Pan-Canadian Core Competencies for the Clinical Nurse Specialist: A Comprehensive Study Guide

Introduction

This foundational document, developed by the Canadian Nurses Association (CNA) in June $2014$ , clearly articulates the core competencies of the clinical nurse specialist (CNS).
It was created to reflect the diversity of specialty areas and practice environments in which CNSs work, and to support the evolution of the CNS role to meet the changing needs of patients and the Canadian health-care system.
The document's purpose is to:
- Promote clarity of the CNS role.
- Facilitate understanding and highlight the importance of the CNS role for improving health and the delivery of health-care services.
- Guide the development of CNS education curricula and outcomes.
- Support CNSs in advancing their practice.
- Support employers who are implementing CNS roles in their organizations.

The Clinical Nurse Specialist (CNS) Role

The CNS is an advanced practice role. It involves analyzing, synthesizing, and applying nursing knowledge, theory, and research evidence to foster system-wide changes and advance nursing care and the profession as a whole (CNA, $2008$ ).
Qualifications: A registered nurse (RN) who holds a graduate degree in nursing and has a high level of expertise in a clinical specialty.
Areas of Specialization: Expertise may focus on a specific population, a practice setting, a disease or subspecialty, a type of care, or a type of health problem.
Role in Outcomes: The CNS improves client, population, and health system outcomes by integrating knowledge, skills, and expertise in clinical care, research, leadership, consultation, education, and collaboration.
Role Variability: The CNS role can change in response to:
- The dynamic needs of clients, nursing staff, and practice settings.
- Changing strategic directions of the organization.
- Economic and policy priorities of health-care funders and ministries of health.
Core Aim: Despite role variability, all CNS work is aimed at ensuring safety, quality of care, and positive health outcomes.

How the CNS Influences Care

The CNS influences care primarily at the client level, within the practice setting, and at the organizational/systems level.
Influence at the client level:
- Works with clients of varying age, race, gender, language, education, culture, socio-economic background, religion, and sexual orientation.
- Clients are often from vulnerable populations and may have acute and/or chronic conditions.
- Supports direct client care by:
  - Assessing and managing risks and complications.
  - Providing therapeutic interventions.
  - Planning and coordinating care.
  - Monitoring and evaluating outcomes.
  - Advocating for health and social services that best meet the client’s needs.
- Provides consultation and specialized care, especially for individuals with complex health conditions (Canadian Centre for Advanced Practice Nursing Research [CCAPNR], $2012$ ).
Influence within the practice setting:
- Works with other nurses to promote excellence in nursing practice by:
  - Leading quality improvement initiatives.
  - Designing and implementing evidence-based policies and practices.
  - Supporting nurses and other health-care professionals to use best practice guidelines.
- Supports nursing colleagues by providing mentorship and working to improve nursing recruitment and retention.
Influence at the organizational/systems level:
- Works with managers, educators, policy-makers, administrative decision-makers, regulators, and other health professionals to improve the quality and safety of client care.
- May lead initiatives to improve the quality of care at an organizational, provincial, and/or national level.
- Instrumental role in reducing costs associated with acute health-care services, for example by:
  - Promoting the use of evidence-based interventions to prevent adverse events and reduce complications, thereby reducing the lengths of hospital stays.
  - Better preparing clients and their families for discharge and strengthening client self-care abilities to reduce hospital stays.
  - Avoiding readmission to hospital and emergency department visits through ongoing assessment, early detection and management of client health problems, care coordination, and referral to appropriate community services (CCAPNR, $2012$ ).

Overview and Assumptions of CNS Core Competencies

The CNS competencies expand upon the competencies required of a registered nurse (RN) and reflect advanced nursing practice.
They are consistent with and build upon CNA’s Advanced Nursing Practice: A National Framework ( $2008$ ), articulating competencies specific to the CNS role.
The core competencies in this framework are grouped into four categories:
1. Clinical care
2. System leadership
3. Advancement of nursing practice
4. Evaluation and research
Key Assumptions underlying the competencies (essential for understanding how they apply to CNS practice in all roles, settings, and client populations):
1. The CNS uses systematic approaches to retrieve, critically appraise, apply, and translate research knowledge into practical information for clients, family members, nurses, other health-care providers, health-care decision-makers, and policy-makers.
2. CNS practice encompasses and builds on the professional role and scope of practice of the RN to assess and manage complex health-care issues and support innovation to improve the delivery of nursing and health care.
3. Direct and indirect care are the core components of CNS practice.
4. Graduate nursing education is essential for operationalizing all areas of CNS practice across diverse practice settings and client populations.
5. CNS practice is grounded in client-centered care, an approach where clients are viewed as whole persons, involving advocacy, empowerment, and respecting client autonomy, voice, self-determination, and participation in decision-making (Registered Nurses’ Association of Ontario, $2002$ ).
6. The CNS identifies, initiates, and leads clinical therapeutic and health service interventions that result in beneficial short, intermediate, and/or long-term outcomes for clients and family members, nurses and other providers, organizations, and the health-care system.
7. The integration of the CNS role in the health-care delivery system is essential for the development and evolution of professional practice environments that support high-quality nursing care.
8. The CNS role helps to improve quality of care, achieve better health outcomes, avoid unnecessary costs through prevention of adverse events and complications, and reduce acute health-care costs through more efficient models of delivery.
9. The CNS is an autonomous practitioner who collaborates with clients and other providers as a member of the interprofessional health-care team to deliver high-quality client care.
10. The CNS understands and influences provincial/territorial, federal, and socio-political issues and the impact of these issues on health services and healthy public policy.
11. The CNS works through an advanced nursing practice lens and has knowledge, skills, and abilities achieved through graduate education and practice experience.

