Journal of Clinical Nursing 1998; 7: 283–290

Role transition from staff nurse to clinical nurse

specialist: a case study
SALLY GLEN MA (Ed), MA (Phil), RGN, RSCN, RNT
Professor of Nursing Education, Dean of the School of Nursing and Midwifery, University of
Dundee, Dundee

KATHRYN WADDINGTON BSc, MSc, RGN, RNT

Senior Lecturer, School of Health and Social Care, South Bank University, London

Accepted for publication 26 September 1997

Summary
• Over the last decade, nursing in the United Kingdom has witnessed a major
development and expansion in the number of Clinical Nurse Specialists.
• These nurses are considered to be experts in their own specialities, have in-
depth knowledge and provide a service for patients, relatives and staff.
• There is, however, a paucity of literature relating to role transition from experi-
enced Staff Nurse to Clinical Nurse Specialist.
• Using Nicholson’s (1984) model of work-role transition and Wanous’ (1992)
four-stage model of organizational socialization, this study explores the transition
of two nurses from experienced Staff Nurses to novice Clinical Nurse Specialists.

Keywords: clinical nurse specialists, organizational socialization, role transition,

staff nurses.

Introduction offer guidelines relating to appropriate preparation and

The concept of the nurse as Clinical Nurse Specialist
(CNS) has been described in the literature for over 90
years. Over the last decade, nursing in the United
Kingdom has witnessed a major development and expan-
sion in the number of CNSs. These posts have been devel-
oped across a wide range of practice areas. The CNS is
regularly described as a highly skilled and knowledgeable
person (Buzzell, 1977; Anderson & Hicks, 1986). The liter-
ature does not, however, identify the factors that facilitate
or indeed impede transition from Staff Nurse to Clinical
Nurse Specialist. The study described in this paper aims to
increase understanding of the process of transition and
Correspondence to: Professor Sally Glen, School of Nursing and
Midwifery, University of Dundee, Ninewells, Dundee DD1 9SY, UK.
supervisory support if novice CNSs are to complete transi-
tion from Staff Nurse to CNS as effectively as possible.
TOWARDS A DEFINITION
CNSs are a very diverse group. Project 2000 describes the
newly registered nurse as receiving advice and help from
‘specialist practitioners’ who have attained further
qualifications leading to higher standards of professional
practice. The UKCC (1994) defines a CNS as a:
practitioner who exercises higher levels of judgement
and discretion in clinical care in order to function as a
specialist nursing practitioner.
The Royal College of Nursing (1988) document on ‘spe-
cialities’ indicates that a considerable amount of confusion
about the nurse specialist role stems from the fact that

