• It is an exciting time for nursing in the United States however, there are a number of key challenges
facing CNSs as nurse leaders.
“ In health care, the focus is no longer just on the process of how care is delivered, but on the outcomes of
that care. More attention is being given to documenting that the care is provided according to specific
standards associated with better outcomes. Many of the standards are directly related to the care given by
nurses, including some indicators that are specifically sensitive to nurse intervention. There is also a new
focus on federal reporting of patient satisfaction with the services provide. Producing quality outcomes,
high patient satisfaction and effective measurements of both are now a central theme for the entire hospital
administrative team. For the CNS, however, it represents explicit accountability for managing and leading the
staff responsible for providing the patient care. The ability to assure nursing effectiveness will likely be
achieved by redesigning the manner in which nurses work and deliver care. Safety and quality issues are
directly linked to financial pressure. Reimbursement for hospital services is being whittled away as
financial accountability for services receives greater scrutiny from the federal government and private
insurers. Close on the heels of the financial challenge is the ever present workforce shortage. Another
troublesome challenge is the absence of an adequate pipeline for nursing leaders. Current nurse leaders in
the U.S. are in their 50s and anticipated retirements may reduce leadership numbers to critical levels. There
is an urgent need to develop new leaders at all levels. Middle management vacancies in roles such as the CNS
and nurse manager are extremely difficult to fill. (Thompson, P.A. (2008). Key challenges facing American
nurse leaders. Journal of Nursing Management, 16, 912)”.
“Leadership is a hallmark of CNS practice in all three spheres of influence. The essence of leadership is
fundamentally the capacity to influence. Influence is the ‘power of producing an effect without apparent
exertion of force or direct exercise of command’ (Merriam-Webster Online Dictionary, 2008). Influence and,
therefore, leadership is not about having postion authority; it is the ability to get others to be motivated
to work toward accomplishing a vision. The importance of influence as the major avenue through which CNSs
positively impact both patient outcomes and cost-effectiveness is reflected in the adoption of ‘ spheres of
influence’ as the framework for the Natinal Association of Clnical Nurse Specialists (NACNS) Statement on
Clinical Nurse Specialist Practice and Education (2004). (Lyon, BL (2010), Transformational leadership as the
clinical nurse specialist’s capacity to influence, pp149. In Clinical Nurse Specialist Practice, Springer
Because the CNS is often charged with directly or indirectly monitoring quality of care, this advanced
practice nurse is uniquely positioned to effect change throughout and across the health care continuum.
Richardson (2010) identifies a number of characteristics of successful change agents:
“ability to combine unrelated ideas, ability to energize others, skill in human relations, integrative
thinking (big-picture focus and detail oriented), flexibility to modify ideas, persistence to resist
nonproductive tampering; confidence, realistic thinking regarding timelines, trustworthiness, history of
previous successes, ability to articulate a vision, ability to handle resistance (p81)”.
CNS Core Competencies (NACNS, 2010)
Systems Leadership Competency: The ability to manage change and empower others to influence clinical practice
and political processes both within and across systems.
C. 1 Facilitates the provision of clinically competent care by staff/team through education, role modeling,
teambuilding, and quality monitoring.
C.2 Performs system level assessments to identify variables that influence nursing practice and outcomes,
including but not limited to:
C.2.a. Population variables (age distribution, health status, income distribution, culture)
C.2.b. Environment (schools, community support services, housing availability, employment opportunities)
C.2.c. System of health care delivery
C.2.d. Regulatory requirements
C.2.e. Internal and external political influences/stability
C.2.f. Health care financing
C.2.g. Recurring practices that enhance or compromise patient or system outcomes.
C.3 Determines nursing practice and system interventions that will promote patient, family and community
C.4 Uses effective strategies for changing clinician and team behavior to encourage adoption of
evidence-based practices and innovations in care delivery.
C.5 Provides leadership in maintaining a supportive and healthy work environment.
C.6 Provides leadership in promoting interdisciplinary collaboration to implement outcome-focused patient
care programs meeting the clinical needs of patients, families, populations and communities.
C.7 Develops age-specific clinical standards, policies and procedures.
C.8 Uses leadership, team building, negotiation, and conflict resolution skills to build partnerships within
and across systems, including communities.
C.9 Coordinates the care of patients with use of system and community resources to assure successful
health/illness/wellness transitions, enhance delivery of care, and achieve optimal patient outcomes.
C.10 Considers fiscal and budgetary implications in decision making regarding practice and system
C.10.a. Evaluates use of products and services for appropriateness and cost/benefit in meeting care needs
C.10.b. Conducts cost/benefit analysis of new clinical technologies
C.10.c. Evaluates impact of introduction or withdrawal of products, services, and technologies
C.11 Leads system change to improve health outcomes through evidence based practice:
C.11.a. Specifies expected clinical and system level outcomes.
C.11.b.Designs programs to improve clinical and system level processes and outcomes.
C.11.c.Facilitates the adoption of practice change
C.12 Evaluates impact of CNS and other nursing practice on systems of care using nurse-sensitive outcomes
C.13 Disseminates outcomes of system-level change internally and externally
Hamric, A.B., Spross, J.A., & Hanson, C.M. (2008). Clinical and professional leadership, 249-282.
Huston, C. (2008). Preparing nurse leaders for 2020. Journal of Nursing Management, 16, 905-911.
Shirey, M.R. (2008). Influencers among us. A practical approach for leading change. Clinical Nurse
Specialist. 22(2). 63-65. Shirey-Influencers among us 2008.pdf
Shirey, M.R. (2007). Leadership and organizational strategies to increase innovative thinking.
Clinical Nurse Specialist. 21(4), 191-194. Shirey-Leadership & Org Strat 2007.pdf
Shirey, M.R. (2007). Moral intelligence for the leader and entrepreneur. Clinical Nurse Specialist,
21(2), 71-73. Shirey-Moral Intelligence 2007.pdf
Spreir, Fontaine, & Malloy (June 2006).Leadership run amok: The disruptive potential of
overachievers. Harvard Business Review, 72-82. Spreier-Leadership-2006.pdf
Keele, R. (2012. Implementing evidence-based nursing practice: An overview. In Nursing Research and
Evidence -Based Practice: Ten steps to success. Hones & Bartlett Learning, LLC. 80586_CH05_Keele.pdf
Goleman, D. & Boyatzis, R. (2008). Social intelligence and the biology of leadership. Harvard
Business Review, 86(9), 74-81. Biology of leadership.
Discuss how CNS leadership and change agent roles will play out in your clinical practicum project. Relate
discussion to the literature cited in your reading list. Be sure to briefly explain purpose of your project
in 2 sentences.
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