AACN Advanced Critical Care Volume 26, Number 1, pp. 50-57 © 2015 AACN
Role of the Clinical Nurse Specialist in the Journey to Magnet Recognition M. Dave Hanson, RN, MSN, ACNS-BC, NEA-BC
ABSTRACT Clinical nurse specialists (CNSs) work with and through other nurses as well as interprofessional team members to advance nursing practice, improve outcomes, and provide clinical expertise to effect system-wide changes to improve programs of care. They practice across the continuum and through 3 spheres of influence, encompassing the patient, nurse, and system. Clinical nurse specialists possess expertise in developing and refining structures, strategies, and processes to optimize outcomes at both the unit (micro) level and
the organization or system (macro) level. This unique vantage point positions CNSs as ideal individuals to assume several key roles when a health care organization makes the decision to embark on the Magnet journey and to maintain Magnet recognition. The competence and competencies of CNSs and a health care organization’s desire to achieve and/or maintain Magnet recognition represent a synergistic match. Keywords: clinical nurse specialist, Magnet journey, Magnet recognition, role
Magnet Overview Since 1994, when the first Magnet award was bestowed on the University of Washington Medical Center in Seattle, more than 400 health care organizations have become Magnet-recognized in the United States, Lebanon, Saudi Arabia, Singapore, Australia, and New Zealand. Magnet is thought to be the highest level of recognition a health care organization can achieve for excellence in nursing services.1 Today, both US News & World Report and the Leapfrog Hospital Survey use ANCC Magnet recognition as an indicator in determining the quality of care
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he American Nurses Credentialing Center’s (ANCC’s) Magnet Recognition Program “recognizes health care organizations for quality patient care, nursing excellence and innovations in professional nursing practice.”1 The journey to successfully becoming a Magnet-recognized health care organization requires unwavering commitment and collaboration from the boardroom to the bedside. Many individuals are involved in achieving the goal of Magnet recognition, including the clinicians providing quality care as well as those individuals tasked with developing structures, processes, and measuring outcomes of care delivery. Clinical nurse specialists (CNSs) are uniquely qualified to assume several key leadership roles in the Magnet journey. This article examines why CNSs are well suited to make significant contributions to an organization’s journey toward Magnet recognition as well as the various Magnet-related roles that align with the skills and competencies of CNSs.
M. Dave Hanson is Regional Director, Professional Practice and Clinical Standards, Providence Health & Services Southern California, Douglas & J. Glass Family Center, 5315 Torrance Blvd, Ste B-2, Torrance, CA 90503 (davehanson@ prodigy.net). The author declares no conflicts of interest. DOI: 10.1097/NCI.0000000000000068
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lapping and interrelated spheres of influence, involving the patient, nurse, and health care system.6 In each of the spheres of influence, the primary goal of the CNS is continuous improvement of patient outcomes and nursing care. Clinical nurse specialists work with and through other nurses and health care team members by mentoring and advancing system changes, with the ultimate goal of creating and sustaining environments of excellence. “Within the 3 CNS spheres of influence are 7 core competencies that are intended to guide the practice of individual CNSs and delineate contributions CNSs make to the health and welfare of the public, as well as link the expectations of CNS practice to health care organizations employing these APRNs.”7 The 7 CNS core competencies and associated performance outcomes are depicted in Table 1.
Figure 1: The American Nurses Credentialing Center Magnet Recognition Program Model. ©2013 American Nurses Credentialing Center. All rights reserved. Reproduced with the permission of the American Nurses Credentialing Center. This figure is available in color in the article on the journal website, www.aacnadvancedcriticalcare.com, and the iPad.
Role of the CNS in Achieving and Sustaining Magnet Recognition Anecdotal feedback from many CNOs indicate that CNS practice is indispensable in providing the clinical expertise, leadership, and system organizational influence necessary for achieving and sustaining ANCC Magnet recognition. Because CNSs possess the ability to influence practice in 3 overlapping and interrelated spheres, this APRN role is uniquely qualified to assume numerous key roles in the journey to Magnet recognition. “The basis for optimizing practice changes and sustained process improvement, the underpinning of Magnet recognition, is solidly grounded in the combined educational preparation and systems impact of CNS practice.”9 For organizations contemplating and sustaining the coveted Magnet recognition, the engagement and leadership of CNSs throughout the journey are a strategic investment likely to yield a positive organizational return on investment. The various Magnet roles that align with the CNS role are framed according to CNS core competencies.