© 1998 Blackwell Science Ltd 283

284 S. Glen and K. Waddington
there are many nurses in specialist posts who are not spe-
cialists. In the United Kingdom, the variety of levels
(certificate, first and higher degrees) of preparation has also
resulted in confusion.
Aim of the study
The key aim of the case study was to identify those factors
that both facilitated and impeded transition from Staff
Nurse to Clinical Nurse Specialist.
METHODOLOGICAL APPROACH
Data for this study were collected over a period of one year
using a case study of two CNSs employed in a National
Health Service (NHS) Trust. The Trust is predominantly
involved in tertiary care, incorporating a number of smaller
specialist referral centres. The Trust therefore encom-
passes a variety of organizational and professional cultures,
reflected in the diversity of individual and collective beliefs,
values and expectations (Zamanou & Glaser, 1994). The
CNSs had both been in post for almost one year when the
case study began, having been appointed from the grade of
Senior Staff Nurse. Both CNSs were appointed from
outside the Trust.
RATIONALE
Case study research is widely used in organizational
research (see Hartley, 1994) and is an appropriate strategy
to use in nursing, health and social research (Fawcett &
Downs, 1992; Hart & Bond 1995). Case study research
consists of:
detailed investigation, often with data collected over a
period of time, of one or more organisations, with a
view to providing an analysis of the context and
process of the phenomenon under study (Hartley,
1994, p. 209).
Additionally, case study research in nursing has been
described by Woods & Catanzaro (1988) as a strategy for
investigating contemporary experience in a setting over
which the investigator has little or no control. The
researchers therefore felt that a case study was an appropri-
ate approach to adopt in the circumstances of the Trust and
CNSs described above.
An important aspect of the case study is understanding
the processes in context, which that tensions and con-
straints experienced by articipants in their day-to-day work
can be taken into account when analysing aspects of the role
transition. Because context is deliberately part of the
design, the case study approach is not a method as such,
but is better described as a research strategy (Hartley,
1994). However, as Fawcett & Downs (1992) point out, the
case study is an excellent research strategy to use in
exploratory, descriptive studies. Within such a broad strat-
egy a number of data collection methods may be used. In
this study, data were collected from taped individual super-
vision sessions, semi-structured group interviews and
written reflective accounts from both CNSs. It was antici-
pated that the use of a combination of methods would
capture some of the complexity of the experience of role
transition and improve the validity of the findings.
A key feature of case study research is a theoretical
framework, which provides a necessary structure within
which to locate and analyse the data. Without a theoretical
framework, case studies can easily degenerate into anecdo-
tal story-telling. While the latter aspects of case study data
certainly provide richness and detail, absence of theoretical
frameworks can lead to the danger of providing ‘descrip-
tions without meaning’ (Hartley, 1994; p. 210). The theo-
retical framework for this study was drawn largely from the
field of organizational psychology relating to work-role
transitions and organizational socialization. These frame-
works are outlined in the following section. Extracts from
reflective accounts from both CNSs have been intertwined
throughout to illustrate the application and relevance of
theoretical perspectives identified.
Theoretical frameworks
WORK-ROLE TRANSITIONS
Nicholson’s model of ‘work-role transitions’ was the main
influence on the study (e.g. Ashforth & Saks, 1995; West &
Rushton, 1989; Nicholson, 1984; West, 1987). The theory
of work-role transitions maintains that entry into a new role
induces personal and/or role development, i.e. adaptation
of the person in response to environment demands, or
manipulation of the environment to meet personal needs.
Personal adjustment involves change in an individual’s
frame of reference, values or attributes that relate to their
personal identity. Environmental manipulation involves
changing role requirements such as task objectives, ways of
working that are central to role performance and interper-
sonal relationships. The theory proposes that ways of
adjusting to a new role are influenced by the following:
• role requirements (discretion and novelty of role
demands);
• induction socialization processes;
• prior occupation socialization;
• individual personality characteristics (desire for control
and desire for feedback).
© 1998 Blackwell Science Ltd, Journal of Clinical Nursing, 7, 283–290

