national association of clinical nurse specialists

1: National Association of Clinical Nurse Specialists Advanced Practice Nursing Consensus Conference June 9, 2004 An Invitational Meeting

3: A 15 Minute Summary of NACNS Positions Risks.. Too little time to reach understanding of CNS practice and related issues. Leading to misunderstanding and misinterpretation. Benefit… Brief overview will generate more meaningful dialogue.

4: Definition of a CNS:Education CNSs are licensed registered professional nurses with graduate preparation (earned master’s or doctorate) from a program that prepares CNSs. May also be prepared in an accredited post-master’s CNS program.

5: Definition of a CNS:Expertise CNSs possess advanced knowledge of the science of nursing with a specialty focus. CNSs apply that knowledge to nursing assessment, diagnosis, and interventions and the design of interventions (ANA, 2004).

6: Definition of CNS:Independence CNSs function independently to provide theory and evidence-based care to patients/clients in the attainment of health goals.

7: Definition of CNS:Autonomy CNSs practice autonomously under the authority granted by the registered nurse license. CNSs expand the depth and breath of nursing practice within existing autonomous authority.

8: Advanced Nursing Practice Consistent with ANA’s longstanding position… APN is an umbrella term to describe RNs with educational preparation at the graduate level with a unique focus of clinical practice CNS, NP, CNM, CRNA

9: Defining Characteristics of CNS Practice Clinical expertise in the assessment, diagnosis, and treatment of illness and the prevention or remediation of risk behaviors through nursing interventions.

10: Define Illness Illness is the subjective experience of symptoms and functional problems. Illness can be experienced in the absence or presence of disease. The presence of illness does not preclude health. Illness problems are problems amenable to autonomous nursing interventions.

11: Give me an exampleProblems amenable to autonomous nursing interventions… Patient in bed complains of back pain. Repositioning the patient to relieve pain is an autonomous nursing intervention – all RNs are educationally prepared and have legal authority to reposition the patient to promote comfort. Advanced Nursing Practice – CNS – Using advanced theory and science education may.. Research anatomy & physiology of positioning Explore elements of bed/mattress Derive “best” positioning for skeletal traction Change care standard for orthopedic unit Autonomous CNS practice under the authority of the RN license. Is NOT the scope of practice of a “generalist” RN

12: Outcomes of CNS Advanced Nursing Practice Decreased use of pain medication Decreased length of stay Shorter return to functional status Return to work – decreased sick leave costs Shorter return to social role status Ability to maintain family structure/function

13: CNSs achieve quality cost-effective outcomes through… Providing direct care to patients/clients; Advancing nursing practice standards and norms that influence the care delivered by nurses and nursing personnel, and; Influencing change within organizations/systems to facilitate nursing practice and thus improved patient outcomes.

14: Should CNSs have prescriptive authority? Prescriptive authority may be a characteristic of some CNSs individual practice. Prescriptive authority is not the defining characteristic of CNS practice. Prescriptive authority for CNSs is optional.

15: Define Specialty Specialization is a division of a generic field or a recombination of aspects of different fields that occurs along some logical lines. Specialization focuses on a narrow piece of a field, which allows for greater development of the specialty.

16: CNS Specialty Practice Specialty focus is the hallmark of CNS practice. CNS specialty is built on generalist preparation as an RN. CNS specialties may be broad or narrow, well established or emerging.

17: Specialty Focus Client Individual, family, community Populations Pediatrics, geriatrics, women Type of problem Pain, wounds, stress Setting Emergency unit, burn unit, Type of care Rehabilitation, palliative care, wellness Disease/medical specialty Diabetes, oncology, psychiatry

18: NACNS Educational Standards

19: Framework for Core CNS Practice: Spheres of Influence Patient/Clients (individuals, families, communities) – direct care activities Nurses/Nursing practice –nurses and nursing personnel/nursing practice standards and norms Organization/Systems – influencing organizations to support the delivery of nursing care

20: Core Competencies Described in Statement, 2004 Core competency statements describe skills essential to fulfill outcomes of CNS practice. Core competencies in client sphere (direct care) are basis of competencies in other two spheres (nurses/nursing practice & organization/network).

21: CNS Education Recommendations Graduate education that prepares CNS and includes 500 clinical hours focused on CNS preparation and supervised by a CNS. Theory/science and clinical support the specialty focus.

22: Certification Certification for CNS was, until recently, a measure of excellence in practice. Now, certification has shifted to entry level competency in practice. Regulatory trend toward using psychometric exams offered by professional organizations as a proxy for second license/authority to practice.

23: Matching Certification to Specialty Practice Existing certification exams are inadequate to capture specialty practice 40 specialties; 9 exams It is not economically feasible to develop exams in areas where there are small numbers of CNSs. Alternative mechanisms to psychometric exams are needed. Specialty practice cannot be constrained by a requirement for a priori exams.

24: Certification: What Model of CNS Practice? American Nurses Credentialing Center (ANCC): 5 sub-roles model. American Association of Critical Care Nurses (AACN): Synergy Model of practice. Oncology Nursing Society (ONS): Relies on ANA scope and standards of practice.

25: Certification: A Modular Approach NACNS supports a modular certification model: Earned graduate degree in nursing with a CNS clinical focus. A module to validate core CNS practice competencies. Specialty module options to address specialty competencies.

26: Options for Modules Psychometric examination Portfolio Other alternative strategies All options must be legally defensible

27: Regulation for CNSs Title protection Definition of advanced scope of CNS practice Additional regulation if prescriptive authority is sought NACNS does not support the Uniform APRN Compact

28: Current CNS Regulation Review of 48 states revealed 6 types of regulation Recognition in statute only Document of recognition Certificate Approval Registration Licensure

29: Is a second license necessary? CNS practice involves practicing NURSING differently within the existing nursing scope of practice. CNS is not a nurse practicing in another authorized scope of practice not currently authorized by a nursing license.

30: Regulatory Issues Over-Regulation requiring CNSs to obtain a separate authority to practice is over-regulation for the majority of CNSs. Insurmountable Barriers requiring certification by exam for a CNS to practice (with or without prescriptive authority) is a barrier that denies public access to needed services.

31: Specialty Organizations NACNS positions reflect commonalities among its CNS members regardless of specialty. Specialty organizations develop standards of practice for the unique specialty population.

33: Summary NACNS positions were developed by the board of directors in response to membership concerns. Positions have been discussed with members, affirmed by the Board of Directors, and published for public information and debate. NACNS seeks meaningful dialogue with colleagues to integrate as many perspectives as possible.

34: About Consensus… Tyranny of Consensus Banister & Schreibner (2004). International Journal of Nursing Education Scholarship, 1(1). Consensus based on unanimous agreement fosters… Unresolved conflicts Lingering bad feelings Undermining of previous work Unspoken resentments Win/lose decisions

35: Avoiding tyranny Identify and examine values State core principles Address informal power (resources, position, experience) that can lead to coercion Account for all perspectives

36: NACNS Recommendations One organization is not authorized to speak for another – organizations representing NPs, CNM, or CRNAs not speak for NACNS (it members). Boundaries of one group should not harm the boundaries of another group. Mutual support for positions of other organizations IF said positions do not adversely affect CNSs. Continue dialogue for fuller understanding and avoid unintended consequences.