Lesser Recognised Important Roles of the Clinical Nurse Specialist

Clinical Nurse Specialists (CNS) is by their title clinicians in focus, and the literature emphasises this. However the CNS has many roles, the clinical, educator and researcher roles are frequently articulated but the CNS operates in many other roles also. These include the less articulated roles such as leadership, manager, consultant and change agent/innovator. These roles require functions and competencies, which often define the complete and complex CNS role. It is the competencies and personal characteristics that the CNS display and utilise in all these roles that allow them to function at a specialist level. Certainly, these roles and competencies are supported in the literature [1-5].


Historical Development of Clinical Nurse Specialism
The evolution of clinical nurse specialism is broad and has been recognised in the literature for many years [6,7]. Menard [8] states that the 'future of nursing has always been seen in the past'. To consider CNS roles it is useful to look at how it has developed and the various factors that have influenced that development. Specialist nursing has strong roots in the USA and this can be seen in Menard's [7] work, which traces the growth of clinical nurse specialist and factors that influenced it in the late 19th and early 20th centuries. Crediting Florence Nightingale as introducing some of the first role concepts of the CNS job, Menard traces the growth of specialism, while acknowledging that although the actual term 'specialism' in nursing began with Peplau in the 1940s, the role had existed for many years before that. These role concepts of clinical nurse specialism include education and administration, details of which can be seen in Florence Nightingale's own writings [9]. From such beginnings we now see the nurse working at a specialist and advanced level in many areas of practice. The list of skills and roles required by the nurse working at specialist or advanced level appears to evolve and adapt constantly. The CNS does work directly in clinical care as well as education and research but there are additional roles, including management, leadership, consultancy, change agent and innovator.

Clinical Nurse Specialist Roles and Activities
I worked for many years in diabetes care as a clinical nurse specialist. As the CNS develop and become more formalised and researched it was with great interest I noted the articulation of the CNS roles. Having worked as a CNS and completed my doctoral studies on the role activity of the CNS I was familiar with the complexity of the work and multiplicity of roles in CNS practice. The clinical specialist element of the CNS practice is well recognised. Similarly education and research roles are central elements of CNS practice. The CNS is active in these and other roles including leadership, management, innovation and consultancy roles [5]. Certainly the clinical focus is a core role but to function in this core role requires the CNS is often required to lead, manage, change, innovate, collaborate and consult. Personal experience had shown how it was necessary to weave such important, but lesser recognised roles into the everyday specialist practice as a CNS. When exploring CNS roles in literature there is mention of these other roles. Norton [4] in her exploration of CNS activities identified 'patient related administration' and 'other activities' which included 'general administration' [4]. Some leadership CNS role activities are captured in the study by Elliott et al. [10] where 'guidance and coordination' of the multidisciplinary team, 'initiates and changes' patient care through practice development and policy guideline, development and implementation are all identified examples of the CNS leadership role. Balsdon and Wilkinson [11] echoed this in their review of CNS productivity, showing the CNS active in innovation, leadership roles as well as managing CNS led clinics. So the CNS while focusing on specialist clinical practice is active in other important but less recognised and articulated roles. These roles however add greatly to the CNS and assist the CNS to practice to their full potential.

Management, Administration and Leadership Roles of the CNS
Management and leadership are different entities, although in the literature surrounding clinical nurse specialist, they are linked and frequently combined. Menard [8] was one of the first to do this when she identified management/leadership as an additional role for the CNS. She emphasises that power is essential in leadership and a CNS without power cannot lead, suggesting that 'the functions of the CNS may be enhanced by having the legitimate power of the line position' (p.68) [8]. Management and leadership continue to be linked in the literature [2,10].
Administration is a term sometimes used to encompass the management element of the CNS role. Some level of management and administration is required to allow the CNS to function at their full potential in their specialist role. Implementing clinical practice innovations, increasing caseloads, CNS led clinics -all require some knowledge of management, administration and leadership.
With the dynamic nature of healthcare the CNS, working at the 'coal face' , are in an ideal position to identify gaps in their specialist area of care and contribute to solutions. There are many potential benefits in the CNS being involved in leadership and management, but it is essential that a balance between these roles and clinical roles in order to protect the clinical specialist focus of practice.
If there is lack of activity by the CNS in the manager/administrator and leadership roles, which may occur as it would not be the expected 'norm', hist could limit the full utilisation of the CNS unique clinical specialist experience.

