010). The CNS role and responsibility to contribute to the continuous
improvement of the system as well as having the ability to guide the multidisciplinary team to
address best practice standards from the literature as well as establishing cost-effectiveness is an
essential quality within the nurse to systems sphere (Gurzick & Kesten, 2010).
The CNS demonstrates the sphere of nurse to system for the graduate student often. The
CNS actively engages in the development of new order sets on the units. Recently, the CNS
developed an order-set for the admission of a patient with a Subarachnoid Hemorrhage to the
Neurosciences ICU. For this order set, she did an in-depth review of the diagnosis, treatment
and outcomes. She collaborated with her multidisciplinary team to review orders and met with
the pharmacy to determine the optimal drug dosages for the diagnosis. Once developed, she
facilitated the importance of the forms and how to use them in the clinical setting. With her
expert knowledge and experience, she was able to help facilitate and expedite patient admissions
to quickly initiate the best evidence based care for these patients. Not only has she developed
new order-sets for each unit, but the CNS actively engages in the development and revision of
policies and flow sheets according to new research and clinical evidence.
THE CLINCIAL NURSE SPECIALIST AS A FACILITATOR OF LEARNING
9
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). Being a facilitator of learning is
an essential step in expanding knowledge and skill of the staff, improving the system and
optimizing outcomes. Without this essential step in the nursing process and Synergy, outcomes
may struggle. Through the process of being a facilitator of learning, the CNS may need to also
utilize the other characteristics of the Synergy Model to collaborate with other professionals, be
an advocate for their patient’s and team as well as use clinical inquiry to develop best practice
standards.
There are many barriers to the CNS as a facilitator of learning in the clinical setting.
Many times the CNS verbalizes that she does not want to cross the professional line between her
and staff. She does not want to give the impression of hovering over their work or make it
appear as if she is “looking over their shoulders”. She wants to be available to help and facilitate
information without overwhelming them. Another barrier is that if a clinical dilemma has
happened or a nurse has made a clinical mistake, often a physician or manager comes straight to
the CNS before investigating the cause, and demands that there needs to be re-education. The
CNS has to first determine the cause of the situation and determine if it was a cause from a nurse
knowledge or skill deficit, a system protocol was not followed or understood and then take the
proper actions to address the cause. Another significant barrier to the CNS as a facilitator of
learner is that the CNS verbalizes that she often needs to justify her position in facilitation and
need for an intervention. With systems working towards positive outcomes and budgeting
concerns, it is imperative that objectives are made and often work approved before
THE CLINCIAL NURSE SPECIALIST AS A FACILITATOR OF LEARNING
10
implementation by the CNS. By working through barriers in the role as a facilitator of learning
as well as incorporating the other characteristics and spheres of the Synergy Model, the CNS can
be an effective champion for change within the healthcare system.
THE CLINCIAL NURSE SPECIALIST AS A FACILITATOR OF LEARNING
11
References
Cohen, S., Crego, N., Cuming, R., & Smyth, M. (2002). The synergy model and the role of the
clinical nurse specialists in a multihospital system. American Journal of Critical Care, 11(5).
Curley, M. (1998). Patient-nurse synergy: Optimizing patient's outcomes. American Journal of
Critical Care, 7(1).
Gurzick, M., & Kesten, K. (2010). The impact of clinical nurse specialists on clinical pathways
in the application of evidence-based practice. Journal of Professional Nursing, 26(1), 42-48.
Moloney-Harmon, P. (1999). The synergy model, the contemporary practice of the clinical nurse
specialist.
Zuzelo, P. (Ed.). (2010). The clincial nurse specialist handbook (Second ed.). Philadelphia,
Pennsylvania: Jones and Bartlett.