Clinical Nurse Specialist Education and Practice Challenges
Clinical Nurse Specialist Education and Practice Challenges
CNSs working in clinical practice settings have opportunities to influence quality patient care using both direct and indirect tactics: providing direct care, acting as mentors for frontline nurses and other healthcare professionals, during CNS leadership activities, and in many other ways. The variety in services CNSs can provide, however, may be the very reason challenges in practice arise. While different healthcare settings likely present unique problems for CNSs, shared problems include CNS role-definition, moving evidence into practice, effective change management, prioritization and time management, and demonstrating benefits to the organization. A review of these challenges along with suggestions for mitigating each is discussed.
One challenge CNSs may face is lack of clear-cut role definition. Within and outside the healthcare arena, some people are unfamiliar with the title clinical nurse specialist. If one were to ask a layperson, physician, or even a registered nurse (RN) what a nurse practitioner, certified nurse midwife, or certified registered nurse anesthetist is, a fairly accurate response is likely. Of the four types of APRNs, the CNS seems to be the least familiar to others, despite having over 75,000 CNSs in the United States with the education and credentials to practice as such (National Association of Clinical Nurse Specialists, n.d.). How is it that such a large group has such an identity problem?
One possibility is role diffusion stemming from the chameleon-like abilities of CNSs. CNSs have an array of skills and knowledge and are able to adapt to a variety of professional roles including direct patient care providers, educators, case managers, researchers, clinical improvement project leaders, and more. This flexibility can lead to blurred lines rather than clear role parameters and cause others to assume the CNS has a job title typically associated with these types of activities. For instance, a CNS who spends a great deal of time providing direct patient care in a chronic disease clinic may be mistakenly referred to as a nurse practitioner, while another who focuses on nursing education may be labeled an educator.
Role challenges can be frustrating to CNSs in clinical practice because others' perceptions may lead to limitations in job responsibilities and underutilization of the advanced knowledge and skills CNSs possess. For example, a CNS may face barriers to the credentialing and privileging process necessary for providing medical care to patients and billing for services, even when the CNS has met all appropriate requirements and such practice is permitted by the respective state board of nursing. Other frustrations may be a perceived lack of respect for the CNS's breadth and depth of knowledge, salaries not commensurate with other categories of APRNs, or a diminished sense of leadership responsibilities.
CNSs in clinical practice need to be able to articulate their roles in clear, concise, and meaningful ways. One way to do so is to prepare a brief verbal statement that can be delivered in 30 seconds or less when describing one's own CNS role to others. This is informally referred to as an 'elevator speech.' When developing this description, a CNS might reflect upon the primary role(s) in which he or she functions, then state associated activities and outcomes in concrete terms. The National CNS Competency Taskforce (2010) published CNS Core Competencies, which includes behavioral statements and could be used to generate ideas for developing this description (National CNS Competency Taskforce, 2010). Additionally, the NACNS website has a frequently asked question (FAQ) page on which the CNS role is explained (NACNS, 2013). This explanation offers a starting point for the CNS looking to develop a personalized role description in terms of specialty, population served, and outcomes achieved. An example of an elevator speech is shown in Box A.
In addition to verbal communication, CNSs can develop handouts, brochures or business cards listing key role features to share with colleagues or patients. For organizations with intranets, CNSs can request a webpage to house information about APRNs, including photographs, role descriptions and contact information.
Other ways CNSs can explain their roles is to write or revise CNS job descriptions that accurately reflect the role, and to create performance goals based on CNS functions and desired outcomes. A well-written CNS job description can clarify and legitimize the role of the CNS within a particular organization. This set of expectations can be taken a step further by integrating role and competency related questions into the CNS interview process. CNSs in one organization developed a structured behavioral peer interview process centered on the CNS competencies (Lampe, Geddie, Aguirre, & Sole, 2013). Such an interview process is an excellent opportunity for CNSs to refine role definition within a particular organization so expectations can be clear to all involved. CNSs seeking employment might consider using a similar approach to pose questions to the interviewers about how the CNS role is viewed and operationalized. This could aid in identifying whether or not an employer is a good fit for the job-seeking CNS. Table 1 lists several tools CNSs can use as vehicles to communicate the role to others.
