National Association of Clinical Nurse Specialists

Advanced Practice Nursing Consensus Conference

June 9, 2004

An Invitational Meeting

Who is NACNS?Who we are:

Founded in 1995. Current Membership is 1700 – a 20%

growth in 2003. Representing CNSs regardless of specialty. Only organization solely comprised of CNSs. Represent both practice and education Board of Directors diverse -- deans,

educators, practicing CNSs.

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.

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.

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).

Definition of CNS:Independence

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

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.

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

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.

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.

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

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

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.

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.

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.

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.

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

Consistent with CNSs’ 50 year history, specialty practice is identified by:

ANA Scope and Standards of Practice, 2004; NACNS Statement on CNS Practice and Education, 2004

NACNS Educational Standards

NACNS Statement on CNS Practice and Education includes recommendations for CNS education.

*2003 Survey reports >50% of CNS programs using NACNS educational Recommendations.

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

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).

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.

Overview of Recommendationsfor CNS Curriculum

See handout

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.

See NACNS Talking Points: Certification of CNSs

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.

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.

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.

Options for Modules Psychometric examination Portfolio Other alternative strategies

All options must be legally defensible

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

Current CNS Regulation

Review of 48 states revealed 6 types of regulation Recognition in statute only Document of recognition Certificate Approval Registration Licensure

Lyon, B.L. & Minarik, P. (2001). Clinical Nurse Specialist, 15(3) 108-114.

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.

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.

See NACNS Talking Points: Regulation of CNSs

Specialty Organizations

NACNS positions reflect commonalities among its CNS members regardless of specialty.

Specialty organizations develop standards of practice for the unique specialty population.

ClientDirect Care

Nurses & NursingPractice Standards

Systems &Organizations

Specialty Practice

CNS practice conceptualized as core competencies in 3 interacting spheres actualized in specialty practice, and guided by specialty knowledge and standards.

Specialty Skills/CompetenciesSp

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© J.S. Fulton, 2004

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.

About Consensus…

Tyranny of ConsensusBanister & 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

Avoiding tyranny

Identify and examine values State core principles Address informal power (resources,

position, experience) that can lead to coercion

Account for all perspectives

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.