MARCH 1985, VOL 41, NO 3 A O R N J O U R N A L

The Clinical Nurse Specialist THE ROLE IN THE OR

carol schramm, RN

he clinical nurse s-t (CNS) has evolved in response to an abandonment of clinical T nursing by n m with advanced education

and expertise. Becoming a clinical speclalist provides opportunity for the nurse to advance in his/her career without forsaking clinical practice in favor of administration or education. There has been little written about clinical nurse specialization as it pertains to nursing in the operating room. To help remedy this deficiency, a study examining the role of the CNS in the operating room was done. The role of the CNS in effecting planned change was sped idy addressed.

Conceptuul Framework

s a conceptual framework for practice, role theory can assist n w in analyzing present A functions and planning future. performance.

Role theory holds that people assume roles, or sets of shared expectations focused upon a particular position. When expectations evolve into conflicting, ddlicult, or impossible demands, role stress and role struin result. Role stress is an external force causing ddliculty in the enactment of a role. Role strain is the subjective, internally perceived consequence of role stress, and can be manifested as frustmtion, tension, or anxiety.

Role mdication and role making, in turn, are ways to dissipate role stress and role strain. By modlfymg existing roles or creating new sets of role expectations, nurses can maintain their professional status in contriiuting to health care delivery. Because operating room nurses experience role

stress and role stmin and view role modification and

role making as plausible means for alleviating these, a method for c-g their roles is needed. Change theory is the link between the tenets of role theory and operating room nursing practice. Planned change offers control to the change process by addressing vague, anticipated problems and concrete, existing ones.

Resistance to change is inevitable, and must be considered when planning change. The more effort needed to alter the status quo, the more resistance there will be. A complete lack of resistance to change is also undesirable, because some conflict is necmary for change to last.' There are three major stategies for effecting change.

The empirical-rational approach-change originates through the formal authority of the "changer."

Carolschramm, RN MSN ir the arristont nursing unit admin&a&r for general surgeiy, bums, and ophthhwl- ogv at the Universify of Colorado H& Scknces Center, Denver. She received her MSN from the University of Cobrado, Denver, and her BSN from Bowling Green (Ohio) State Univew.

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The normativereeducative strategy-“chan- gee’s” acceptance of the change is most important“ The powercoercive tadc-sanctionings and punishments are used to effect change.

Literahrre Review

he profession of nursing has become increasingly specialized throughout this T century. As early as 1900, DeWitt foresaw

.spialmtion in nursing as inevitable. She believed speciahtion would be a means of imparting &her quality patient care and greater personal satisfaction for nurses?

Mauksch, however, contended that “during the 195Os, nursing became a technical service, supervised according to an industrial model by nurses who identified strongly with management, denied their practice orientation, and avoided their patient

By the mid-l950s, nursing leaders were reversing this trend. Reiter coined the term ”nurseclinician” to bi the kind of nurse that would retum the profession to its primary mision-quality patient care. Accordmg to Reiter, the n d c i a n could demonstrate clinical competency relative to range of function, depth of understan- and breadth of service.4

Peplau added the aspect of clinical specidmtion and put it in the realm of a master‘s prepared clinician. Some of Peplau’s speclalties-pychiatric, medical- surgical, and maternal-child nursing-exist in master’s programs today?

Educators and administraton today concur on the qualifications for the CNS-they must have a great deal of clinical experience and be able to demonstrate a hgh degree of expertise in a particular field of nursing, and they should have completed a master’s program in nursing with a clinical emphasis.6

Gowers, McGann, and the National League for Nursing (NLN) give five major factors that form the role of the CNS.

1. ClinicaI prmke-the CNS must be involved in patient care, directly or indirectly, by leading and guiding &and should be immune &om distractions pertainingto- tion or management.

2. Comultaiion-the specialist should be a

advocacy r0le.993

. .

resouTce person, a positive support for the staff, and an originator of objectivity and innovation in patient

3. &&n--the CNS facilitates high quality learning situations for the ski& the patients, and their Eunilies. The objective of the CNS role is to improve the level of care delivered, rather than to foster dependence upon the spmahst by staff and patients. Education can assure that the latter does not take

4. Rmeuch-theE must be rigorous testing of theories and interventions if nursing is to progress professionally.

5. Change ag-the speclalists efforts of clinical practice, consultation, education, and research are invested with the potential to elevate the quality of nursing care?