consumers can expect to receive.2 The ANCC Magnet Recognition Program advances 3 goals within health care organizations: • Promotion of quality in a setting that supports professional practice • Identification of excellence in the delivery of nursing services to patients/residents • Dissemination of best practices in nursing services The current ANCC Magnet Recognition Program Model (Figure 1) introduced in 2008 configures the 14 Forces of Magnetism from the previous framework into 5 Model Components in an attempt to provide greater focus on measuring outcomes, while allowing more streamlined documentation.3 Many individuals play an integral role in the Magnet journey, including staff nurses, managers, directors, educators, advanced practice registered nurses (APRNs), and chief nursing officers (CNOs). Results of a study published in 2009 revealed that “CNSs were employed in 87% of Magnet-recognized facilities and of those, 88% indicated CNSs were important in achieving Magnet recognition and 92% indicated CNSs were important in maintaining Magnet recognition.”4
Consultation
“Administrators recognize CNSs have a compelling role as consultants and resources for expert practice as well as the unique capability to influence sustainability by navigating the complexity in organizations.”4 Inherent in CNS practice is clinical expertise and subsequently the skill of consultation. Clinical nurse specialists contribute to the Magnet recognition
Overview of the CNS Role Clinical nurse specialists are APRNs with master’s or doctorate educational preparation in nursing.5 The CNS scope of practice encompasses 3 over51
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Table 1: Clinical Nurse Specialist Core Competencies and Associated Performance Outcomesa Core Competency
Associated Performance Outcome
Direct care
Direct interaction with patients, families, and groups of patients to promote health or well-being and improve quality of life. Characterized by a holistic perspective in the advanced nursing management of health, illness, and disease states.8
Consultation
Patient, staff, or system-focused interaction between professionals, in which the consultant is recognized as having specialized expertise and assists consultee with problem solving.8
Systems leadership
The ability to manage change and empower others to influence clinical practice and political processes both within and across the system.8
Collaboration
Working jointly with others to optimize clinical outcomes. The CNS collaborates at an advanced level by committing to authentic engagement and constructive patient, family, system, and population-focused problem solving.8
Coaching
Skillful guidance and teaching to advance the care of patients, families, groups of patients, and the profession of nursing.8
Research
The work of thorough and systematic inquiry. Includes the search for, interpretation of, and use of evidence in clinical practice and quality improvement, as well as active participation in the conduct of research.8
Ethical decision making, moral agency, and advocacy
Identifying, articulating, and taking action on ethical concerns at the patient, family, health care provider, system, community, and public policy levels.8
a Adapted with permission from Clinical Nurse Specialist Core Competencies Executive Summary 2006–2008. ©2010 National CNS Competency Task Force.
journey through provision of consultation to staff nurses, medical staff, and other professionals. When clinical needs of complex patients are identified by the health care team, the CNS initiates appropriate consultation to prevent or manage problems and facilitate progress along the care continuum. For example, a critical care staff nurse caring for a patient with postoperative complications following gastric bypass surgery consults the CNS because the current pharmacological opioid treatment regimen is ineffective in keeping the patient comfortable. The CNS intervenes by conducting a thorough patient assessment and evaluation of the quantity of pharmacological agents used since admission to the critical care unit, as well as the overall patient’s response to treatment. Using these objective data, the CNS consults the clinical pharmacist and intensivist to devise an effective patient-centered pain management plan, including both pharmacological and nonpharmacological interventions. The CNS tracks and analyzes data from consultations with the goal of developing and revising practice guidelines and standards. This expert consultation by the CNS is integral
to achieving many of the empirical outcomes that ultimately result in a successful Magnet recognition. The CNS also makes consultative contributions for collecting various Magnet sources of evidence, telling the story of the organization, and meeting data display requirements outlined in the Magnet document submission process. Another important area in which the CNS provides consultation is the assistance and support in writing and editing the Magnet application document. Many CNSs bring experience in writing for peer-reviewed publication, making this APRN role ideally suited to provide writing and editing consultation to optimize an organization’s Magnet document submission. Systems Leadership
The skill of the CNS to engage and empower clinicians at the unit and department levels and then facilitate best practice across the organization or system is transformative in the Magnet journey. Clinical nurse specialists are adept at performing system-level assessments to identify variables that influence practice and outcomes. They then evaluate assessment findings 52
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to determine effective system interventions for changing clinician and team behaviors necessary for adopting evidence-based practices (EBPs) and improving outcomes. An example of systems leadership involves the CNS creating standardization of patient care services across the organization to ensure that the same quality of care is provided wherever the patient enters the system. This ability to influence practice, build strategic partnerships, and improve outcomes across the system is vital in helping the organization meet and exceed performance targets of the NDNQI (National Database of Nursing Quality Indicators) nursing-sensitive indicators. The nursing-sensitive indicators are a major aspect of the Magnet journey, and achieving the targets is considered an absolute for an organization to achieve and maintain Magnet recognition. Another significant systems leadership contribution made by the CNS in the Magnet journey is overall management of this highly strategic organizational initiative. Ultimately, the CNO is accountable for the Magnet journey, but typically the journey is managed by the Magnet program director (MPD). Clinical nurse specialists demonstrate knowledge and skill influencing practice at the system and organization level, which makes CNSs capable of assuming the role of leading the Magnet journey as an MPD.
process. With the 5 Magnet components as a guiding framework, Table 2 outlines some specific focus areas of CNS responsibility when serving in the MPD role. Collaboration
The cornerstone role of CNS practice is that of a collaborator. Clinical nurse specialists are leaders when it comes to establishing, improving, and sustaining collaborative relationships that promote patient safety and clinical excellence. Clinical nurse specialists have long understood that health care is less focused on individual achievement and more about the whole team. The needs of patients are optimized when consistent and purposeful interprofessional collaboration occurs. The CNS is uniquely prepared and positioned to make this vision a reality. In the Magnet journey, the role of the CNS as a collaborator is critical in organizations achieving many of the benchmark empirical patient outcomes, such as those related to falls, hospital-acquired pressure ulcers, and patient satisfaction. Successfully meeting benchmarks of these clinical quality foci requires the CNS to work in, through, and across all interprofessional teams to create and sustain lasting improvements. For example, to eliminate ventilator-associated events, the CNS might work in collaboration with medical staff, acute and critical care nurses, assistive personnel, respiratory therapists, and infection control practitioners to develop and consistently implement an effective oral care protocol during mechanical ventilation. The CNS understands that collaboration necessitates ongoing vigilance and nurturing, supported by formal structures and processes that foster joint skilled communication and effective decision making. The potential of each individual team member, as well as the collective capacity of the team, to flourish is directly linked to the degree of collaboration and teamwork. Poor collaboration has an overwhelmingly negative impact on numerous performance indicators, including patient and family satisfaction, patient safety and outcomes, professional staff satisfaction, nurse retention, and health care cost.10,11 The CNO looking to mitigate the potential for such adverse outcomes conducts an organizational assessment and deploys CNSs in high-risk, problem-prone patient populations and clinical areas to influence practice as a clinical expert and interprofessional collaborator.
