Keywords

1 Brief History of CNS Role and Practice

In 1888, the first nursing school was founded in Fuzhou, China. Since then, the nursing development in China progresses in twists and turns; in 2004, we finally finished the construction of a comprehensive nursing education system including Vocational Education, Undergraduate Education, Graduate Education, and Doctoral Education. After the reform and opening-up policy, there were more academic communications between China and abroad, nursing has entered a period of rapid development, and abundance of new nursing philosophy has been introduced in China. But it was not until the early 1990s that the term “clinical nurse specialist” was introduced to China and applied nationally.

In the year of 2001, Guangzhou started the first training school of enterostomal therapist in China. In 2005, the Ministry of Health of the People’s Republic of China issued the Outline of China’s Nursing Development Plan (2005–2010), which initiated the development of CNS in China and published a list containing five core nursing specialties (emergency department nursing, organ transplantation nursing, operating room nursing, oncology nursing, and intensive care nursing). Training syllabus for nurses in specialist nursing field was published in 2007 by the General Office of the Ministry of Health of the People’s Republic of China, which officially clarified the enrollment criteria of the CNS training program, the target, the length of training, the training content, and its evaluation standard. CNS’s importance and development were addressed almost in every version of the Outline of China’s Nursing Development Plan in 2005.

1.1 Definition of CNS

Currently, there is no consensus on the definition of CNS in China, though a lot of nursing scholars have researched to discuss and analyze it. Due to the fact that the proportion of nurses with bachelor’s degree or above was only 14.6%, it is impossible to require every CNS to be a postgraduate as in developed countries. Therefore, the controversy is whether the CNS definition should be aligned with the specialty nurse (SN) or the clinical nurse specialist (CNS). The SN places a greater emphasis on basic nursing practice, while the CNS places more emphasis on advanced nursing practice (Chen and Li 2017).

In the latest research about the definition of CNS, most experts agree that in China, the CNS should lean toward specialty nurse, which has been used for a long time and is more suitable for the situation in China. They come to a conclusion that nurse specialist is a nurse who has been systematically trained in nursing practice and nursing theory in certain nursing specialty, passed the evaluation of SN, and obtained the certificate from the Medical and Health Administration; on the other hand, CNS should have clinical experiences (2–15 years) and be capable of providing high-quality nursing service to patients (Chen and Li 2017).

2 CNS Practice Competencies

The core competencies of specialty nurse have been widely discussed and studied in Mainland; different nursing specialties developed their own core competencies.

In 2017, Liang stated that the core competencies of SN should include professional values, professional development ability, specialty nursing practice skills, clinical teaching skills, clinical research ability, and ability to organize, manage, and cooperate (Liang 2017).

Gao conducted research to construct a competency model of interventional radiology nurses in 2015. This model consists of 17 competency elements and 5 dimensions. The five dimensions are personality characteristics (physical quality, sterile consciousness, inner concentration, confidence, sense of responsibility), the ability to provide direct clinical care (ability to analyze the condition of patients, radiation health knowledge, intervention surgical cooperation), communication and collaboration (verbal and communication skills, teamwork), emergency rescue (control, rescue skills, predictability, flexibility), and research and development (innovation, subject interest, professional learning skills).

3 Outcome Measures and Evaluation

The outcome measures and evaluation vary greatly between hospitals and institutions. In most cases, the exam items are inconsistent with the core competency index of a certain type of SN, and the evaluation is always conducted in the form of a qualification review, paper testing, an interview, and an objective structured clinical examination.

For instance, Guangdong province, the origin place of SN, states that the SN applicant should firstly go through the verification of the qualification, after which the applicant will take paper examinations, interviews, and skill tests (Peng and Chen 2011). In Sichuan province, the applicant only needs to finish the training session and successfully pass the paper examination and skill test, in order to obtain the Certificate of Specialty Nurse issued by Sichuan Nursing Association and the training base (Sichuan Nursing Association 2016).

Generally, there is no consistent certification process in China; in most cases, if the applicant finishes all the training session and passes the evaluation process, they can get the Certificate of Specialty Nurse (Chen and Li 2015).

4 CNS Education

In developed countries through years of development, they already have mature training program. Though our CNS training program has only been developed in recent years, we still achieved good effects. Now we mainly provide the Specialty Nurse education through two ways in China: on-the-job training and academic degree.

5 On-the-Job Training Program for SN

The length of training program for SN in Mainland ranges from 2 to 6 months depending on the training institution, which is shorter than the length of the training program for CNS in abroad, which always lasts for more than 6 months. At present in Mainland, China, the training programs are mainly developed by the Chinese Nursing Association, provincial and municipal nursing association, provincial and municipal nursing quality and control center, some medical schools, hospitals, specialist nurse training center, or some CNS training agency overseas in China. For example, the specialty nurse in Anhui province must finish 4–6 months of theoretical learning and clinical practicing in the clinic (Song et al. 2007).

6 Master of Nursing Specialist

In the year of 2010, Academic Degrees Committee of the State Council in China decided to establish the Master of Nursing Specialist (MNS), aimed at cultivating high-level and specialized nursing professionals and providing a new method to promote the development of SN (Yang et al. 2015). Until 2017, there were 86 colleges that enrolled MNS students in China, and the number of MNS students is growing every year. In China, though no consistent standard of core competencies of MNS has been established, clinical practice skills are widely agreed to be the most important competency that a MNS student should possess, but professional development ability, critical thinking skills, scientific research skills, clinical teaching skills, nursing management skills, communicating and cooperation skills, and ethical decision-making ability are also important (You et al. 2012; Xu et al. 2009).