A key activity of CNSs in clinical settings is to drive changes in practice based upon best available evidence; however, various barriers to adoption and implementation of EBP exist. Impediments to change come from different angles including bedside nurses or nurse leaders and other healthcare professionals reluctant to change, workflow processes, financial constraints, and a host of other factors.
A recent study by Campbell and Profetto-McGrath (2013) examined factors around CNS promotion of EBP. The top five challenges to implementing EBP identified by CNSs in this study were multiple CNS roles, heavy workload, time constraints for bedside clinical nurses, time constraints for CNSs, and lack of resources. All respondents in the study indicated dedicated time, and almost 96% believed assistance/support from others, influenced their abilities to disseminate evidence. The authors concluded CNSs needed individual and organizational support to facilitate EBP (Campbell, & Profetto-McGrath, 2013). Similarly, an integrative review of the literature examining barriers and facilitators to EBP reported that organizational barriers included time, higher prioritized goals for leaders, lack of resources and heavy workloads (Solomons & Spross, 2011). Cultural barriers to EBP were resistance to change, lack of interest, recognition for EBP, and lack of authority to create change.
Individual CNSs' lack of knowledge and comfort in accessing and evaluating evidence can be barriers to EBP (Solomons & Spross, 2011). Concerns can range from how to search for evidence to how to evaluate statistical analyses and conclusions of a research study. Although CNSs are prepared through education and experience to do these things, not everyone has the same comfort level while engaging in these activities.
Facilitators to EBP within organizations have also been identified. These include linking EBP to job descriptions and promotions, having nurse representation on organizational committees, discussing EBP in orientation, and giving nurses dedicated time for literature review and participation in practice changes (Solomons & Spross, 2011). Some hospitals have EBP committees and/or journal clubs, which allow nurses to develop their own skills, then pass this on to others through mentoring and guidance (Solomons & Spross, 2011). Another approach is using existing groups as opportunities to facilitate EBP activities, such as requesting time on the agenda at staff meetings or other council meeting for dialogue about the importance of EBP (Dogherty, Harrison, & Graham, 2010).
Outside of formal committee structures, CNSs can shift culture by embracing informal opportunities to teach EBP and the benefits to patients, nurses and the organization. CNSs can teach data-base searching skills and critical appraisal methods. The CNS can connect the medical librarian with the staff and introduce internet-based resources such as PubMed, Google Scholar, or websites of professional nursing organizations with access to evidence-based resources. Fostering a personal connection helps in translating research into practice. Patient-focused case examples illustrating negative outcomes of eluding EBP and positive outcomes from using EBP can be an effective strategy used to aid in adoption of EBP. Sustaining a culture of EBP requires mentoring and supporting staff champions, translating research into user-friendly language, and providing frequent feedback on project progress and outcomes.
With growing disparity in the US population, sicker patients, increasing regulatory requirements, and shrinking reimbursement, balancing the demands to survive requires organizations to respond quickly, with never-ending change a consequence. While clinical practice reforms have always been a cornerstone of CNS practice, CNSs may be called upon to lead transformation beyond the bedside to address these challenges. Acquiring new products or capital equipment, remodeling a nursing unit, developing a model for APRN practice, or working on a team to map workflow and design in an electronic health record are some examples where CNSs may assume a leadership role.
No matter what the change, hurdles are likely. Erwin (2009) identified three main challenges to success when studying change in hospitals. The first challenge focused on a cluster of gaps in the skills of people within the organization to plan and implement change. The second involved beliefs about financial performance in conflict with quality patient care. The third was a gap in maintenance of energy, commitment and patience to sustain performance. Recommendations were to provide leadership development, to make thinking about financial measures part of the organizational culture and a value for all members, and to recognize the need to invest time coupled with patience and courage to accept change (Erwin, 2009). Related considerations for the CNS are to continuously improve as a change manager by learning to apply different approaches, demonstrate the financial impact of change alongside quality outcomes, and to persist in worthwhile change projects, even when they move slowly or setbacks are encountered.
CNSs will need to employ collaboration competencies to facilitate change because just as healthcare delivery requires a multidisciplinary team, change is a team activity. CNSs can contribute to change management by participating on, facilitating, or leading improvement teams, and involving staff nurses and other stakeholders in implementing change. Leaders in an organization's quality department can be good resources for CNSs seeking information about preferred organizational approaches for process improvements and change management.