The model of work-role transitions provides a useful frame-
work for considering aspects and influences of personal and
role developments when entering a new role, although per-
sonal and role development may not necessarily act as com-
pletely independent processes. For example, Ashforth &
Saks (1995) conducted a longitudinal study of Nicholson’s
model using self-report data from business school gradu-
ates before and after entry into a new job, and argue that
personal and role development are interactive in nature.
With regard to nursing, West & Rushton (1989) exam-
ined the effects of role requirements, socialization
processes and personality in a UK Study of 145 student
nurses using questionnaires and diary recording methods.
Findings were that those with a high desire for control (a
personality variable measured psychometrically) were more
likely than others to role innovate, and experienced greater
levels of personal change and emotional frustration. In this
study, perceived job discretion for student nurses was low,
which contributed to the frustration experienced and
intention to leave. Discretion at work was measured using
an adaptation of the job discretion measure used by Alban-
Metcalfe and Nicholson (see West & Rushton, 1989, p. 276)
and was based upon the dimensions of:
• acting independently of superiors;
• setting work targets;
• choosing the order in which different parts of the job are
done; and
• choosing with whom to deal in order to carry out job
duties.
These dimensions are appropriate to the role of the CNS.
For example, when asked ‘why do people seek out CNS
posts?’ one participant replied:
Because they are not ward-based and you’re
perceived to have more autonomy.
Therefore the CNSs were asked to reflect upon their role
in relation to these dimensions of job discretion. Extracts
from their reflective accounts demonstrate that team and
organizational factors affect the amount of discretion they
feel able to exercise.
ACTING INDEPENDENTLY OF SUPERIORS
The CNSs felt that the ability to practise autonomously
was an important aspect of their role:
Autonomy is paramount for individual clinicians in
the multidisciplinary team . . . . in theory there should
be no superiors (in practice this may not always
occur) . . . . power struggles and conflicts are more
likely to arise if members of the team feel they are
more superior or consistently function independently
of other team members.
© 1998 Blackwell Science Ltd, Journal of Clinical Nursing, 7, 283–290
Role transition 285
Could be argued there are no superiors to act
independently.
In those posts it is hard to tell which superiors one
is supposed to take guidance from . . . . line
management is confused due to posts set up in
haste.
From these comments, it is clear that they did not always
feel able to exercise autonomy, and that there is a need for
role clarity in some instances.
SETTING WORK TARGETS
Setting work target relates to goal setting, which can
enhance job satisfaction and motivation (McKenna, 1994).
However, there is a potential for conflict between the indi-
vidual CNS’s goals and targets and those of the multidisci-
plinary team:
Probably the hardest part is to see a goal and work for
it in isolation. It is an essential, not a described part of
the job, but I have realised that it is essential.
Within the multidisciplinary team there are team
targets in addition to individual targets. In my
experience team targets often take priority,
particularly in teams which have not been established
too long. Team targets are also often hindered by
politics which can lead to individual dissatisfaction.
Setting work targets on an individual level can be
aided through appraisal and supervision.
Issues relating to organizational power and politics, and
conflict in interprofessional relationships, may therefore
impact adversely upon the ability to set realistic work
targets and result in job dissatisfaction.
CHOOSING THE ORDER IN WHICH DIFFERENT PARTS OF
THE JOB ARE PERFORMED
Similarly, the priorities identified by the CNS did not always
match those of the team, which was another potential source
of dissatisfaction:
The order in which different parts of the job are done
is often determined on the basis of priorities,
particularly when resources are stretched.
Priorities are a necessity but here again there may
be individual priorities and team priorities and often
team priorities come first . . . . disillusionment is likely
when an individual member of the team constantly
meets team priorities but is unable to meet individual
priorities.
Prioritising skills makes the job easier, this tends to
be a skill that an experienced nurse will have prior to
the job.
286 S. Glen and K. Waddington
These comments suggest that the CNSs are very much
aware of the need to prioritize, balancing individual skills
and needs with team and organizational priorities.
CHOOSING WITH WHOM TO DEAL IN ORDER TO CARRY OUT
THE JOB
The opportunity and ability to choose colleagues with
whom to carry out the job is an aspect of autonomous
practice and job discretion. The comments below suggest
that this is sometimes possible, and can be a factor in estab-
lishing and maintaining supportive interpersonal relation-
ships:
Yes, sometimes this is possible, and if possible, the
best person for the job is chosen. However, there is
always a responsibility to choose the less skilled at
times and train where necessary.
You can’t choose whom to deal with all the time,
whilst this can be difficult, it can also be a learning
process for both parties.
Building own support network around the hospital,
to find those you like, those who are of use, those who
are influential, etc., in order to facilitate the smooth
administration of the service.
For these CNSs, their perception of the amount of job
discretion they experience in their role is contingent upon
many other factors, not all of which promote high levels of
discretion. Additionally, feelings of frustration were experi-
enced by both CNSs:
I realised that there was a strong hidden agenda, also
that my Trust is a combination of many cultures due
to continuing mergers. It was very frustrating to
know that what I wanted but not to be able to get to
that end with any modicum of speed.
The frustration phase lasted much longer than the
orientation phase and was particularly intense and
difficult. It was characterised by feelings of
discouragement, inadequacy and insecurity.
Frustration is identified by Hamric & Taylor (1989) as an
early phase of role development of the CNS. Reasons for
the frustration experienced were attributed to organiza-
tional culture, working in an unfamiliar environment, and
encountering resistance to change from medical and
nursing colleagues, which contributed to feelings of stress:
I took about a year to get on top of an already existing
pain service and found it very stressful until I realised
that there is a right time and place to do everything
and to try to force nurses before they are good and
ready wastes energy.
Therefore entering a brand new post that needs
designing, learning a new speciality without any prior
training and also not having any prior knowledge of the
remit of the CNS, all increased the stress experienced.
The relationship between an individual’s role in the
organization and stress at work has been widely docu-
mented (see, for example, Newell, 1995; Sutherland &
Cooper, 1990). This relates to:
• role conflict;
• role ambiguity;
• role overload;
• role underload;
• role complexity; and
• occupying a boundary role.
The role of the CNS appears to encompass many of these
aspects of stress. For example, intrarole conflict occurs
when different people have different expectations about
what the role holder should do. The role set refers to the
network of others who interact with an individual occupy-
ing a particular role, such as other CNSs, superiors and
medical staff. The expectations of two or more of these may
be incompatible, and these are a common feature of bound-
ary roles (McKenna, 1995). Individuals who occupy a
boundary role have contact with people in other depart-
ments and/or outside of the organization.
Role ambiguity is different in that, rather than being
caused by a conflict of expectations, there is lack of clarity
regarding what those expectations actually are. This may
occur because the individual does not understand what is
expected of him/her; or understands, but is unclear as to
how he/she will meet those expectations. Alternatively,
his/her perception of what the job ought to be differs from
that of other members of the role set. This is clearly de-
monstrated in the following quote from one of the CNSs:
It became apparent that members of the chronic pain
team had particular expectations about the role and
functions of a nurse specialist and, at the time, these
were in conflict with my own.
Finally, role overload also appears to be a feature of the
role of the CNS. This occurs when expectations and
demands of the job are in excess of the ability, or perceived
ability, of the person occupying the role. Quantitative over-
load relates to having more work than is possible to achieve
in work time. Qualitative overload occurs when the person
does not have, or does not perceive themself to have, the
abilities and skills to undertake the job as required (see
Newell, 1995). Again, this was described:
[the role ambiguity] coincided with an expanding
workload for the chronic pain team and further
increased the pressure on the team members.
I became increasingly aware that my knowledge
base, skills and competency lay in a more holistic
palliative care approach to chronic pain management
© 1998 Blackwell Science Ltd, Journal of Clinical Nursing, 7, 283–290
 Role transition 287