7 Credentialing: Regulatory, Legal, and Certification Requirements

Currently, there are no national entry criteria for SN in China; it varies among different provinces. In Guangdong province, the entry criteria for SN are as follows: (1) registered nurse; (2) bachelor degree or higher; (3) more than 8 years of clinical nursing experience and more than 5 years of working experience in specialized nurse department; (4) certain level of English language (CET-4); (5) strong clinical observation, evaluation, and complex problem-solving abilities; and (6) valid theoretical foundation and skilled nursing expertise (Peng and Chen 2011). In Jiangsu province, their entry criteria for SN are nurses with college degree or above, have 10 ~ 15 years of clinical working experience, and have working experience in this specialized nursing field. SN certificate is issued by the national/provincial government or nursing associations or CNS organization (Wang et al. 2017).

After SN obtained their certificate, they still need to be evaluated and to register again several years later. In 2018, Shanxi Medical Academy constructed and published the national specialized nurse assessment standard for re-registration (Guo et al. 2018). In this standard, five aspects of evaluation were addressed as shown below (Table 13.1):

Table 13.1 Specialized nurse evaluation for re-registration (Guo et al. 2018)
Full size table

The roles of SN are as follows:

  1. 1.

    Clinical nurses should offer specialized nursing care and resolve complex clinical problems in the form of consultation.

  2. 2.

    Supporter and coordinator should be responsible for explaining and coordinating problems between colleagues or patients with nurses.

  3. 3.

    Educator should have sharp sensitivity and deep understanding of patient’s problems, promoting patients’ self-management as well as being a leader among peers in nursing theoretical teaching, skill training, and evaluation.

  4. 4.

    Researcher should pay close attention to the latest development in the specialized nurse field and apply the research finding in daily work.

  5. 5.

    Clinical leaders should actively engage in the promotion of the development of nursing (Wang et al. 2017).

For the work arrangement of SN, some of the SN works in collaboration with the doctors. For example, in the endocrinology, gynecology, and obstetrics departments, the doctors will refer patients to the nurse clinic, while some nurse clinics, such as PICC or Wound Care Clinic, require patient to make an appointment. According to a survey, more than 30% of SN take the roles of SN and head nurse at the same time, and 80% of their time are spent administering the nursing department, indicating that we need to further clarify the division of responsibility and the role of positioning.

8 Moving Forward: Challenges and Opportunities

Through years of hard work, we have made huge progress in SN cultivation and management. In most hospitals across China, the leaders of medical institutions place ever-increasing importance on the SN, and every year, a large number of nurses will go to different institutions to attend the SN training program. The SN also established their own network (http://www.gc-nurse.com/) to share their experience and latest information about the development of SN both in China and abroad. Many nursing scholars are now conducting a lot of research about the training curriculum, evaluation, registration, and management of CNS.

But challenges remain in the way to the further development of SN in China. Firstly, until now, we do not have consistent definition of SN, which will lead to different levels of comprehension and threaten the possibility of national regulation and communication in nursing, thereby obstructing the development of specialist nurses. Secondly, in comparison with the large number of trainees, we still need more qualified training teachers. Thirdly, we need to improve the quality of training programs. Fourthly, in order to manage SN more efficiently, we need to establish a more unified qualification certification system and issue related laws to ensure the conduct of SN in clinic. Last but not the least, traditional Chinese medicine has been widely acknowledged for curing chronic and complex diseases, and as an old Chinese proverb goes, “three points treated seven point nursing.” We should emphasize the development of traditional Chinese medicine SN in the near future (Wang et al. 2017).

9 Exemplar of Clinical Nurse Specialist Practice

9.1 Nurse-Led Clinics for Diabetic Patient

In nurse-led clinics in China, nursing practice is performed by a group of experienced, highly educated, and higher professionally ranked nurses. SN offer advanced practice in certain nursing areas. Their work is conducted independently or in collaboration with other healthcare workers. Rather than making diagnoses or providing treatment, SN in a nurse-led clinic will apply the holistic view as a nursing principle and cooperate with patients to meet the needs of the patients and their families, as well as maintain or promote the health condition of the patient.

In 2002, the first nurse-led clinic for diabetic patients in China was opened in Beijing. Since then, more hospitals opened nurse-led clinics for diabetic patients. SN in a nurse-led clinic for diabetic patients will provide health education in person, hold regular lectures in the clinic, and organize different forms of health education for diabetic patients, such as disseminating brochures, experience sharing with peers, family visiting, etc.

The work content of SN in the clinic includes informing the patients about the procedure, cooperation tips, the meaning of oral glucose tolerance test, medication knowledge, psychological consultation, feet caring, self-monitoring of blood sugar, how to give insulin injection, how to recognize the symptoms of hyperglycemia and hypoglycemia, etc.

During the work of SN in the nurse-led clinic for diabetic patients, problems still exist, for example, the SN works in the nurse-led clinic as well as in other departments, there are only a few hospitals equipped with such institution, a unified management scheme has no consensus on clinic working time, SN’s qualification, nursing procedure, work scope, etc. Their contributions to the clinic are under no connection with their work performance, which means the billing is directly charged from the doctors’ registration fees rather than individual nursing fees.