CNS as Magnet Program Director
The role of an MPD is similar to the role of a project manager in that the MPD has responsibility for assessing, planning, organizing, implementing, motivating, and allocating necessary resources to achieve Magnet recognition. This role is imperative to a successful Magnet journey and requires a seasoned individual with knowledge and skills for managing an organizational initiative of such strategic magnitude. Because CNSs are educated to influence and lead at the system level, this APRN role is an ideal match for the MPD role. As an MPD, the CNS is responsible for oversight, direction, and management of the Magnet journey, with accountability for implementing the nursing strategic plan tactics related to attaining and maintaining Magnet recognition, as well as ensuring that the organizational milieu reflects internalization of the 5 components of Magnet. The CNS in this role assumes responsibility for coordination of the Magnet application, designation, and redesignation 53
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• Direct development of a systemwide PPM • Evaluate patient care delivery model • Oversee standardization of nursing job descriptions and competencies to reflect PPM and patient care delivery model • Evaluate NPR process to ensure ongoing effectiveness and relevancy • Serve as a liaison to APRN Council • Build and sustain interprofessional partnerships that provide opportunities for communication, collaboration, and effective decision-making among members of health care team
• Manage and facilitate Shared Governance Councils • Develop structure for nursing involvement in community • Annual evaluation of professional development reimbursement policies related to tuition, specialty certification and conferences • Track progress toward goals related to numbers of nurses with higher degrees and specialty certifications • Collaborate with Professional Development Department to allocate resources for academic affiliations • Oversee implementation and annual evaluation of Clinical Ladder Program
• Authentically role model the vision for Magnet and actively engage others throughout the Magnet journey • Organizational resource and point person for all things Magnet-related • Partner with CNO to develop Nursing Strategic Plan • Develop and oversee implementation of nursing leadership development program (in partnership with Professional Development Department) • Develop and implement a quarterly nursing newsletter • Coordinate Nursing Annual Report
• Ensure effective implementation of nursing research • Develop annual targets for involvement in nursing research • Coordinate with Professional Development Department on the education plan for nurses related to evidence-based practice and nursing research • Partner with Information Services to optimize nursing informatics structure and support • Direct nurse-initiated innovation initiatives such as Transforming Care at the Bedside and Clinical Scene Investigator Academy
New Knowledge, Innovations & Improvements Component
• Develop Nursing Dashboard composed of nursing sensitive quality indicators and other Magnet-related goals • Monitor Magnetrelated outcomes and collaborate with stakeholders to develop action plans that address gaps • Oversee collection and submission of key nursing outcome indicators • Coordinate all document submissions and demographic reports to ANCC Magnet Recognition Program
Empirical Outcomes Component
Abbreviations: ANCC, American Nurses Credentialing Center; APRN, advanced practice registered nurse; CNO, chief nursing officer; NPR, nursing peer review; PPM, professional practice model.
Exemplary Professional Practice Component
Structural Empowerment Component
Transformational Leadership Component
Table 2: Example Responsibilities of Clinical Nurse Specialists Serving in the Magnet Program Director Role
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This strategic move by the CNO can better position the organization for a seamless and successful Magnet journey.
as the requisite to increase the number of certified nurses throughout the organization. Clinical nurse specialists contribute to the Magnet journey by promoting the vision of an educated nursing workforce and showcasing the growing body of research affirming the positive relationship between a more highly educated nursing workforce and clinical outcomes such as patient morbidity, mortality, and failure to rescue. As a clinical expert, teacher, and researcher, the CNS is viewed as a role model for staff nurses, which allows the CNS to easily segue to the role of a career coach for the purpose of advising nurses about various options for advancing academic progression, availability of nursing specialty certifications, and other avenues for evolving professional development.