Insufficient time for self- or organization-defined accomplishments and responsibilities has been identified as a barrier for CNSs' effectiveness (Campbell, & Profetto-McGrath, 2013; Dogherty, Harrison, Graham, 2010). Given the reality of much work to be done and a finite amount of time, CNSs must become experts in time management and priority setting to maximize desired results and decrease feelings of being chronically overworked.
Ellis and Abbott (2011) provide several suggestions for time management aimed at nurse managers, but equally pertinent to CNSs. One is to maintain focus, have a vision, and leverage a team to achieve that vision. CNSs can apply these principles by working with teams of other CNSs, nurses, managers, educators, and/or other stakeholders to maximize efforts of all toward achieving desired outcomes. CNSs need to prioritize work and focus on what is determined to be most important: activities that bring value to the organization, to the patient population, to the nursing staff, or sometimes to the CNS. Creating a list then evaluating each item in terms of time-sensitivity and value can help clarify which activities take priority. In the face of competing agenda items with no clear top priority, the CNS may want to seek input from administrative leaders to ensure focus on priorities for the organization.
Other time management tactics described by Ellis and Abbott (2011) are setting aside time each day to work on key initiatives, saying no to non-productive activities, prioritizing meetings and/or sending a designee, and setting daily goals. Using technology such as sharing web-based work sites can decrease the number of meetings and make better use of time. CNSs should remember to include at least some activities that offer professional gratification each week in order to maintain a sense of purpose and self-care.
Another reality in the healthcare arena is the need to demonstrate the value CNSs bring to an organization. Terms such as "indirect caregivers" and "non-productive time" are used in budgets, and, to the less informed, can suggest employees in such roles are wasteful overhead. CNS positions may fall into these categories because they are not typically included in direct patient care staffing. CNS positions may be at risk when budgets are tight and cutbacks are necessary. CNSs need to be clear about how they contribute to the organization in concrete ways nurse and non-nurse leaders can appreciate.
Ideally the value a CNS brings can be quantified financially. An EBP project to reduce catheter-associated urinary tract infections (CAUTI), for instance, has financial implications because of reimbursement changes from the Centers for Medicare and Medicaid Services (CMS) that took effect in 2008 (Department of Health and Human Services, Centers for Medicare and Medicaid Services, 2012). A CNS who participates in this type of work needs to work with the quality, infection control, supply management and hospital finance departments to analyze the financial benefits of EBP changes. Pre- and post-implementation data can be used to compare cost of care before and after the project to demonstrate the impact of a CNS-influenced initiative.
There are several other ways CNS activities can produce positive financial outcomes. CNSs may contribute to improvements in nurse retention by mentoring others or developing an innovative program to reduce the number of hours newly hired nurses spend in orientation. CNSs who manage a specific population of patients, such as those with heart failure, may be able to demonstrate reduced lengths of stay or recidivism rates. CNSs who bill for services can report their contribution to a facility's reimbursement income. CNSs should look for opportunities to translate CNS activities into financial benefits. Demonstrating the value a CNS brings not only helps justify the individual CNS's position, but raises awareness of the role's value and contributes to the financial security of the institution.
There are various ways CNSs can demonstrate value to the organization (Table 2). One approach is developing a portfolio to showcase a variety of professional activities and associated outcomes (Shirey, 2009; Hespenheide, Cottingham, & Mueller, 2011). Another is creating a spreadsheet or dashboard listing key activities of the CNS with specific outcomes. Benefits of a dashboard include the ability to succinctly record information that can be used to monitor progress so timely adjustments can be made if needed (Harrington, et al, 2005). Another approach is to ensure annual performance goals include measurable outcomes a CNS can use as evidence of contributions to the organization. CNSs who do not already contribute to development of their own performance goals may want to consult with their superiors to discuss ways to do so. This collaborative approach can be mutually beneficial: articulating annual goals can assist the CNS in setting priorities and focus on activities most likely to achieve desired results for both the individual and the organization.
CNSs in clinical practice face various challenges. Depending on the situation, there are opportunities to use effective ways to untangle complex, organizational issues, or to experiment with novel approaches. CNSs are well qualified to respond with expertise in advanced nursing practice, knowledge of patient and family concerns, and systems thinking. Educators must consider these realities when developing didactic content, clinical practica, and other learning opportunities in order to adequately prepare CNSs for the complexities of a chaotic, ever changing healthcare system.
