Clinical Nurse Specialists

Leaders in Managing Patients With Chronic Conditions

Mary P. Hansen; Mitzi M. Saunders; Cynthia R. Kollauf; Ludmila Santiago-Rotchford


Nurs Econ. 2019;37(2):103-109. 

In This Article

Background Information

CNSs are master or doctorate-prepared advanced practice registered nurses (APRNs) whose function is to improve outcomes in patient care, support the work of the nurse, and lead practice changes across healthcare systems. CNSs are uniquely prepared in evidence-based practice to drive outcomes by moving fluidly across the three spheres of CNS influence known as patient, nurse, and system (NACNS, 2018). The CNS raises the level of care and improves work processes and patient satisfaction while lowering costs of care (Saunders, 2015).

The competencies of CNS practice are direct care, consultation, systems leadership, collaboration, coaching, research, ethical decision-making, moral agency, and advocacy (NACNS, 2010). A sample behavior for each competency, listed in Table 1, shows the breadth of CNS practice. For example, in the direct care competency under the nursing sphere, CNSs address the six components of quality care issued by the Institute of Medicine (IOM, 2001). The sample behaviors show the autonomous nature of CNS practice; demonstrate how the role supports accessible, high-quality, evidence-based health care; and depicts reimbursable CNS services (NACNS, 2010).

A CNS practices where leadership is needed and responds to the ever-changing climate in health care (NACNS, 2010). One distinguishing attribute of the CNS is the ongoing incorporation of the science of nursing that is based on current evidence facilitating the recognition of patterns in health behaviors in order to make changes to improve outcomes. It is this expertise in managing patient populations, especially those with chronic conditions, that augments self-management and bridges gaps in the continuity of care (NACNS, 2017).

The literature frequently refers to complex care as that which considers the social determinants of health as integral to the provision of medical care (NACNS, 2017). There is increasing evidence that social factors have greater impact on health outcomes than do medical services (McGinnis, Crawford, & Somers, 2014). These challenges present opportunities for improving care coordination. While this strategy is largely recognized as key to reigning in healthcare costs, models such as Accountable Care Organizations have not achieved this outcome in patients with multiple chronic conditions and multiple providers (McWilliams, 2016). The CNS, under state licensure, national core competencies, and scope of practice developed within the Consensus Model for APRN Regulation (APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee, 2008) is well positioned to promote and enhance evidence-based practice within the complexities of health care for this patient population.