Gordon, author of the initial treatise calling for inclusion of change agentry in the CNS role definition, contends that the CNS holds “ultimate responskdity for the dissemination of new knowledge and the development of new nursing methods.”*

Edlund and Hodges, Padilla and Padilla, and the NLN stated that the CNS must be a change agent to properly fulfill the role’s requirements? Change agentry weaves the other four facets of the CNS role to yield improvements in nursing care delivery. As a result, the five divisions coalesce to form clinical work that is exciting, rewarding, “and often much more stimulating than the management and education options which had appeared to be the only avenues open to nurses wanting to use their initiative and decision-making skills.”10

care.

Place.

Methalology

A5 exploratory descriptive design was used this study, allowing for the investigation attitudes and opinions while addmg to

the body of knowledge regarding clinical nurse speaahtion in the operating room. The two variables were the operating room nursing role and clinical nurse specialization-integration. The operating room nursing role was dehed as the set of professional values held and functions performed by registered nurses currently p d c i n g in operating rooms. Clinical nurse speclalization-integration was defined as clinical practice, consultative, educative,

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Fig I

Please place a check in the box under the number that best describes your response to the following statements. The number key is:

LikertItems

1 = strongly disagree 2=dlsagree 3=unsure 4=agree 5 = strongly agree

1.

2.

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4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

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21.

The role of the nurse today is very clear.

Nurses are free to decide how they wish to provide care.

Current trends in health care payment will not benefit nursing. More interesting and ful6hg nursing jobs will keep nurses from leaving the profession.

The nurses on my unit experience job-related stress.

Seldom is my job so demanding that I feel tired or inefficient.

Fiscal demands in my facility will compromise the care provided on my unit.

Nursing jobs today should make better use of nurses’ intelligence and abilities.

Reacting to problems as they arise is the best way to handle d8iculties.

Nurses need more control over their jobs.

I see initiating change as part of my job.

The best way to change things is by pushing hard for change.

The nurses on my unit have an obligation to obey my directions.

The less conflict on my unit, the better.

Change is usually short-lived unless people want to accept it.

A little conflict helps insure that change will last.

Masters preparation of nurses can improve patient care.

The clinical nurse specialist is not a viable role today.

Nurses who remain in staff positiom generally earn as much respect as those in administration or education.

I would like to give more direct patient care than I do.

A clinical nurse speclalist would be good for my unit.

22. Hiring a clinical nurse specialist would mean that nursing care on my unit

23. Clinical nurse speaalsts have been good for nursing.

24. Nursing research has little impact on provision of care.

is lacking.

1 2 3 4 5

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research, and change agentry functions performed by clinically s p e c k h d , mastefs prepared nurses, and their placement in nursing hierarchies. A nonrandom, convenience samphng of operating room head nurses, supervisorS, and staff development coordinators from the Denver metropohtan area was used.

Instrument

data gathering instrument was developed from an analysis of role theory, change A theory, and clinical nu= specialization

literature. It contained 24 Likert items and five open- ended items assessing the following questions (Figs 1 and 2).

1. How are operahng room nurses today affected by role stress, role strain, role modification, and role

2. Does clinical nurse spemdization and its inherent change agentry provide a means for improving patient care and, to that end, where should the role be placed within nursing hierarchies?

A cover letter and copy of the instrument were mailed to each member of the sample population. Twenty-eight of 34 (82%) eligible persons participated in the study.

making?

F ~ n g s and Analyst5

he data were analyzed by using descriptive statistics and content analysis. The mean, T standard deviation, and mode were computed

for each Likert item, with responses being divided by participant subgroups of head nurses-supervisors (HNSs) and staff development coordinators (SDCs). Content analysis was performed on data from the openended items.

To validate the comparison of group means for Likert item, a Student’s t-test for paired samples was computed. The test demonstrated that neither group exhibited significantly more polarity of response than the other. Therefore, each group’s means may be compared against one another. For data analysis, a Likert score of more than 3.00 was considered a tendency to agree with a statement and a score of less than 3.00 was considered a tendency to disagree.