Challenges in Clinical Nurse Specialist Practice
CNSs working in clinical practice settings have opportunities to influence quality patient care using both direct and indirect tactics: providing direct care, acting as mentors for frontline nurses and other healthcare professionals, during CNS leadership activities, and in many other ways. The variety in services CNSs can provide, however, may be the very reason challenges in practice arise. While different healthcare settings likely present unique problems for CNSs, shared problems include CNS role-definition, moving evidence into practice, effective change management, prioritization and time management, and demonstrating benefits to the organization. A review of these challenges along with suggestions for mitigating each is discussed.
Role Clarity
One challenge CNSs may face is lack of clear-cut role definition. Within and outside the healthcare arena, some people are unfamiliar with the title clinical nurse specialist. If one were to ask a layperson, physician, or even a registered nurse (RN) what a nurse practitioner, certified nurse midwife, or certified registered nurse anesthetist is, a fairly accurate response is likely. Of the four types of APRNs, the CNS seems to be the least familiar to others, despite having over 75,000 CNSs in the United States with the education and credentials to practice as such (National Association of Clinical Nurse Specialists, n.d.). How is it that such a large group has such an identity problem?
One possibility is role diffusion stemming from the chameleon-like abilities of CNSs. CNSs have an array of skills and knowledge and are able to adapt to a variety of professional roles including direct patient care providers, educators, case managers, researchers, clinical improvement project leaders, and more. This flexibility can lead to blurred lines rather than clear role parameters and cause others to assume the CNS has a job title typically associated with these types of activities. For instance, a CNS who spends a great deal of time providing direct patient care in a chronic disease clinic may be mistakenly referred to as a nurse practitioner, while another who focuses on nursing education may be labeled an educator.
Role challenges can be frustrating to CNSs in clinical practice because others' perceptions may lead to limitations in job responsibilities and underutilization of the advanced knowledge and skills CNSs possess. For example, a CNS may face barriers to the credentialing and privileging process necessary for providing medical care to patients and billing for services, even when the CNS has met all appropriate requirements and such practice is permitted by the respective state board of nursing. Other frustrations may be a perceived lack of respect for the CNS's breadth and depth of knowledge, salaries not commensurate with other categories of APRNs, or a diminished sense of leadership responsibilities.
CNSs in clinical practice need to be able to articulate their roles in clear, concise, and meaningful ways. One way to do so is to prepare a brief verbal statement that can be delivered in 30 seconds or less when describing one's own CNS role to others. This is informally referred to as an 'elevator speech.' When developing this description, a CNS might reflect upon the primary role(s) in which he or she functions, then state associated activities and outcomes in concrete terms. The National CNS Competency Taskforce (2010) published CNS Core Competencies, which includes behavioral statements and could be used to generate ideas for developing this description (National CNS Competency Taskforce, 2010). Additionally, the NACNS website has a frequently asked question (FAQ) page on which the CNS role is explained (NACNS, 2013). This explanation offers a starting point for the CNS looking to develop a personalized role description in terms of specialty, population served, and outcomes achieved. An example of an elevator speech is shown in Box A.
In addition to verbal communication, CNSs can develop handouts, brochures or business cards listing key role features to share with colleagues or patients. For organizations with intranets, CNSs can request a webpage to house information about APRNs, including photographs, role descriptions and contact information.
Other ways CNSs can explain their roles is to write or revise CNS job descriptions that accurately reflect the role, and to create performance goals based on CNS functions and desired outcomes. A well-written CNS job description can clarify and legitimize the role of the CNS within a particular organization. This set of expectations can be taken a step further by integrating role and competency related questions into the CNS interview process. CNSs in one organization developed a structured behavioral peer interview process centered on the CNS competencies (Lampe, Geddie, Aguirre, & Sole, 2013). Such an interview process is an excellent opportunity for CNSs to refine role definition within a particular organization so expectations can be clear to all involved. CNSs seeking employment might consider using a similar approach to pose questions to the interviewers about how the CNS role is viewed and operationalized. This could aid in identifying whether or not an employer is a good fit for the job-seeking CNS. Table 1 lists several tools CNSs can use as vehicles to communicate the role to others.
The CNS and Evidence-based Practice (EBP)
A key activity of CNSs in clinical settings is to drive changes in practice based upon best available evidence; however, various barriers to adoption and implementation of EBP exist. Impediments to change come from different angles including bedside nurses or nurse leaders and other healthcare professionals reluctant to change, workflow processes, financial constraints, and a host of other factors.
