Lecturer‟s Name and Course Number
Articulation of personal thoughts and actions is known as reflection. For nursing
specialists, it has another meaning which focuses on the interaction with their working environs
and working partners in order to have an understanding of their own behavior and actions. This
provides the nursing specialists an opportunity to chart out their future course of action while
building on their existing capabilities which ultimately develops their professionalism and adds
to core working values. Reflection has two sub-categories: the reflection-on-action and the
The most known and common form is this one. When the happenings in the recent past
are examined by pondering upon those events, the reflection-on-action takes place and through
this articulation the nurse practitioners are able to develop better and effective professional ways
for the future.
This is the pinnacle of nursing specialists' professionalism as through this, their actions as
well as the actions of the colleague are examined. Reflection-in-action is usually developed with
nursing practice. It often is the result of experience and skills that the CNS goes through the
process of Reflection in action.
In the realm of nursing, Reflective practice has turned into a key issue and is consistently
mentioned (Gustafsson, Asp, & Fagerberg, 2007). Due to deep interest in reflective practice, it
has been a topic on which various research studies have been carried out to have more
understanding (Smith and Fagerberg, 2007) so that the existing gaps between the theory of
nursing and its practice can be overcome and the knowledge embedded in practice can be
developed. This is a continuous cycle which blends nursing experience and the reflection on
Importance of Reflective practice:
For long, advocates within the medical profession have recommended reflective practices
as a valuable tool to bridge the gap that exists between nursing practice and nursing theory. For
the nursing specialists, it helps update their skills and professionalism and in the case of nursing
specialists involved in rehabilitation of older persons, it helps enable them to identify their
strengths and area of development. Reflective practice helps in making the use of opportunities
that helps the nursing specialists get the feedback of their impact on the older patients and their
The practice of 'Being Available':
The core therapeutic practice is the nurse specialist's being available to others
(patient/family) in order to guide them to find meaning in their health-illness experience so as to
make the best decisions about their health/lives, and to appropriately assist them to meet their
Most of the time the nursing specialists‟ involved with the care and rehabilitation of old
age persons feel that the only thing they lack is a little time to live their own personal life, let
alone give some reflection to it. But every problem has some solution, hence by following the
below mentioned actions the nursing specialists can overcome this phenomenon:
Coming in different forms from many other people, it is something which has direct
connection with the professionalism, skills and capabilities that the nursing specialists have;
including their behavior. Had it not been for the feedback from other, both negative and positive,
the nursing specialists would not have been what they are. Feedback comes from other people in
many different forms, both verbal and non-verbal. We receive feedback from others about our
behavior, our skills, our values and the way we relate to others, and about our very identity. It
can be argued that we are who we are because of the feedback we receive from others. For this
reason, feedback is central to the process of reflection.
They should not be afraid to ask relevant persons as to how these people perceive and
think about them. Just by requesting a little feedback for someone who is known to a nursing
specialists, can provide them with valuable and honest information about them. These feedbacks
are not to be accepted as a whole, but at least some consideration might be given about them
The learning curve
The nursing care specialists should ask themselves as to what they have learnt in a whole
working day. If they find something that had upset them, they should think of ways to overcome
such incidents in future. It is the best process through which nursing care specialists develop new
skills and capabilities and develop their reflective skills.
The nursing care specialists should make some time available to ponder upon the various
things that have been very satisfying. This should not be done to just celebrate one's success, but
to improve them.
Ponder upon experiences
The best way towards a successful method for developing the clinical nurse specialist
practices is to recall some recent past happening in which the nursing specialist was involved
with someone else. Pondering on what the other players did and what the nursing specialist
actions were at that moment, about what was said and done, can help develop skills and practices
(Marrs, & Lowry, 2009)
Reflecting on the recent interactions that turned into a conflict of some kind may help. By
adopting empathic position and trying to think of being at the place of that person with which
this uncalled for incident happened, can be tremendously helpful to analyze the specialist's own
Diary of events
Writing all reflections in a diary including remarks can be helpful in the long run when
the specialist needs to have some future plans, as through this diary the specialist can easily
compare what happened and what could have been averted. Although it looks like a huge task
yet it can be helpful in deciding priorities.
Planning future to develop nursing skills
The best outcome of reflective process is planning the future after making sense of
reflective practices. Planning to make some critical changes the behavior of nursing specialist is
at times very effective for the development of nursing practices; especially for those who are
involved as a clinical nurse specialist for the rehabilitation of older persons.
It is mandatory that clinical nurse specialists have a considerable expertise within a
specific practice realm and can be accessible to patients or older people in need of rehabilitation.