Coaching
Coaching as a core CNS competency is defined as the “skillful guidance and teaching to advance the care of patients, families, groups of patients, and the profession of nursing.”8 Clinical nurse specialists have a rich history of working with staff nurses to build and advance their foundational skills, with the goal of performance improvement. In the role of a clinical coach, the CNS supports staff nurses to expand and deepen their clinical knowledge and leadership skills, with the goal of improving the quality of patient care. In addition, the CNS fosters professional growth and development of staff nurses by serving in the role of a career coach and advisor. For example, a seasoned critical care staff nurse in the medical intensive care unit will soon be serving as a new chair of the unit-based practice council and is not feeling confident in leading this team. The staff nurse seeks guidance from the CNS, who begins one-on-one coaching with the staff nurse on leading and facilitating teams. An overarching theme of the Magnet journey is the adoption and advancement of evidence-based nursing practices. The work by the CNS to grow the knowledge and clinical skills of staff nurses is directly linked to the attainment and maintenance of evidence-based nursing practice. Clinical nurse specialists understand that a successful Magnet journey depends on identifying nurses who have the capacity to help in establishing and maintaining a robust evidence-based nursing practice environment. The CNS contributes significantly to the Magnet journey as a clinical coach by assisting staff nurses to strengthen areas of their practice that will result in improved patient outcomes. Clinical nurse specialists use many clinical coaching techniques, including direct observation of a nurse’s clinical care, reviewing a nurse’s documentation of care delivery, facilitating journal clubs, developing case studies, and providing feedback through the nursing peer-review process.12 As a clinical coach, the CNS is uniquely positioned to help other members of the interprofessional team translate knowledge into practice. A major underpinning of the Magnet journey is the educational eligibility requirements of direct-care nurses and nurse leaders, as well
Research
“Research is the systematic investigation aimed at generating new knowledge or refining existing knowledge.”13 Clinical nurse specialists are integral in leading and advancing the scientific base of nursing practice. The CNS fulfills this important function by conducting and facilitating nursing research, disseminating research findings through presentations and publications, and analyzing current nursing research methods and results for purposes of expanding and improving clinical care and empirical outcomes. The New Knowledge, Innovations & Improvements Magnet component is an area in which the CNS plays a significant role in contributing to the Magnet journey. Clinical nurse specialists role model, teach, coach, and mentor nursing staff about the use and evaluation of research findings and EBP that enhance quality and safety outcomes. Hallmarks of a vibrant Magnet journey include CNSs leading efforts to cultivate a climate of clinical inquiry, as well as a laser sharp focus on CNSs as interpreters and translators of research and evidence into clinical practice. The graduate and doctoral educational preparation of CNSs gives them a distinct body of knowledge related to both EBP and research. When CNOs make the decision to embark on the Magnet journey, they are sometimes compelled to hire external consultants to help address the research and EBP requirements outlined in the New Knowledge, Innovations & Improvements Magnet component. Chief nursing officers mitigate the need for external consultants by employing and engaging CNSs in the Magnet journey to help guide nursing 55
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research and hardwire EBP throughout the organization. The CNS begins by assessing system barriers and facilitators in the adoption of EBPs and then develops structures and processes for effective implementation of research findings and other evidence in clinical practice. When insufficient or no evidence exists, the CNS works with and through others to develop a plan of action for conducting research to address a clinical problem. Similarly, CNSs engage frontline staff nurses as collaborators and leaders to become actively involved in research and EBP projects.
APRN role to influence outcomes at each level affords health care organizations employing CNSs a distinct advantage in creating environments of excellence and improving clinical quality. The CNS practice is generally characterized as essential in establishing, maintaining, quantifying, and safeguarding the continuity of quality patient care.14 The ANCC Magnet Recognition Program is the criterion standard for quality, excellence, and innovations in nursing care. “Magnet recognition yields a financial return on investment including improved staff retention and decreased turnover, improved satisfaction, improved quality and safety, and increased customer attraction for hospital selection, as well as superior business results with an increase in operating margin from 4% to 16% due to investment in nursing services rather than cutting expenses of salaries and staffing levels.”15 As CNOs evaluate Magnet organizational readiness, an important consideration is identifying who in the organization possesses the knowledge and skill set to assume a key leadership role in the Magnet journey. The CNS role is ideally prepared and positioned to help successfully advance the Magnet journey while making substantial contributions as a consultant, systems leader, collaborator, coach, researcher, and facilitator of ethical decision making. Since its origin, the CNS role has been multifaceted and focused on improving care delivery at both the micro and macro levels. Clinical nurse specialists are indispensable in helping organizations achieve and sustain Magnet recognition.
Ethical Decision Making, Moral Agency, and Advocacy
Magnet-recognized organizations are expected to have educated their nursing staff on the American Nurses Association Code of Ethics as well as to have structures and processes in place for addressing ethical concerns. The CNS role is considered vital in helping organizations successfully meet the Magnet criterion related to ethical decision making, moral agency, and advocacy. An underpinning of CNS practice is the creation of environments that promote ethical decision making and patient advocacy. Throughout the Magnet journey, CNSs role model, teach, coach, and mentor to develop the advocacy and moral agency skills of nurses. The CNS also works with and through interprofessional teams to address moral distress and ethical concerns related to patient care. For example, one of the most common ethical challenges for acute and critical care staff nurses is end-of-life issues involving withholding life-sustaining treatments, respecting the wishes of the patient, and counseling the patient’s family. In this situation, the CNS facilitates ethics and palliative care consultation to meet the following goals:
REFERENCES 1. American Nurses Credentialing Center. Program overview. http://www.nursecredentialing.org/Magnet/Program Overview. Accessed July 28, 2014. 2. Broom C, Tilbury M. Magnet status: a journey, not a destination. J Nurs Care Q. 2007;22(2):113–118. 3. American Nurses Credentialing Center. Magnet. http:// www.nursecredentialing.org/MagnetModel.aspx . Accessed July 28, 2014. 4. Walker JA, Urden LD, Moody R. The role of the CNS in achieving and maintaining Magnet status. J Nurs Adm. 2009;39:515–523. 5. National Association of Clinical Nurse Specialists. CNS FAQs. http://nacns.org/html/cns-faqs.php. Accessed July 28, 2014. 6. APRN Joint Dialogue Group Report. APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee (7 July 2008). Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. http://www.aacn.nche .edu/education-resources/APRNReport.pdf. Accessed August 4, 2014. 7. Baldwin KM, Lyon BL, Clark AP, et al. Developing clinical nurse specialist practice competencies. Clin Nurse Spec. 2007;21(6):297–303.