Clinical Care Competencies

The CNS is an independent practitioner within their identified scope of practice who uses advanced clinical judgments to assess, intervene, and evaluate the clients they serve.
They use advanced and expert knowledge, skills, and abilities to develop, coordinate, and evaluate a collaborative plan of care for highly complex and unpredictable clinical situations, focusing on optimizing health and quality of life for the client.
The CNS provides direct and indirect care based on their specialty knowledge, practice context, and specialty area.
The clinical nurse specialist:
1. Conducts comprehensive in-depth assessments using advanced nursing knowledge and skills for specific clients, nursing practice situations, or systems.
2. Collects data about the context and etiology (cause, set of causes, or manner of causation) of conditions that are amenable to CNS interventions.
3. Analyzes the complex interaction of sociological, psychological, and physiological processes, determinants of health, and clients’ lived experiences to develop, implement, evaluate, and revise plans of care.
4. Differentiates actual or potential risks to client safety, autonomy, and quality of care based on assessment and client/population validation.
5. Analyzes patterns of client responses and needs within a complex population and develops strategies to create unit-based, organization-based, and system-based changes to optimize health-care outcomes.
6. Synthesizes the assessment data using advanced knowledge, experience, critical thinking, clinical inquiry, and clinical judgment to develop a plan of care.
7. Designs care plans for clients with highly complex and often unpredictable needs.
8. Uses clinical inquiry to identify the need for reassessment, match intervention to etiology, and choose appropriate methods to evaluate outcomes.
9. Uses a variety of communication and counseling techniques applicable to specific and highly complex and often unpredictable clinical and team situations.
10. Provides consultations in highly complex and often unpredictable clinical situations that require advanced specialized knowledge and skills.
11. Measures indicators such as quality of life, client safety, timeliness, effectiveness, efficiency, efficacy, client-centered care, cost-effectiveness, and appropriateness on a continuous basis.
12. Facilitates knowledge translation in a clinical setting to support the care plan in highly complex and often unpredictable situations.
13. Collaborates with clients and appropriate interprofessional team members within the clinical area to achieve optimal health outcomes.
14. Advocates for client-centered care to meet their needs in highly complex and often unpredictable situations.
15. Coordinates health care to facilitate safe and seamless transitions among points of care in highly complex and often unpredictable situations.

Systems Leadership Competencies

The CNS is a nursing leader. Systems leadership includes the ability to manage change and influence clinical practice and political processes both within and across systems.
This involves advocating for and promoting the importance of access to care and advanced nursing services to clients, nurses, other health professionals, the public, legislators, and policy-makers (CNA, $2008$ ).
The clinical nurse specialist:
1. Facilitates interprofessional collaboration, internally and externally to the organization, to achieve desired client outcomes.
2. Leads the development and implementation of standards of nursing practice, practice guidelines, education strategies, quality management, research initiatives, and/or system change.
3. Critically analyzes socio-political, demographic, and economic issues, trends, and policies, and contributes to the political process to influence change for optimizing health outcomes.
4. Integrates knowledge of clients’ perspectives during policy development and planning.
5. Leads initiatives to promote professional growth, continuous learning, and collaborative practices of nurses and other members of the health-care team to ensure client safety and quality of care.
6. Fosters an organizational culture of learning, quality, and safety through preceptorship, role modeling, mentorship, and coaching of nurses, other members of the health-care team, and students.
7. Applies knowledge of existing resources and the cost-effectiveness of interventions to inform resource decisions at the practice setting, organizational, and system levels.
8. Implements strategies to achieve the intended nurse-sensitive client outcomes for a defined population.
9. Leads the implementation and integration of the CNS role within the health-care team, organization, and broader health system.
10. Applies advanced nursing knowledge and skills to communicate, negotiate, and build coalitions to manage change and resolve conflict.
11. Negotiates complex relationships at the individual, practice setting, and organizational levels with the goal of optimizing client outcomes.
12. Recognizes potential and existing gaps in clinical care to influence client and organizational decision-making and change.
13. Anticipates future changes (e.g., needs related to technology, systems, professional development) and recommends and implements appropriate actions.
14. Identifies needs and advocates for the necessary human, material, and organizational system resources for safe client care.
15. Develops and leads strategies to promote the uptake of evidence-informed practices to optimize identified client outcomes.
16. Participates in key quality and safety initiatives with both internal and external stakeholders from the micro to the macro level and vice versa.
17. Evaluates gaps and operational issues at the organizational and community levels to contribute to the development of innovative solutions.
18. Collaborates in the development of strategic program planning and evaluation to foster innovative care for specific client populations.