Posts like these have already been founded successfully in the health care realm, especially in
America and the UK. Hence nurses in general have different perceptions of the role and the
rewards (Hamric, Spross, & Hanson, 2009). Technology has advanced so much that it has turned
complex to manage them properly in health care disciple, the intricate surgical operations and
methods have made the nursing specialists' job even more demanding hence there is an acuity of
patient care delivery. Today the old age rehabilitation centers are not meant just for patients with
chronic diseases or with mental disorder syndromes, it also accommodates old age patients who
have serious fall or injury and require the services of a competent CNS in the rehab center. The
rehabilitation centers provide inpatient rehabilitation services in an environment which looks
more like residential, rather than a clinical setting. These old age rehab centers can be either
located in a hospital premises or a specially built housing which is assisted with nursing care and
living facilities. Rehab centers offer twenty four hours care and treatment and the patient's
progress is also consistently monitored. Sometimes, when a person's medical condition is such
that all the services including treatments required could not be offered in an alternate setting,
then it calls for an acute inpatient rehabilitation. Rehab centers provide all sorts of treatments
which is mandatory in rehab centers in America, these consists of treatments for restoring
communication capabilities, mobility improvement, training to use wheel chairs and walkers as
well as carrying routine chores like taking a shower and dressing besides all care and holistic
support is given to manage emotional support which is common with such patients. Hence a
CNS has functions which go much beyond the functions of a common nurse, the reason why
they are called CNS.
The American Nurses Association has deﬁned clinical nurse specialists (CNSs) as
"The clinical nurse specialist is a clinical expert who provides direct patient care services
including health assessment, diagnosis, health promotion and preventive interventions and
management of health problems, in a specialized area of nursing practice. The clinical nurse
specialist promotes the improvement of nursing care through education, consultation, research,
and in the role of change agent in the health care system" (ANA, 2009, p. 3).
Therefore the urgency and need for clinical nursing care specialists with an advanced
knowledge and skill is the demand of all health care organizations, especially rehabilitation
centers. CNS with the ability to work with other medical and Para-medical staff, organize,
manage and coordinate the care of patients either in hospitals or rehab centers are a major
requirement by all health care institutions (Martin, Hamilton, Sutton, Ventura, Menacker, et al.,
For a clinical health care specialist, it is often tough to truly describe their role as their
roles are consistently changing in order to face the challenges posed in the health needs of an
equally changing patient population across the globe. To measure the impact the clinical health
care specialists make on patients outcomes, is difficult due to the role ambiguity. Various nursing
care specialists can be found in such streams as, psychiatric, gerontology, oncology, pediatrics,
cardiovascular, neuroscience, old age rehab, dementia, diabetes besides others (Scherer, Bruce,
& Runkawatt, 2007).
The professional nurses who are registered and have earned graduate preparation at the
Master's level are known as the CNS. The dire need of nurses having wide knowledge and broad
expertise, those who can get involved with other members of the staff to asses, chart out future
course of action, implement the plan and evaluate the results for the patients, is always present.
Developments never stops, it is an ongoing process in all parts of profession including nursing
The core competencies
It is centered upon and within the nursing‟s disciplinary perspective and the caring about
those relationships which help facilitate the process of healing and health. This core is delineated
speciﬁcally in the philosophic and theoretic foundations of nursing (Gordon, 2007).
As a specialist nurse, it the duty of every CNS to make sure that all the members of the staff
along with students remain focused on the wellbeing of the patients, but it does not mean that
small tasks like dressing of clothes and washing of utensils should also be included in their task.
When a patient is healthy enough to do it, it is better to let him or her do it because patient
motivation helps in more ways than one. To make them think that they are now better than the
day they were brought, triggers the healing effect which is completely psychological and
Scope of Practice
APN education is about getting to know about nursing well. Numerous researches were
conducted to ascertain and classify the phenomenon of mental concern to the nurses; these
studies have been fruitful in the understanding of the scope of nursing practice. According to a
regulatory framework, the scope of practice is determined by focusing on population, while other
initiatives delineate the substantive basis of nursing (NANDA. 2009). Reflective practice is all
about the relationships and the caring of individual needs as well as to the emotional and
personal feelings which often make an impact on the learning curve of reflective practice.