1. Improve overall quality of life for patients and their families at risk for high symptom burden and emotional distress at end-of-life. 2. Provide support for health care team members who accompany these critically ill patients through their journey of illness and suffering. Conclusion The CNS practice is unique in that it spans 3 overlapping and interrelated spheres, including patient, nurse, and system. The ability of this 56
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8. The National CNS Competence Task Force. National Association of Clinical Nurse Specialists. Clinical Nurse Specialist Core Competencies Executive Summary 20 06-20 08 . http://www.nacns.org/docs/CNSCore CompetenciesBroch.pdf. Accessed August 4, 2014. 9. Muller AC, Hujcs M, Dubendorf P, et al. Clinical nurse specialist practice and Magnet designation. Clin Nurse Spec. 2010;24(5):252–259. 10. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome from intensive care in major medical centers. Ann Intern Med. 1986;104: 410–418. 11. Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: Institute
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of Medicine Committee on the Work Environment for Nurses and Patient Safety; 2003. Ervin NE. A strategy for enhancing evidence-based nursing practice. Clin Nurse Spec. 2005;19(6):296–301. Burns N, Grove SK. The Practice of Nursing Research: Conduct, Critique, and Utilization. 4th ed. Philadelphia, PA: Saunders; 2001. La Scale C, Connors P, Pedro J, Phipps M. The role of the clinical nurse specialist in promoting evidencebased practice and effecting positive patient outcomes. J Contin Educ Nurs. 2009;38:262–270. DeSilets L, Pinkerton SE. Administrative angles: the financial return on Magnet recognition. J Contin Educ Nurs. 2005;36(2):51–52.
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Role of the Clinical Nurse Specialist in the Journey to Magnet Recognition M. Dave Hanson, RN, MSN, ACNS-BC, NEA-BC
ABSTRACT Clinical nurse specialists (CNSs) work with and through other nurses as well as interprofessional team members to advance nursing practice, improve outcomes, and provide clinical expertise to effect system-wide changes to improve programs of care. They practice across the continuum and through 3 spheres of influence, encompassing the patient, nurse, and system. Clinical nurse specialists possess expertise in developing and refining structures, strategies, and processes to optimize outcomes at both the unit (micro) level and
the organization or system (macro) level. This unique vantage point positions CNSs as ideal individuals to assume several key roles when a health care organization makes the decision to embark on the Magnet journey and to maintain Magnet recognition. The competence and competencies of CNSs and a health care organization’s desire to achieve and/or maintain Magnet recognition represent a synergistic match. Keywords: clinical nurse specialist, Magnet journey, Magnet recognition, role
Magnet Overview Since 1994, when the first Magnet award was bestowed on the University of Washington Medical Center in Seattle, more than 400 health care organizations have become Magnet-recognized in the United States, Lebanon, Saudi Arabia, Singapore, Australia, and New Zealand. Magnet is thought to be the highest level of recognition a health care organization can achieve for excellence in nursing services.1 Today, both US News & World Report and the Leapfrog Hospital Survey use ANCC Magnet recognition as an indicator in determining the quality of care
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he American Nurses Credentialing Center’s (ANCC’s) Magnet Recognition Program “recognizes health care organizations for quality patient care, nursing excellence and innovations in professional nursing practice.”1 The journey to successfully becoming a Magnet-recognized health care organization requires unwavering commitment and collaboration from the boardroom to the bedside. Many individuals are involved in achieving the goal of Magnet recognition, including the clinicians providing quality care as well as those individuals tasked with developing structures, processes, and measuring outcomes of care delivery. Clinical nurse specialists (CNSs) are uniquely qualified to assume several key leadership roles in the Magnet journey. This article examines why CNSs are well suited to make significant contributions to an organization’s journey toward Magnet recognition as well as the various Magnet-related roles that align with the skills and competencies of CNSs.
M. Dave Hanson is Regional Director, Professional Practice and Clinical Standards, Providence Health & Services Southern California, Douglas & J. Glass Family Center, 5315 Torrance Blvd, Ste B-2, Torrance, CA 90503 (davehanson@ prodigy.net). The author declares no conflicts of interest. DOI: 10.1097/NCI.0000000000000068
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lapping and interrelated spheres of influence, involving the patient, nurse, and health care system.6 In each of the spheres of influence, the primary goal of the CNS is continuous improvement of patient outcomes and nursing care. Clinical nurse specialists work with and through other nurses and health care team members by mentoring and advancing system changes, with the ultimate goal of creating and sustaining environments of excellence. “Within the 3 CNS spheres of influence are 7 core competencies that are intended to guide the practice of individual CNSs and delineate contributions CNSs make to the health and welfare of the public, as well as link the expectations of CNS practice to health care organizations employing these APRNs.”7 The 7 CNS core competencies and associated performance outcomes are depicted in Table 1.
Figure 1: The American Nurses Credentialing Center Magnet Recognition Program Model. ©2013 American Nurses Credentialing Center. All rights reserved. Reproduced with the permission of the American Nurses Credentialing Center. This figure is available in color in the article on the journal website, www.aacnadvancedcriticalcare.com, and the iPad.
