As national leaders construct policies, appropriate funding and set forth reform agendas, nursing representation often is absent from the decision-making table. Strides in healthcare reform for the past decade have led to rapid change, requiring nursing professionals to carve new territories with unprecedented innovation and collaboration for meeting goals of reduced costs and improved patient outcomes. The 2011 Institute of Medicine report The Future of Nursing: Leading Change, Advancing Health1 recognized the importance of nurse-led contributions and the impact the profession could have in promoting change within healthcare nationwide, calling for us to prepare and enable nurses to lead change and advance health. As a professional organization, I challenge the members of the National Association of Clinical Nurse Specialists to ponder; what is our response in answering this call?
BARRIERS TO INVOLVEMENT
Barriers preventing nurses' participation in healthcare reform changes include as follows: (1) nurses are not perceived as important decision makers, (2) nurses are not perceived as revenue generators compared with physicians, and (3) nurses do not have a single voice on national issues.2 The result is nursing's chronic underrepresentation in important change movements.
Important Decision Makers
The American Nurses Association3 identifies clinical nurse specialists (CNSs) as providers of leadership for advancing the practice of nursing in the areas of quality and cost-effective patient outcomes, as well as providers of leadership for multidisciplinary groups designing and implementing innovative alternative solutions that address system problems and/or patient care issues. As clinical experts, we know we are involved in, and leading, changes that positively influence patients, nurses, and the organization. Occasionally, our work extends beyond our employer organization to impact local or regional activities, but rarely do we engage in or publicize any leadership efforts at the national level. This begs the question, how do we influence leaders beyond our organization to demonstrate that nurses are critical to healthcare reform decision-making processes?
Revenue Generators
Although progress has been made to advance the CNS as a professional, advanced practice nurse, complex issues remain that prevent us from generating revenue similar to that of our physician colleagues. As the American population continues to age and the gap for providers widens, we must continue our efforts to expand our role where we function at the top of our license across all 50 states. Strong collaborative partnerships with insurance companies, state legislatures, and physicians will be required to successfully accomplish this tremendous goal.
Nursing as a Single Voice
With more than 72 000 CNSs nationwide, finding a collective voice to represent our profession is critically important for positioning us to inform and impact policy at local, state, and national levels.4 Nurses are key leaders in healthcare and need to be at the forefront of reform. A shared governance model is needed at the national level where nursing is included along with physicians, legislators, pharmaceutical, and insurance companies, at the table, making decisions with our influence. Creating structures that promote and support CNS involvement in such activities is imperative.
SUPPORT FOR ENGAGEMENT
Although the barriers to involvement are complex, support exists. Respondents from the Gallup and Robert Wood Johnson Foundation survey indicated that leaders would like to see nurses leverage their influence across several key areas, including reducing medical errors and improving patient safety, improving quality of care, promoting wellness and expanding preventive care, improving healthcare efficiency and reducing costs, coordinating care through the healthcare system, helping the healthcare system adapt to an aging population, and increasing access to healthcare.2 Surprisingly, many of the these elements are already embedded within our scope of practice and our day-to-day work. Although many CNSs had training and experience with organizational policymaking, expanding our scope to include policy responsibilities from a much broader perspective may seem daunting and inapplicable. However, by choosing not to leverage our influence as indicated in the System sphere, we are doing a disservice to our patients, nurses, and organizations. We must embrace the call to action, in a time where our involvement is needed the most, and take steps to better prepare ourselves for engagement.
RECOMMENDATIONS
Review of the CNS education structure, including competencies and outcomes, is long overdue. The Statement on Clinical Nurse Specialist Practice and Education,5 which was last revised in 2004, has provided structure and guidance for both the education and practice of the CNS. Revision of this foundational document is critical to articulating competencies and outcomes pertaining to the responsibility of policy involvement. As CNSs acquire the knowledge, skills, and attitudes necessary to become influential, we will be better positioned to effectively engage in the policy arena and sustain involvement over time.
Within the conceptualized CNS practice model, the Organization and Systems spheres must be revisited. Although the components outlined under the organization aspect of the sphere are still quite pertinent to the role of the CNS, the Systems aspect of the sphere is often overlooked, both in the academic and clinical practice settings. I propose the idea of expanding the content contained within the System sphere and creating a fourth sphere. This new sphere would overlap with the Nurses & Nursing Practice and Organization spheres, demonstrating the critical value and responsibility of political work at the local, state, and national levels. Revision of the System sphere title may be warranted to provide more clarity and better representation of the content encompassed within the sphere.
Providing opportunities for current CNSs to become competent in the creation and revision of healthcare policy is critical. As we modify CNS programs with an enhanced focus on health policy, we must examine the gaps in current CNS knowledge, skills, and attitudes. Similar to the introduction of evidence-based practice in nursing programs, changing nursing culture to identify and embrace the expanded role in policy influence may pose a challenge initially and take time to fully adopt. A well-thought out education approach is needed to ensure not only that experienced CNSs are receiving continuing education on the new sphere but also that there are methods to confirm competency and application of the role components. Clinical nurse specialists serving as preceptors during the transition period may need additional support while they themselves work to develop their competency in health policy.
As CNSs, we must encourage and support ourselves and our colleagues, including frontline nurses, in becoming active board members on local, state, and national levels. Assisting individuals in identifying their strengths and opportunities for growth, while aligning their passion with service opportunities, will undoubtedly better prepare them for a successful experience. Embedding professional organization involvement within the core CNS competencies will likely generate increased participation and lead to a more cohesive nursing voice on healthcare issues. Finding time to participate on boards is often a barrier. Because work days can easily become filled with meetings, project deadlines, mentoring, and consultations, it is difficult to take on yet another commitment. Collectively, we need to identify strategies to incorporate health policy activities, including board membership, into our current roles and influence employers in their understanding and support of this valuable work.
Finally, as a professional organization, the National Association of Clinical Nurse Specialists should encourage dissemination of CNSs' involvement, influence, and impact on healthcare policy through workshops, conferences, journals, and Webinars, among other forums. Dissemination will not only increase awareness and promote the adoption of health policy practice but also likely generate new ideas for becoming involved, all the while exposing the impact of our involvement on nursing practice.
As professionals accountable for the implementation and evaluation of various healthcare reform initiatives, a critical priority exists for national dialog to begin among CNSs in both academia and clinical settings, to redesign the scope and standards of the CNS role.
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