and I had a considerable amount to learn about Organizational socialization

invasive pain management techniques.
In addition to aspects of role conflict, ambiguity and
overload, models and approaches to stress at work fre-
quently refer to the effect of relationships with co-workers
as a source of occupational stress. For example, Leiter and
Maslach (cited by Newell, 1995) found that nurses reported
interactions with co-workers more frequently as a source of
stress than interactions with patients. This needs to be bal-
anced with the support that is gained from colleagues during
stressful events, which was documented by both CNSs:
It is important to remember who was supportive and
in what particular area during the last crisis and to
utilise these people again. These people tend to cover
particular areas, e.g. management, clinical, nursing
issues, hospital culture, department politics, and are
good for bouncing ideas and peer support.
With no suitable role model, I was thankful for the
support of my nurse colleague who led me to the
relevant literature which was very useful.
The presence (or absence as described above) of role
models is a feature of the process of organizational social-
ization, which is explored in the next section.
Socialization refers to the way that newcomers to an orga-
nization change and adapt by learning new roles, norms
and values (Wanous, 1992). While there are clearly some
similarities with the concept of work-role transition, orga-
nizational socialization is a more all-encompassing process.
According to Wanous, socialization incorporates aspects of
interpersonal interaction between the individual and the
group or team. This has been broken down into three com-
ponents.
1 The process – social learning from other people about the
organization’s norms and values.
2 The focus – learning specific and acceptable roles, norms
and values.
3 The unique dynamic of conflict – the underlying assump-
tion that the socialization process occurs in a ‘cauldron
of conflict’ (Wanous, 1992, p. 198).
Wanous goes on to propose an integrative approach to
the stages that occur in the socialization process. This is
four-stage model (Table 1) in which the first three stages
are the socialization process ‘proper’, and the final stage
details the transition from newcomer to insider. It is a