Role of the CNS in Achieving and Sustaining Magnet Recognition Anecdotal feedback from many CNOs indicate that CNS practice is indispensable in providing the clinical expertise, leadership, and system organizational influence necessary for achieving and sustaining ANCC Magnet recognition. Because CNSs possess the ability to influence practice in 3 overlapping and interrelated spheres, this APRN role is uniquely qualified to assume numerous key roles in the journey to Magnet recognition. “The basis for optimizing practice changes and sustained process improvement, the underpinning of Magnet recognition, is solidly grounded in the combined educational preparation and systems impact of CNS practice.”9 For organizations contemplating and sustaining the coveted Magnet recognition, the engagement and leadership of CNSs throughout the journey are a strategic investment likely to yield a positive organizational return on investment. The various Magnet roles that align with the CNS role are framed according to CNS core competencies.
consumers can expect to receive.2 The ANCC Magnet Recognition Program advances 3 goals within health care organizations: • Promotion of quality in a setting that supports professional practice • Identification of excellence in the delivery of nursing services to patients/residents • Dissemination of best practices in nursing services The current ANCC Magnet Recognition Program Model (Figure 1) introduced in 2008 configures the 14 Forces of Magnetism from the previous framework into 5 Model Components in an attempt to provide greater focus on measuring outcomes, while allowing more streamlined documentation.3 Many individuals play an integral role in the Magnet journey, including staff nurses, managers, directors, educators, advanced practice registered nurses (APRNs), and chief nursing officers (CNOs). Results of a study published in 2009 revealed that “CNSs were employed in 87% of Magnet-recognized facilities and of those, 88% indicated CNSs were important in achieving Magnet recognition and 92% indicated CNSs were important in maintaining Magnet recognition.”4
Consultation
“Administrators recognize CNSs have a compelling role as consultants and resources for expert practice as well as the unique capability to influence sustainability by navigating the complexity in organizations.”4 Inherent in CNS practice is clinical expertise and subsequently the skill of consultation. Clinical nurse specialists contribute to the Magnet recognition
Overview of the CNS Role Clinical nurse specialists are APRNs with master’s or doctorate educational preparation in nursing.5 The CNS scope of practice encompasses 3 over51
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Table 1: Clinical Nurse Specialist Core Competencies and Associated Performance Outcomesa Core Competency
Associated Performance Outcome
Direct care
Direct interaction with patients, families, and groups of patients to promote health or well-being and improve quality of life. Characterized by a holistic perspective in the advanced nursing management of health, illness, and disease states.8
Consultation
Patient, staff, or system-focused interaction between professionals, in which the consultant is recognized as having specialized expertise and assists consultee with problem solving.8
Systems leadership
The ability to manage change and empower others to influence clinical practice and political processes both within and across the system.8
Collaboration
Working jointly with others to optimize clinical outcomes. The CNS collaborates at an advanced level by committing to authentic engagement and constructive patient, family, system, and population-focused problem solving.8
Coaching
Skillful guidance and teaching to advance the care of patients, families, groups of patients, and the profession of nursing.8
Research
The work of thorough and systematic inquiry. Includes the search for, interpretation of, and use of evidence in clinical practice and quality improvement, as well as active participation in the conduct of research.8
Ethical decision making, moral agency, and advocacy
Identifying, articulating, and taking action on ethical concerns at the patient, family, health care provider, system, community, and public policy levels.8
a Adapted with permission from Clinical Nurse Specialist Core Competencies Executive Summary 2006–2008. ©2010 National CNS Competency Task Force.
journey through provision of consultation to staff nurses, medical staff, and other professionals. When clinical needs of complex patients are identified by the health care team, the CNS initiates appropriate consultation to prevent or manage problems and facilitate progress along the care continuum. For example, a critical care staff nurse caring for a patient with postoperative complications following gastric bypass surgery consults the CNS because the current pharmacological opioid treatment regimen is ineffective in keeping the patient comfortable. The CNS intervenes by conducting a thorough patient assessment and evaluation of the quantity of pharmacological agents used since admission to the critical care unit, as well as the overall patient’s response to treatment. Using these objective data, the CNS consults the clinical pharmacist and intensivist to devise an effective patient-centered pain management plan, including both pharmacological and nonpharmacological interventions. The CNS tracks and analyzes data from consultations with the goal of developing and revising practice guidelines and standards. This expert consultation by the CNS is integral
to achieving many of the empirical outcomes that ultimately result in a successful Magnet recognition. The CNS also makes consultative contributions for collecting various Magnet sources of evidence, telling the story of the organization, and meeting data display requirements outlined in the Magnet document submission process. Another important area in which the CNS provides consultation is the assistance and support in writing and editing the Magnet application document. Many CNSs bring experience in writing for peer-reviewed publication, making this APRN role ideally suited to provide writing and editing consultation to optimize an organization’s Magnet document submission. Systems Leadership
The skill of the CNS to engage and empower clinicians at the unit and department levels and then facilitate best practice across the organization or system is transformative in the Magnet journey. Clinical nurse specialists are adept at performing system-level assessments to identify variables that influence practice and outcomes. They then evaluate assessment findings 52
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to determine effective system interventions for changing clinician and team behaviors necessary for adopting evidence-based practices (EBPs) and improving outcomes. An example of systems leadership involves the CNS creating standardization of patient care services across the organization to ensure that the same quality of care is provided wherever the patient enters the system. This ability to influence practice, build strategic partnerships, and improve outcomes across the system is vital in helping the organization meet and exceed performance targets of the NDNQI (National Database of Nursing Quality Indicators) nursing-sensitive indicators. The nursing-sensitive indicators are a major aspect of the Magnet journey, and achieving the targets is considered an absolute for an organization to achieve and maintain Magnet recognition. Another significant systems leadership contribution made by the CNS in the Magnet journey is overall management of this highly strategic organizational initiative. Ultimately, the CNO is accountable for the Magnet journey, but typically the journey is managed by the Magnet program director (MPD). Clinical nurse specialists demonstrate knowledge and skill influencing practice at the system and organization level, which makes CNSs capable of assuming the role of leading the Magnet journey as an MPD.