Role &jinkioion. Likert items one through eight determine how clearly dehed the role of the operating room nurse is, the existence of role stress and role strain in operating room nursing, and if role modification and role making could be answers for the s t r ~ and strain. Both HNSs and SDCs tended to agree that operating room nurses experience j o b related stress, that nursing jobs should make better use of nurses’ intellgene and abilities, and that more interesting and fblilhg jobs might keep nurses from leaving the profession. Both groups tended to cllsagree that they seldom feel tired or inefficient in the performance of their jobs, that nurSeS have freedom in deciding how to provide care, and that nursing roles today are clearly dehed. The HNSs shghtly agreed that prospective reimbursement will not benefit nursing, while shghtly m e e i n g that fiscal demands in their institutions will compromise the care provided on their units. The SDCs shghtly agreed with both items (Fig 1). Effective change. Likert items nine through 16

assess the respondents’ desire for change and measure their knowledge and application of the tenets of change theory. Both groups tended to agree that initiating change is part of their job, that change is usually short-lived unless people want to accept it, that nurses need more control over their jobs, and that a little conflict is neoessary for change to be lasting. Similarly, the two groups tended to drsagree that reacting to problems as they arise is a good way to handle difficulties, that low conflict levels are good for their units, and that nurses on their units have an obligation to obey their orders. While the staff development coordinators tended to drsagree that pushing hard best accomplishes change, head nurses-supekrs were evenly split (Fig 1).

CNS role. Likert items 17 through 24 ascertain the sample population’s comprehension of and receptivity to the CNS role. Both groups tended to agree that the CNS role has been good for nursing and would be good for their units. The HNSs m e e d that master’s preparation of nurses could improve patient care and the SDCs were evenly divided. Regarding if the respondents wished to provide more direct patient care than they are able to do now, HNSs only slightly agreed they would like to and SDCs were split. While HNSs slightly agreed that nurses in staff positions earn as much

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respect as those in administration or education, SDCs slightly disagreed. Both groups tended to cllsagree that nursing research has little impact on the provision of care, that hiring a CNS would indicate deficient care on their units, and that the CNS role is nonviable

Open-endid h. Question one of the open- ended items (Fig 2) was formulated to document the existence of role conflict and how respondents handle it. Eighty-two per cent of both groups reported that they do experience role conflict-resulting f?om conflicting sets of expectations thrust upon them by physicians, staff, management, and themselves. Additionally, HNSs often cited unclear role differentiation leading to a lack of accountability in their departments and paperwork superceding desired clinical involvement. The SDCs were subject to role conflict because of staff indifference to their efforts, and staff viewing scrubbing and circulating only as legitimate types of work.

communication was the most fiquently cited means of dealing with role conflict by both head nurses-supervisors (91%) and staff development coordinators (78%). Secondly, HNSs suggested prioritizing and delegating of task, SM3s also suggested prioritizing tasks, but carried out the duties themselves.

Change agent. Openended item two related to change and how respondents would apply it to their own jobs and to operating room nursing. The answers demonstrated a strong desire to accomplish change in both areas-88% of the HNSs and 72% of the SDCs indicated they would change their own jobs if given the chance, and only one person offered no suggestions for changing operating room nursing. Both groups felt nurses should be more professional, which they charactew as collegml, committed, assertive, and accountable. The second, most desired change was increased preoperative and postoperative involvement.

CNSmt2bm. Openended item three asked prhcipants to apply the functions of the CNS to their own units. Responses indicated that the role’s credibility is founded upon clinical proficiency. The CNS was envisioned by both HNSs and SDCs as a role model, preceptor, penoperative practitioner, patient advocate, change agent, innovator of new nursing techniques, and a developer of objective

today (Fig 1).

Fig 2

Open-e&Item 1. Role conflict is a common problem for nurses.

It occurs, for example, when a person must perform two incompatible jobs or when people have conflicting expectations of what a job ought to be. How does role mnflict affect you and how do you handle it?

2. As operating room nurses, we must face daily changes in our jobs. If it were up to you, how would you change your job and how would you change operating room nursing?

3. Clinical nurse speaahzation includes chca l practice, consultation, education, and research, among other things. How do you think that your unit would benefit most &om performance in each of those four areas?

4. Clinical nurse s@t qualifications generally focus on past experience and present ability, or expertise. If you were hiring a clinical nurse spemht for your unit, what sorts of experience and expertise would you look for?

5. Placement of the clinical nurse speclalist can affect how well the spemht does her job. Line placement means being part of the formal chain of command; ssaff placement means giving service, advice, and counsel, but having no formal authority; functional placement means having formal authority over staff nurses’ activities only as they relate to actual delivery of care. Of those three types of placement, which would you choose for the clinical nurse speclalist and why?

means for quantifying nursing performance. Additionally, the CNS was viewed as being able to translate nursing research and theoretical concepts into daily practice, to we nursing @om, and to establish stan&& of care.