Table 1 Stages in the process of organizational socialization adapted from: Wanous (1992), p. 209

Stage 1: Confronting and accepting organizational reality

Confirmation/disconfirmation of expectations
Conflict between personal job wants and those of the organization
Discovering which personal aspects are reinforced, which are not reinforced and which are punished by the organization

Stage 2: Achieving role clarity

a) Being initiated to the tasks in the new job
b) Defining one’s interpersonal roles
ii) with respect to peers
ii) with respect to one’s boss
c) Learning to cope with resistance to change
d) Congruence between a newcomer’s own evaluation of performance and the organization’s evaluation of performance
e) Learning how to work within the given degree of structure and ambiguity

Stage 3: Locating oneself in the organizational context

Learning which modes of behaviour are congruent with those of the organization
Resolution of conflicts at work, and between outside interests and work
Commitment to work and to the organization
The establishment of an altered self-image, new interpersonal relationships and the adoption of new values

Stage 4: Detecting signposts of successful socialization

Achievement of organizational dependability and commitment
High satisfaction in general
Feelings of mutual acceptance
Job involvement and internal work motivation
The sending of ‘signals’ between newcomers and the organization to indicate mutual acceptance

© 1998 Blackwell Science Ltd, Journal of Clinical Nursing, 7, 283–290

288 S. Glen and K. Waddington
model that Wanous uses to analyse and interpret individu-
alsí experiences of entry into a new organization in a
number of case studies. The stages in the socialization
process are shown in Table 1.
While the stages may not necessarily unfold sequentially,
the issues contained within the process of organizational
socialization are relevant for newcomers to an organization.
The CNSs identified a number of factors that related
specifically to Stages 1, 2 and 3. These stages refer predom-
inantly to the way in which newcomers to an organization
reconcile the conflict between personal and professional
needs and expectations, the demands of the job, and the
organizational structure and culture. For example:
Encountering resistance to change was another
problem area during the frustration phase. On
occasions, I found myself shattering myself against
what appeared to be immovable objects in an attempt
to bring about changes which I though would be
beneficial. I have since learned the art of moving
around immovable objects and bringing about
changes with subtlety and in a more timely way.
I made the mistake of thinking that I should be
working as an acute pain sister from the moment that
I entered the Trust, to coin the phrase ‘to hit the
ground running’. This was a mistake, in hindsight I
should have spent time building up a network and
getting to understand the culture.
Then one day it dawns that charts are being
completed, that a difficult ward is asking for advice
and taking notice and there is a sense of achievement.
It is important to try to remember to find a way
round, not to go through, and to utilise these skills
next time.
Hamric & Taylor’s (1989) phases of role development
can also be clearly located within this model of occupational
socialization, particularly in relation to stages 2 and 3. The
CNSs final reflections upon their role after almost two
years in post still indicate high levels of frustration and
stress, although there is clear evidence of personal and role
development. The latter is congruent with the model of
work-role transitions in terms of adaptation of the individ-
ual CNS in response to environmental demands and
manipulation of the environment to meet personal needs.
Frustration and stress occur when personal needs cannot
be met because of organizational, team and environmental
constraints. For example:
Lack of staff to meet increased workload,
overcrowded offices and poor working environment.
Team conflict and tension which is undoubtedly
exacerbated by lack of resources and work
environment . . . . as a team we are not always very
good at supporting each other, and it is less easy to
support others when you’re just trying to keep
yourself afloat.
I am still frustrated by the resistance to change. I
do not feel this represents the ‘frustration stage’, just
my lack of patience.
I still very much feel that I am in the first stages of
development in relation to Hamric’s stages of role
development, i.e. I am still in the implementation/
frustration and introduction and have not moved
towards the integration section.
Close examination, however, suggests that while this
quote may describe this particular CNS’s perception of her
own development, she goes on to outline feelings of:
having reached a plateau and am taking a breather and
then will surge forward making waves and start
implementation of yet more change
which relate to a more advanced stage of role develop-
ment. She also identifies an element of complacency:
I am beginning to find some of the work dull and
routine, but am aware there is still room for
improvement
which Hamric sees as a final stage of role development.
Hamric sees that a key developmental task for this stage is
the need to re-energize and reconfigure the role.
The following comments from both CNSs demonstrate
personal development and learning, particularly with
regard to time management and prioritization:
Learning the hard way – I’ve come to the conclusion
that I’ve given too much to the service in terms of
time and energy, and taken on too much
responsibility . . . . The new resolution is to work
within my contracted hours and deal with priorities.
I am not as frustrated as before with all areas such
as management and medical staff. I do not feel as
inadequate when asked why I have not tackled a
particular area – I just say that I only have limited
hours.
There is also evidence of role development and innova-
tion in some aspects of the CNS role, either now or in the
future. This has occurred in conjunction with personal
development, suggesting that the model of work-role tran-
sitions is integrative:
I am convinced that if we had our own premises to
run, certain clinics’ quality of care and improved
treatment benefits for the patients would be achieved.
I could expand my role in a number of directions
and I’m not always sure which direction would be
best in the long term. With no source of supervision,
it’s not always easy to work through what would be
best.
© 1998 Blackwell Science Ltd, Journal of Clinical Nursing, 7, 283–290

