Clinical nurse specialist

A clinical nurse specialist (CNS) is an advanced practice registered nurse, with graduate preparation (earned master's or doctorate) from a program that prepares CNSs. According to the APRN Consensus Model for Regulation (2008) "The CNS serves a unique APRN role in integrating care across the continuum and through three spheres of influence: patient, nurse, system. One of the key elements of CNS practice is to create environments through mentoring and systems change that empower nurses to develop caring, evidence-based practices, alleviate patient distress, facilitate ethical decision-making for nurses, patients, families and systems, respond to diversity and serve as a strong patient advocate in order to facilitate quality and patient safety. The CNS assists patients and families to navigate a complex healthcare system from wellness through complex, acute states of illness to a peaceful death. From a systems perspective this environment encompasses the continuum of wellness-illness from home care to tertiary care and all systems and agencies of the practice environment" (p.7). CNSs are clinical experts in a specialized area of nursing practice and in the delivery of evidence-based nursing interventions.[1]

A recent systematic review concluded that utilizing CNSs in a hospital setting reduced length of stay and costs of care while improving patient outcomes. [2]



CNSs work with other nurses to advance their nursing practices, improve outcomes, and provide clinical expertise to effect system-wide changes to improve programs of care. CNSs work in specialties that are defined by one of the following categories:

  • Population (e.g., pediatrics, geriatrics, women’s health)
  • Setting (e.g,. critical care, emergency room)
  • Disease or Medical Subspecialty (e.g., diabetes, oncology)
  • Type of Care (e.g., psychiatric, rehabilitation)
  • Type of Problem (e.g., pain, wounds, stress)

Spheres of influence

There are three domains of CNS practice, known as the three spheres of influence (NACNS 2004):

  • Patient
  • Nursing personnel
  • System (healthcare system)

The three spheres are overlapping and interrelated, but each sphere possesses a distinctive focus. In each of the spheres of influence, the primary goal of the CNS is continuous improvement of patient outcomes and nursing care.

Core competencies

Within the three spheres of CNS practice, Sparacinio (2005)[3] identified seven core competencies:

  1. Direct clinical practice includes expertise in advanced assessment, implementing nursing care, and evaluating outcomes.
  2. Expert coaching and guidance encompasses modeling clinical expertise while helping nurses integrate new evidence into practice. It also means providing education or teaching skills to patients and family.
  3. Collaboration focuses on multidisciplinary team building.
  4. Consultation involves reviewing alternative approaches and implementing planned change.
  5. Research involves interpreting and using research, evaluating practice, and collaborating in research.
  6. Clinical and professional leadership involves responsibility for innovation and change in the patient care system.
  7. Ethical decision-making involves influence in negotiating moral dilemmas, allocating resources, directing patient care and access to care.

Although these core competentcies have been described in the literature they are not validated through a review process that is objective and decisive. They are the opinion of some within the profession. A set of core competencies has now been described and validated through a consensus process (2008) that clearly defines the spheres of influence, the synergy model and the competencies as defined by Sparacino (2005). These core competencies are now expected to be used in all educational programs and will be revised in the coming years in order to be maintained as current and reflective of practice.

International perspectives

Historically, in North America, the CNS role developed within the acute care (hospital) setting.[3] Currently, in addition to the traditional acute care setting, CNSs practice in a variety of non-acute care settings.

In the Australian Health System, however, a clinical nurse specialist refers to a promotional position, rather than a qualification.


  1. ^ [1] What is a CNS?
  2. ^ Newhouse, Robin; Julie Stanik-Hutt, Kathleen M. White, Meg Johantgen, Eric B. Bass, George Zangaro, Renee F. Wilson, Lily Fountain, Donald M. Steinwachs, Lou Heindel, Jonathan P. Weiner (September/October 2011). "Advanced Practice Nurse Outcomes: 1990-2008: A Systematic Review". Nursing Economic$ 29 (5). Retrieved 16 August 2011. 
  3. ^ a b Sparacino, P. S. A. (2005). The clinical nurse specialist. In A. B. Hamric, J. A. Spross & C. M. Hanson (Eds.), Advanced practice nursing: An integrative approach (3rd ed., pp. 415–446). St. Louis: Elsevier

See also

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