A recent study by Campbell and Profetto-McGrath (2013) examined factors around CNS promotion of EBP. The top five challenges to implementing EBP identified by CNSs in this study were multiple CNS roles, heavy workload, time constraints for bedside clinical nurses, time constraints for CNSs, and lack of resources. All respondents in the study indicated dedicated time, and almost 96% believed assistance/support from others, influenced their abilities to disseminate evidence. The authors concluded CNSs needed individual and organizational support to facilitate EBP (Campbell, & Profetto-McGrath, 2013). Similarly, an integrative review of the literature examining barriers and facilitators to EBP reported that organizational barriers included time, higher prioritized goals for leaders, lack of resources and heavy workloads (Solomons & Spross, 2011). Cultural barriers to EBP were resistance to change, lack of interest, recognition for EBP, and lack of authority to create change.
Individual CNSs' lack of knowledge and comfort in accessing and evaluating evidence can be barriers to EBP (Solomons & Spross, 2011). Concerns can range from how to search for evidence to how to evaluate statistical analyses and conclusions of a research study. Although CNSs are prepared through education and experience to do these things, not everyone has the same comfort level while engaging in these activities.
Facilitators to EBP within organizations have also been identified. These include linking EBP to job descriptions and promotions, having nurse representation on organizational committees, discussing EBP in orientation, and giving nurses dedicated time for literature review and participation in practice changes (Solomons & Spross, 2011). Some hospitals have EBP committees and/or journal clubs, which allow nurses to develop their own skills, then pass this on to others through mentoring and guidance (Solomons & Spross, 2011). Another approach is using existing groups as opportunities to facilitate EBP activities, such as requesting time on the agenda at staff meetings or other council meeting for dialogue about the importance of EBP (Dogherty, Harrison, & Graham, 2010).
Outside of formal committee structures, CNSs can shift culture by embracing informal opportunities to teach EBP and the benefits to patients, nurses and the organization. CNSs can teach data-base searching skills and critical appraisal methods. The CNS can connect the medical librarian with the staff and introduce internet-based resources such as PubMed, Google Scholar, or websites of professional nursing organizations with access to evidence-based resources. Fostering a personal connection helps in translating research into practice. Patient-focused case examples illustrating negative outcomes of eluding EBP and positive outcomes from using EBP can be an effective strategy used to aid in adoption of EBP. Sustaining a culture of EBP requires mentoring and supporting staff champions, translating research into user-friendly language, and providing frequent feedback on project progress and outcomes.
CNS as Change Agent
With growing disparity in the US population, sicker patients, increasing regulatory requirements, and shrinking reimbursement, balancing the demands to survive requires organizations to respond quickly, with never-ending change a consequence. While clinical practice reforms have always been a cornerstone of CNS practice, CNSs may be called upon to lead transformation beyond the bedside to address these challenges. Acquiring new products or capital equipment, remodeling a nursing unit, developing a model for APRN practice, or working on a team to map workflow and design in an electronic health record are some examples where CNSs may assume a leadership role.
No matter what the change, hurdles are likely. Erwin (2009) identified three main challenges to success when studying change in hospitals. The first challenge focused on a cluster of gaps in the skills of people within the organization to plan and implement change. The second involved beliefs about financial performance in conflict with quality patient care. The third was a gap in maintenance of energy, commitment and patience to sustain performance. Recommendations were to provide leadership development, to make thinking about financial measures part of the organizational culture and a value for all members, and to recognize the need to invest time coupled with patience and courage to accept change (Erwin, 2009). Related considerations for the CNS are to continuously improve as a change manager by learning to apply different approaches, demonstrate the financial impact of change alongside quality outcomes, and to persist in worthwhile change projects, even when they move slowly or setbacks are encountered.
CNSs will need to employ collaboration competencies to facilitate change because just as healthcare delivery requires a multidisciplinary team, change is a team activity. CNSs can contribute to change management by participating on, facilitating, or leading improvement teams, and involving staff nurses and other stakeholders in implementing change. Leaders in an organization's quality department can be good resources for CNSs seeking information about preferred organizational approaches for process improvements and change management.