Conclusions to be drawn are that the theoretical models
outlined above provide an appropriate framework in which
to understand complex issues of role transition from senior
staff nurse to CNS.
Conclusions and recommendations
One must be cautious in making generalizations from a case
study of only two CNSs, and the small sample is a limita-
tion of this investigation. Furthermore, it has been
acknowledged that case studies are weak in their capacity to
be generalized to other situations (Hartley, 1994). However,
as Woods & Cantanzaro (1988) point out, the purpose of a
case study is not to discover universal truths, but to identify
important factors in a given phenomenon. In this instance
it was the experience of role transition in the two CNSs and
the factors influencing this transition that was investigated.
However, clear findings have emerged. Both participants
have developed both personally and professionally, and
have demonstrated adaptation and innovation in the role.
However, the experience of role transition has not always
been unproblematic. For example, the role is perceived as
being high in discretion, but this is negatively affected by
team and organizational factors (e.g. culture, politics, resis-
tance to change). These CNSs experienced high levels of
stress and frustration, indicating a clear need for role
clarity, support and supervision. Factors facilitating transi-
tion are outlined in Table 2, and those impeding transition
are outlined in Table 3.
The transition from Staff Nurse to Clinical Nurse
Specialist is always a challenge. However, it is possible to
identify factors that can positively influence the transition.
• The CNS must develop a method of maintaining clinical
competence. Being a competent practitioner is the basis
of being an effective CNS. Reading current nursing lit-
erature, attending conferences, sharing information with
colleagues and providing direct patient care are all
methods available to achieve this objective.
Table 2 Factors facilitating transition
• Need for induction into and preparation for role including
professional, clinical and organizational aspects of role, time
management, stress management
• Clear role definitions and boundaries
• Effective interprofessional relationships, particularly between
CNSs and doctors
• Appraisal and supervision
• A CNS support network
• Clearly articulated career pathways and professional development
for role of CNS
© 1998 Blackwell Science Ltd, Journal of Clinical Nursing, 7, 283–290
Role transition 289
Table 3 Factors impeding transition
• Absence of any of the factors shown in Table 2
• Resistance to change
• The identification of a strong preceptor is imperative. A
preceptor is able to guide and reinforce agendas that
occur in the daily experiences of the novice CNS, as well
as clarifying questions. Similarly, peer support needs to
be available to foster the professional growth and devel-
opment of nurses in such roles.
• Multiple expectations are placed on the CNS by staff,
peers, managers, administration and by the CNS him/
herself. In order to alleviate the pressures, the CNS
might create a tracking record, daily log or weekly journal
to document the effectiveness of the role, evaluate priori-
ties and set short- and long-term goals. Record keeping
is essential to validate and promote a CNS practice.
• Finally, by seeking support and accepting constructive
criticism from other professionals and performing con-
tinuous self-evaluation, these passages may be part of a
smooth transition (Bass 1993).
Acknowledgements
We thank Louise Boden, Chief Nurse, UCLH Trust
(London) and the two CNSs for their permission to publish.
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