process. With the 5 Magnet components as a guiding framework, Table 2 outlines some specific focus areas of CNS responsibility when serving in the MPD role. Collaboration
The cornerstone role of CNS practice is that of a collaborator. Clinical nurse specialists are leaders when it comes to establishing, improving, and sustaining collaborative relationships that promote patient safety and clinical excellence. Clinical nurse specialists have long understood that health care is less focused on individual achievement and more about the whole team. The needs of patients are optimized when consistent and purposeful interprofessional collaboration occurs. The CNS is uniquely prepared and positioned to make this vision a reality. In the Magnet journey, the role of the CNS as a collaborator is critical in organizations achieving many of the benchmark empirical patient outcomes, such as those related to falls, hospital-acquired pressure ulcers, and patient satisfaction. Successfully meeting benchmarks of these clinical quality foci requires the CNS to work in, through, and across all interprofessional teams to create and sustain lasting improvements. For example, to eliminate ventilator-associated events, the CNS might work in collaboration with medical staff, acute and critical care nurses, assistive personnel, respiratory therapists, and infection control practitioners to develop and consistently implement an effective oral care protocol during mechanical ventilation. The CNS understands that collaboration necessitates ongoing vigilance and nurturing, supported by formal structures and processes that foster joint skilled communication and effective decision making. The potential of each individual team member, as well as the collective capacity of the team, to flourish is directly linked to the degree of collaboration and teamwork. Poor collaboration has an overwhelmingly negative impact on numerous performance indicators, including patient and family satisfaction, patient safety and outcomes, professional staff satisfaction, nurse retention, and health care cost.10,11 The CNO looking to mitigate the potential for such adverse outcomes conducts an organizational assessment and deploys CNSs in high-risk, problem-prone patient populations and clinical areas to influence practice as a clinical expert and interprofessional collaborator.
CNS as Magnet Program Director
The role of an MPD is similar to the role of a project manager in that the MPD has responsibility for assessing, planning, organizing, implementing, motivating, and allocating necessary resources to achieve Magnet recognition. This role is imperative to a successful Magnet journey and requires a seasoned individual with knowledge and skills for managing an organizational initiative of such strategic magnitude. Because CNSs are educated to influence and lead at the system level, this APRN role is an ideal match for the MPD role. As an MPD, the CNS is responsible for oversight, direction, and management of the Magnet journey, with accountability for implementing the nursing strategic plan tactics related to attaining and maintaining Magnet recognition, as well as ensuring that the organizational milieu reflects internalization of the 5 components of Magnet. The CNS in this role assumes responsibility for coordination of the Magnet application, designation, and redesignation 53
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• Direct development of a systemwide PPM • Evaluate patient care delivery model • Oversee standardization of nursing job descriptions and competencies to reflect PPM and patient care delivery model • Evaluate NPR process to ensure ongoing effectiveness and relevancy • Serve as a liaison to APRN Council • Build and sustain interprofessional partnerships that provide opportunities for communication, collaboration, and effective decision-making among members of health care team
• Manage and facilitate Shared Governance Councils • Develop structure for nursing involvement in community • Annual evaluation of professional development reimbursement policies related to tuition, specialty certification and conferences • Track progress toward goals related to numbers of nurses with higher degrees and specialty certifications • Collaborate with Professional Development Department to allocate resources for academic affiliations • Oversee implementation and annual evaluation of Clinical Ladder Program
• Authentically role model the vision for Magnet and actively engage others throughout the Magnet journey • Organizational resource and point person for all things Magnet-related • Partner with CNO to develop Nursing Strategic Plan • Develop and oversee implementation of nursing leadership development program (in partnership with Professional Development Department) • Develop and implement a quarterly nursing newsletter • Coordinate Nursing Annual Report
• Ensure effective implementation of nursing research • Develop annual targets for involvement in nursing research • Coordinate with Professional Development Department on the education plan for nurses related to evidence-based practice and nursing research • Partner with Information Services to optimize nursing informatics structure and support • Direct nurse-initiated innovation initiatives such as Transforming Care at the Bedside and Clinical Scene Investigator Academy
New Knowledge, Innovations & Improvements Component
• Develop Nursing Dashboard composed of nursing sensitive quality indicators and other Magnet-related goals • Monitor Magnetrelated outcomes and collaborate with stakeholders to develop action plans that address gaps • Oversee collection and submission of key nursing outcome indicators • Coordinate all document submissions and demographic reports to ANCC Magnet Recognition Program
Empirical Outcomes Component
Abbreviations: ANCC, American Nurses Credentialing Center; APRN, advanced practice registered nurse; CNO, chief nursing officer; NPR, nursing peer review; PPM, professional practice model.
Exemplary Professional Practice Component
Structural Empowerment Component
Transformational Leadership Component
Table 2: Example Responsibilities of Clinical Nurse Specialists Serving in the Magnet Program Director Role
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This strategic move by the CNO can better position the organization for a seamless and successful Magnet journey.
as the requisite to increase the number of certified nurses throughout the organization. Clinical nurse specialists contribute to the Magnet journey by promoting the vision of an educated nursing workforce and showcasing the growing body of research affirming the positive relationship between a more highly educated nursing workforce and clinical outcomes such as patient morbidity, mortality, and failure to rescue. As a clinical expert, teacher, and researcher, the CNS is viewed as a role model for staff nurses, which allows the CNS to easily segue to the role of a career coach for the purpose of advising nurses about various options for advancing academic progression, availability of nursing specialty certifications, and other avenues for evolving professional development.