Advancement of Nursing Practice Competencies

The CNS leads and fosters the professional development of RNs and nursing practice to maximize the scope and depth of practice, leading to optimal client outcomes.
The clinical nurse specialist:
1. Models professionalism and accountability in all interactions within the health-care team.
2. Advocates for and implements change to create safe and healthy workplace environments.
3. Advocates for and implements changes that optimize the development of RNs in their roles.
4. Evaluates nursing practice against established benchmarks and evidence-informed practice standards.
5. Engages in reflective practice to ensure that professional standards of practice are met.
6. Improves nursing practice through mentoring, role modeling, consultation, and education.
7. Incorporates knowledge from continuous learning to inform, evaluate, and advance nursing practice.
8. Disseminates knowledge from continuous learning to advance practice at the local, regional, and national level.
9. Promotes the role of the CNS through involvement in academic pursuits, professional associations, and special-interest groups.
10. Builds capacity and succession planning by mentoring RNs to pursue graduate studies with a focus on acquiring CNS competencies.
11. Promotes the role and the relevance of the CNS to educators, policy-makers, administrative decision-makers, regulators, other health-care providers, and the public.
12. Identifies and develops indicators for measuring and evaluating the CNS role.
13. Promotes ethical nursing practice through the development of strong moral climates in the practice setting.

Evaluation and Research Competencies

As a knowledge translator, the CNS searches for, critiques, interprets, synthesizes, uses, and disseminates evidence in clinical practice and for quality improvement and client safety initiatives.
Development and evaluation of programs and services at various levels are often driving factors behind CNS practice.
The CNS acts either as an investigator or as a collaborator with other members of the health-care team or community to identify, conduct, and support research that enhances or benefits nursing practice (CNA, $2008$ ).
The clinical nurse specialist:
1. Evaluates and critiques current practice against best available evidence/benchmarks.
2. Evaluates the need for practice improvement to promote safe, effective, and reliable care that has a positive impact on client and system outcomes.
3. Uses systematic approaches to redesign care delivery to promote safe, effective, and reliable care that has a positive impact on client and system outcomes.
4. Uses research and outcome data to formulate, evaluate, and/or revise policies, procedures, protocols, client-specific programs, and client standards of care.
5. Addresses identified research practice gaps and opportunities through the use of relevant evidence in practice.
6. Integrates new evidence into the practice setting and with specific client populations.
7. Ensures that ethical standards are promoted and maintained in the practice environment when research and quality improvement initiatives are being conducted.
8. Implements and evaluates quality management processes.
9. Identifies and incorporates relevant data needed for quality management.
10. Uses research principles to answer clinical questions to address the quality of client outcomes.
11. Uses a wide range of strategies to encourage health-care teams to engage in clinical inquiry.
12. Leads and participates in research initiatives that facilitate the generation of new evidence.
13. Participates in outcome evaluation of nurse-sensitive indicators.

Methodology for Competency Development

The Pan-Canadian Core Competencies for the Clinical Nurse Specialist document was created, reviewed, and validated using an evidence-informed approach to competency development.
The process heavily relied on the expertise of a diverse group of clinical nurse specialists from across Canada, representing more than $125$ involved stakeholders.
Five phases of development were undertaken:
1. Phase 1: The CNS steering committee completed a review of current CNS practice and competency frameworks, then provided advice on a framework.
2. Phase 2: A three-day workshop convened an experienced, diverse group of CNSs from across the country. After receiving training in competency development, they created a competency profile.
3. Phase 3: The CNS steering committee reviewed the competencies and provided feedback, which was integrated into the document for validation.
4. Phase 4: Involved a review and validation of the competencies by a broad group of stakeholders using an online survey, designed by Assessment Strategies Inc. with CNA guidance.
  - Respondents were asked to rate each of the $59$ competencies for applicability to entry-to-practice, its importance for safe and effective practice, its frequency of use, and its level of impact (i.e., client, practice setting, or organizational/system).
  - Using a snowball approach, $93$ surveys were completed between March $23$ and April $20, 2014$ .
  - All competencies were rated as highly applicable, with all $59$ receiving an applicability rating of at least $80 \%$ .
  - Qualitative feedback from respondents was also reviewed.
  - Based on results, the CNS steering committee recommended revisiting some competencies with relatively low ratings to verify their relevance to safe and effective practice.
5. Phase 5: CNA and the CNS steering committee made final decisions based on the survey results.
  - In total, $2$ competencies and sub-competencies were added.
  - $4$ were modified.
  - This iterative process resulted in the final competency profile comprising $59$ competencies.