Time Management
Insufficient time for self- or organization-defined accomplishments and responsibilities has been identified as a barrier for CNSs' effectiveness (Campbell, & Profetto-McGrath, 2013; Dogherty, Harrison, Graham, 2010). Given the reality of much work to be done and a finite amount of time, CNSs must become experts in time management and priority setting to maximize desired results and decrease feelings of being chronically overworked.
Ellis and Abbott (2011) provide several suggestions for time management aimed at nurse managers, but equally pertinent to CNSs. One is to maintain focus, have a vision, and leverage a team to achieve that vision. CNSs can apply these principles by working with teams of other CNSs, nurses, managers, educators, and/or other stakeholders to maximize efforts of all toward achieving desired outcomes. CNSs need to prioritize work and focus on what is determined to be most important: activities that bring value to the organization, to the patient population, to the nursing staff, or sometimes to the CNS. Creating a list then evaluating each item in terms of time-sensitivity and value can help clarify which activities take priority. In the face of competing agenda items with no clear top priority, the CNS may want to seek input from administrative leaders to ensure focus on priorities for the organization.
Other time management tactics described by Ellis and Abbott (2011) are setting aside time each day to work on key initiatives, saying no to non-productive activities, prioritizing meetings and/or sending a designee, and setting daily goals. Using technology such as sharing web-based work sites can decrease the number of meetings and make better use of time. CNSs should remember to include at least some activities that offer professional gratification each week in order to maintain a sense of purpose and self-care.
Value to the Organization
Another reality in the healthcare arena is the need to demonstrate the value CNSs bring to an organization. Terms such as "indirect caregivers" and "non-productive time" are used in budgets, and, to the less informed, can suggest employees in such roles are wasteful overhead. CNS positions may fall into these categories because they are not typically included in direct patient care staffing. CNS positions may be at risk when budgets are tight and cutbacks are necessary. CNSs need to be clear about how they contribute to the organization in concrete ways nurse and non-nurse leaders can appreciate.
Ideally the value a CNS brings can be quantified financially. An EBP project to reduce catheter-associated urinary tract infections (CAUTI), for instance, has financial implications because of reimbursement changes from the Centers for Medicare and Medicaid Services (CMS) that took effect in 2008 (Department of Health and Human Services, Centers for Medicare and Medicaid Services, 2012). A CNS who participates in this type of work needs to work with the quality, infection control, supply management and hospital finance departments to analyze the financial benefits of EBP changes. Pre- and post-implementation data can be used to compare cost of care before and after the project to demonstrate the impact of a CNS-influenced initiative.
There are several other ways CNS activities can produce positive financial outcomes. CNSs may contribute to improvements in nurse retention by mentoring others or developing an innovative program to reduce the number of hours newly hired nurses spend in orientation. CNSs who manage a specific population of patients, such as those with heart failure, may be able to demonstrate reduced lengths of stay or recidivism rates. CNSs who bill for services can report their contribution to a facility's reimbursement income. CNSs should look for opportunities to translate CNS activities into financial benefits. Demonstrating the value a CNS brings not only helps justify the individual CNS's position, but raises awareness of the role's value and contributes to the financial security of the institution.
There are various ways CNSs can demonstrate value to the organization (Table 2). One approach is developing a portfolio to showcase a variety of professional activities and associated outcomes (Shirey, 2009; Hespenheide, Cottingham, & Mueller, 2011). Another is creating a spreadsheet or dashboard listing key activities of the CNS with specific outcomes. Benefits of a dashboard include the ability to succinctly record information that can be used to monitor progress so timely adjustments can be made if needed (Harrington, et al, 2005). Another approach is to ensure annual performance goals include measurable outcomes a CNS can use as evidence of contributions to the organization. CNSs who do not already contribute to development of their own performance goals may want to consult with their superiors to discuss ways to do so. This collaborative approach can be mutually beneficial: articulating annual goals can assist the CNS in setting priorities and focus on activities most likely to achieve desired results for both the individual and the organization.
CNSs in clinical practice face various challenges. Depending on the situation, there are opportunities to use effective ways to untangle complex, organizational issues, or to experiment with novel approaches. CNSs are well qualified to respond with expertise in advanced nursing practice, knowledge of patient and family concerns, and systems thinking. Educators must consider these realities when developing didactic content, clinical practica, and other learning opportunities in order to adequately prepare CNSs for the complexities of a chaotic, ever changing healthcare system.
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