Coaching
Coaching as a core CNS competency is defined as the “skillful guidance and teaching to advance the care of patients, families, groups of patients, and the profession of nursing.”8 Clinical nurse specialists have a rich history of working with staff nurses to build and advance their foundational skills, with the goal of performance improvement. In the role of a clinical coach, the CNS supports staff nurses to expand and deepen their clinical knowledge and leadership skills, with the goal of improving the quality of patient care. In addition, the CNS fosters professional growth and development of staff nurses by serving in the role of a career coach and advisor. For example, a seasoned critical care staff nurse in the medical intensive care unit will soon be serving as a new chair of the unit-based practice council and is not feeling confident in leading this team. The staff nurse seeks guidance from the CNS, who begins one-on-one coaching with the staff nurse on leading and facilitating teams. An overarching theme of the Magnet journey is the adoption and advancement of evidence-based nursing practices. The work by the CNS to grow the knowledge and clinical skills of staff nurses is directly linked to the attainment and maintenance of evidence-based nursing practice. Clinical nurse specialists understand that a successful Magnet journey depends on identifying nurses who have the capacity to help in establishing and maintaining a robust evidence-based nursing practice environment. The CNS contributes significantly to the Magnet journey as a clinical coach by assisting staff nurses to strengthen areas of their practice that will result in improved patient outcomes. Clinical nurse specialists use many clinical coaching techniques, including direct observation of a nurse’s clinical care, reviewing a nurse’s documentation of care delivery, facilitating journal clubs, developing case studies, and providing feedback through the nursing peer-review process.12 As a clinical coach, the CNS is uniquely positioned to help other members of the interprofessional team translate knowledge into practice. A major underpinning of the Magnet journey is the educational eligibility requirements of direct-care nurses and nurse leaders, as well
Research
“Research is the systematic investigation aimed at generating new knowledge or refining existing knowledge.”13 Clinical nurse specialists are integral in leading and advancing the scientific base of nursing practice. The CNS fulfills this important function by conducting and facilitating nursing research, disseminating research findings through presentations and publications, and analyzing current nursing research methods and results for purposes of expanding and improving clinical care and empirical outcomes. The New Knowledge, Innovations & Improvements Magnet component is an area in which the CNS plays a significant role in contributing to the Magnet journey. Clinical nurse specialists role model, teach, coach, and mentor nursing staff about the use and evaluation of research findings and EBP that enhance quality and safety outcomes. Hallmarks of a vibrant Magnet journey include CNSs leading efforts to cultivate a climate of clinical inquiry, as well as a laser sharp focus on CNSs as interpreters and translators of research and evidence into clinical practice. The graduate and doctoral educational preparation of CNSs gives them a distinct body of knowledge related to both EBP and research. When CNOs make the decision to embark on the Magnet journey, they are sometimes compelled to hire external consultants to help address the research and EBP requirements outlined in the New Knowledge, Innovations & Improvements Magnet component. Chief nursing officers mitigate the need for external consultants by employing and engaging CNSs in the Magnet journey to help guide nursing 55
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research and hardwire EBP throughout the organization. The CNS begins by assessing system barriers and facilitators in the adoption of EBPs and then develops structures and processes for effective implementation of research findings and other evidence in clinical practice. When insufficient or no evidence exists, the CNS works with and through others to develop a plan of action for conducting research to address a clinical problem. Similarly, CNSs engage frontline staff nurses as collaborators and leaders to become actively involved in research and EBP projects.
APRN role to influence outcomes at each level affords health care organizations employing CNSs a distinct advantage in creating environments of excellence and improving clinical quality. The CNS practice is generally characterized as essential in establishing, maintaining, quantifying, and safeguarding the continuity of quality patient care.14 The ANCC Magnet Recognition Program is the criterion standard for quality, excellence, and innovations in nursing care. “Magnet recognition yields a financial return on investment including improved staff retention and decreased turnover, improved satisfaction, improved quality and safety, and increased customer attraction for hospital selection, as well as superior business results with an increase in operating margin from 4% to 16% due to investment in nursing services rather than cutting expenses of salaries and staffing levels.”15 As CNOs evaluate Magnet organizational readiness, an important consideration is identifying who in the organization possesses the knowledge and skill set to assume a key leadership role in the Magnet journey. The CNS role is ideally prepared and positioned to help successfully advance the Magnet journey while making substantial contributions as a consultant, systems leader, collaborator, coach, researcher, and facilitator of ethical decision making. Since its origin, the CNS role has been multifaceted and focused on improving care delivery at both the micro and macro levels. Clinical nurse specialists are indispensable in helping organizations achieve and sustain Magnet recognition.
Ethical Decision Making, Moral Agency, and Advocacy
Magnet-recognized organizations are expected to have educated their nursing staff on the American Nurses Association Code of Ethics as well as to have structures and processes in place for addressing ethical concerns. The CNS role is considered vital in helping organizations successfully meet the Magnet criterion related to ethical decision making, moral agency, and advocacy. An underpinning of CNS practice is the creation of environments that promote ethical decision making and patient advocacy. Throughout the Magnet journey, CNSs role model, teach, coach, and mentor to develop the advocacy and moral agency skills of nurses. The CNS also works with and through interprofessional teams to address moral distress and ethical concerns related to patient care. For example, one of the most common ethical challenges for acute and critical care staff nurses is end-of-life issues involving withholding life-sustaining treatments, respecting the wishes of the patient, and counseling the patient’s family. In this situation, the CNS facilitates ethics and palliative care consultation to meet the following goals:
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1. Improve overall quality of life for patients and their families at risk for high symptom burden and emotional distress at end-of-life. 2. Provide support for health care team members who accompany these critically ill patients through their journey of illness and suffering. Conclusion The CNS practice is unique in that it spans 3 overlapping and interrelated spheres, including patient, nurse, and system. The ability of this 56
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