“Faith, beauty, peace, music, baths, exercises, sports, competitions and one or two light drugs:
that was the only medicine known to our forefathers . . .” The modern rehabilitation is build
around this idea today (Trueta, 1963, p. 346)
Roles of a Clinical Nurse Specialist
The clinical nurse specialist or the CNS has four crucial roles which demand great focus
and skills, these are, a clinical expert professional, an educator, a nursing consultant and a
researcher. ((Scherer, Y. K., Bruce, S. A., & Runkawatt, V. 2007). A CNS blends all these four
ingredients into her practice thus creating diversity and flexibility in a medical environment
which is multifaceted. Besides these crucial roles, a CNS has other roles like providing
integrated care to the old age persons who either have one or various aliments or are bed ridden
due to age problems, it is also necessary for a CNS to act as a mentor and supervise the quality of
care in order to improve it. Neo natal and pediatric care are also the roles which a clinical nurse
specialist has to play (Gallo, A., Angst, D., & Knaﬂ , K. 2009). It is mandatory to complete a
four year nursing degree program in order to be a clinical nurse specialist; she also must have
one year nursing experience. Today the role of CNS is undisputed, whether it is in a hospital,
clinic, rehabilitation centre or in research or managerial post in any health care organization
((ANA. 2008). Care for the old people is nicely provided when the environment is
multidisciplinary. A comprehensive, multidisciplinary care and management are the
requirements of the older people who either suffer from various age factor afflictions, or
disabling conditions or are in dire need of specialist care which can only be given by CNS.
Clinical nurse specialists are of different types based on their choice and expertise, like
CNS in community health, old age rehabilitation, acute care, occupational health, oncology,
psychiatric, infectious diseases and geriatric etc. CNS role in old age rehabilitation is very
crucial. Old age rehabilitation is basically a very creative and client centered process involving
flexibility to adopt changes in certain seen or unseen circumstances. Just like the physically fit
but medically unfit people, the disabled people should also enjoy the same care and the social
model of disability considers what changes would be necessary so that people are facilitated to
live ordinary independent lives (APRN, 2008). This is programmed to help the client get
maximum or considerable level of functioning thus help minimize any handicap from physical
impairment. It is a shared activity between client, care and professionals who recognize the
individual contribution of all concerned.
Henderson recommends that the holistic nature of CNS should be always „rehabilitators
par excellence‟. Holism is the basis of a nursing care specialist practices especially those who are
engaged in the old age rehab centers. Roper, Logan and Tierney‟s model utilizes a
dependence/independence continuum which explains how a disabled person might be able to
achieve that can be expected of only from a healthy persons (Pearson, L. 2009). For those CNS
who work within the rehab, it is important to understand development of others in a healthcare
organization, because it reduces rivalry within groups in a team and also expands
interdisciplinary practice especially within a modern rehab center. Trying to understand how and
why someone's specialty has come from, and then trying to follow that, is a way to improvement
and development of professionalism. The CNS at Gerontological rehabilitation centers uses
holistic caring approach while providing care to the elderly and the disabled. They make it their
duty with absolute devotion to provide the best level of physical and psychological care for the
well being of the old aged persons.
American Nurses Association (ANA). (2008). Draft. Nursing‟s Social Policy Statement: The
essence of the profession. Washington DC: Author. Available from:
Bednash, P. (2009). The state of the schools: Creating a professional workforce for the future.
Chornick, N. (2008). Advanced practice registered nurse educational programs and regulation: A
need for increased communication. JONA‟S Healthcare, Law, Ethics, and Regulation,
Cajulis, C. B., & Fitzpatrick, J. J. (2007). Levels of autonomy of nurse practitioners in acute care
setting. Journal of the American Academy of Nurse Practitioners, 19, 500–507
Chornick, N. (2008). Advanced practice registered nurse educational programs and regulation: A
need for increased communication. JONA‟S Healthcare, Law, Ethics, and Regulation,
Council on Certiﬁ cation of Nurse Anesthetists (CCNA). (2008). 2008 candidate handbook.Park
Ridge, IL: Author.
Gallo, A., Angst, D., & Knaﬂ , K. (2009). Disclosure of genetic information within families.
American Journal of Nursing, 109, 65–60.
Hamric, A., Spross, J., & Hanson, C. (2009). Advanced practice nursing: An integrative
approach. Philadelphia: Elsevier
International Council of Nurses. International nurse practitioner/advanced practice nursing
network. Retrieved April 8, 2009, from www.icn-apnetwork.org
Kleinpell, R. M., Ely, E. W., & Grabenkort, R. (2008). Nurse practitioners and physician
assistants in the intensive care unit: An evidence-based review, Critical Care Medicine
cine, 36(10), 2888–2897.
Marrs, J. A. & Lowry, L. W. (2009). Nursing theory and practice: Connecting the dots. In P. G.
Reed & N. C. Shearer (Eds.), Perspectives on Nursing Theory (5th ed, pp. 3–12).
Philadelphia: Lippincott, Williams & Wilkins.
McLaughlin, R. (2007). Preparation for negotiating scope of practice for acute care nurse
practitioners.Journal of the American Academy of Nurse Practitioners, 19, 627–634.
Pearson, L. (2009). The Pearson report. The American Journal of Nurse Practitioners, 13, 8–71.
Available from: www.webnp.net/downloads/pearson
Percy, M. S., & Sperhac, A. M. (2007). State regulations for the pediatric nurse practitioner in
acute care. Journal of Pediatric Health Care, 21(1), 29–43.