Collaboration liaison/Resource Role
Collaboration is another name for teamwork, an essential element of specialist practice. The CNS also works in a liaison/resource role, consulting and advising patients, their families and carers as they deal with their diagnoses and/or health issues. The CNS consults both internally and externally, in inter-and intradisciplinary case conferences, developing care plans etc. This role encompasses a key personal quality of the CNS -communication. Communication is essential in many areas, from working with patients to collaborating with colleagues. The CNS will acts as a collaborator/resource in their specialist area for other nursing staff and students. The CNS holds a wealth of knowledge that can contribute greatly to patient care, but to enable this knowledge to be utilised, it must be accessed. These consultant/liaison/resource roles allow this wealth of knowledge to be available to other healthcare personnel who may look to the CNS for solutions to clinical problems in the CNS specialist area of practice. While the CNS may not always be able to provide the answers, their knowledge allows them to seek answers from appropriate sources.

Change Agent, Innovator Role
Healthcare is dynamic and constantly undergoing changes. It is important for the CNS to keep up to date with these changes and implement them as appropriate and where they have the potential to improve patient care. The CNS need to actively engage in care innovations in their field of practice and should implement appropriate and relevant ones. These innovations are not implemented in isolation; many CNS utilise their collaborator role, working with their healthcare colleagues to innovate, implement, change and improve patient care. It is essential that the CNS is active in this role in order to survive and thrive in today's changing healthcare climate. It is obvious that the CNS is functioning in this change agent/innovator role.

Discussion
As mentioned, the CNS has many and varied roles. The title of this article speaks about the 'lesser' CNS roles. This is not to suggest that these roles are lesser in importance or impact but rather lesser in visibility. The clinical, educator and researcher roles are frequently explored and commented on in the literature [1][2][3][4][5]10,12]. However the CNS does operate in many additional roles which greatly contribute to their work and patient care. Examples of the CNS work in these roles can be found in the literature but requires searching and is usually confined to literature on specific areas of practice. For example, in an interesting article on the CNS in pain management [13], where Barrie speaks of CNS led clinics, case load management and coordinating services. All such work requiring the CNS to act in the roles mentioned above.
In their recent work Jokinieimi et al., [14] found a 'cautiousness to include leadership as a domain of CNS practice' inferring it may lead to confusion between leadership and management roles [14]. The implication being that the CNS management role should not be articulated. While agreeing CNS are not nursing managers, they do and should have a management role in their specialist practice. The strong clinical focus of the CNS may discourage administrative and managerial roles. However this risks little or no input from CNS in many important areas, such as policy and planning. Absence of the CNS in such areas is not beneficial. Their very clinical focus of the CNS puts them in an ideal position to contribute to future planning and decision-making relating to clinical matters.
Considering the CNS position, with up-to-date clinical expertise and close to the patient, the CNS are in an ideal position to contribute to the management process. Like the consultancy role, input into management and administration can benefit both patients and medical staff, and here again the specialist knowledge of the CNS needs to be utilised. Lack of activity by the CNS in the manager/administrator role -perhaps as it is n ot the expected 'norm' -will hinder the CNS in allowing their patients' voices to be heard and the utilisation of their unique clinical specialist experience.

Conclusion
There is a clear need to further explore specialist nursing practice within the clinical context and articulate and capture all the roles of the CNS. Additional role components, apart from the clinical, education and research roles are recognised by those working in individual specialist areas [5,12] and may be based on deep knowledge and skill experience in the specialist field,. Management and administration of the healthcare system is an important and rapidly developing area, the CNS must have an input and contribute to and manage change. If they are to take the lead in care, they must contribute and take part in administrative work to ensure that their knowledge and expertise is utilised. The CNS is a valuable resource and it is essential that they are utilised to their full potential to support best patient care. Failure to recognise some of their roles will lessen the opportunity for utilisation. There is a serious need to highlight and research the 'lesser' but very important CNS roles.