Most respondents thought consultative functions should be performed within the unit, on a staff resource level. Several persons envisioned the CNS being a liaison to other units within the hospital, while a few said consultation could extend to other institutions.

The CNS as educator was seen as a teacher of new staff and provider of ongoing staff development.

MARCH 1985, VOL 41, NO 3 AORN J O U R N A L

Educative functions also mentioned were patient and family education, teachq sterile technique on other units, and advising other nufses in the continuance of their education.

Research efforts for the CNS most commonly suggested were enlarging quality assurance functions beyond chart audits and documenting the worth of professional nursing in the operating room.

CNS qd-m. Openended item four inquired as to the education, experience, and the expertise neceSSary to properly llfill the CNS role. A majority of participants wanted the CNS to possess a master’s degree, while only 10% thought no degree was needed. In tern of operating room nursing experience, the trend was that more was better, although onethird of the HNSs said one to two years would be acceptable. Of that group, most attached a qualification of additional floor or critical care experience, as did 80% of all HNSs. The SDCs were divided on the value of nursing experience outside the operating room. In addition, respondents generally wanted the CNS to have much scrubbing and circulating experience, plus some teaching ability.

Line, shff, orfuractionar Openended item five asked participants to select the ideal placement in the nursing hierarchy for the CNS. Most frequently, respondents chose line placement. Functional placement was second, and staff placement was last in selection.

Study L i m i b n s

ome aspects of this study limit the application of its findings. Becaw the data gathering S instrument was developed by the researcher,

it needs further testing to adequately establish reliability and validity. Also, the sample population was drawn solely from the Denver metropolitan area. The inclusion of individuals from other a r m throughout the country might render a more balanced view of clinical nurse specialization in the operating room. In addition, a larger sample size might have resulted in more generalized findings. Finally, failure to obtain demographic data prevented the researcher from recognizing the response trends relative to the participant’s age, education, institution size, and so forth.

Implications

number of implications for operating room nursing arise fiom this study. Because the A participants widely confirmed the existence

of role stress and role strain in their jobs and on their units, efforts must be made to counteract the negative impact those phenomena create. Operating room nursing leades must work to clanfy the role and document the worth of professional nursing in the surgical suite. As prospective health care reimbursement has hospital administrators examining all possible ways of reducing expenditures, nursing leaders must strive to prove the benefits of comprehensive nursing care over routine technical performance-in light of patient outcomes, s W g flexibility and role interchangeability, absenteeism and sick time utilization, and staff turnover.

The positive attitude conveyed by respondents toward the CNS role suggests there is a definite place for such n m in operating rooms today. More master’s prepared operating room nurses are needed to fullfill this role and advance nursing practice. 0

NdeS

Prentice-Hall, h~, 1982) 382-388. 1. J A Stoner, Managemew (Englewood CWb, NJ:

2. K LkWitt, “Specialties in nursing,”Ameerican Journal of Nursing 1 (October 1900) 14-17.

3. I C M a k h , “Faculty practice: a profmional imperative,” Nurse Educator 5 (May/June 1980) 22,

4. F Reiter, “The nurse clinician,” Americun Journal of Nursing 66 (February 1966) 274-280.

5. H Peplau, ‘‘SSpeclaluation in professional nursing,” Nursing Science 3 (August 1965) 268-287.

6. M R McGann, ”The clinical specialist: from hospital, to clinic, to community,” Journal of Nusing Adminis-

7. S Gowers, “Clinical nurse specialst: something special,” Nursing Mirror 152 (May 1981) 31; Mffiann, “The clinical speclalist”; National League for Nursing (NLN), “A review of the preparation and roles of the clinical nurse specialisf” in l’k C M Nurse Spc& Interpretahbns, ed J P Riehl, J W McVay (New York Appleton-Century-Crofts, 1975) 1 15-1 17.

8. M Gordon, “The clinical specialist as change agent,” Nursing Outlook 17 (March 1969) 37-39.

9. B J Edlund, L C Hcdges, ”Preparing and using the clinical nurse specialist: a shared responsiity,” Nusing Clinics of North America (September 1983) 499-507; G V Padilla, G J Padilla, “Nursing roles to improve patient care,” Nursing Digest 6 (Winter 1979) 1-13.

10. Gowers, ‘‘Clinical nurse specialist”

Irclrion 5 (MuCh/Apd 1975) 33-37.