Dear Ms Apple and NCSBN Board of Directors
The Board of Directors of the National Association of Clinical Nurse Specialists (NACNS) was pleased to review your letter to the editor of Clinical Nurse Specialist: The Journal for Advanced Nursing Practice. Since your letter raises concerns about points of view expressed in articles and letters that are congruent with the positions of the NACNS Board, the journal editor suggested that we, the NACNS Board, provide a Board-to-Board response to your concerns.
We are pleased to note a number of areas of agreement between the National Council of State Boards of Nursing (NCSBN) positions and NACNS positions. Areas of agreement provide a basis for working through differences and moving to creative solutions. We agree that a master's degree (or higher) from a program that prepares clinical nurse specialists (CNSs) is a requirement for entry into practice. Additionally, we agree that title protection should be afforded to CNSs through state statutes. Articles in this journal have articulated these board positions.
Two areas of disagreement are noted-in the definition of advanced practice nursing and about elements of certification. First, with regard to the definition of advanced practice nursing, you indicate that NCSBN would have "[horizontal ellipsis] no public safety concerns if the CNS practiced within the scope of practice of their RN license and did not practice in the expanded role of the advanced practice registered nurse (APRN) such as including prescriptive authority and making medical diagnoses without fulfilling the requirements of the APRN license." You further state: "Prescriptive authority is part of the APRN scope of practice" and "The CNS would have to meet the requirements for legal recognition as an APRN." If we understand your position correctly, NCSBN believes that medical diagnosis and prescriptive authority are essential characteristics of an advanced practice nurse-that the defining characteristic of an advanced practice nurse is making medical diagnoses and prescribing pharmacological agents. NACNS disagrees with this position if you mean that, to be defined as an APRN, all CNSs should incorporate medical diagnosis and pharmacological prescription in their scope of practice. To require all master's-prepared CNSs to perform medical diagnosis and prescribe pharmacological treatments-to be recognized as an advanced practice nurse-is to ignore the autonomous scope of practice of advanced practice nursing granted by state statute through the registered nurse (RN) license. The breadth and depth of nursing's statutorily created autonomous scope of practice is a logical and sound area to expand and advance the practice of nursing-the primary focus of CNS practice. To deny the autonomy granted by the RN license as a basis of advanced practice nursing is to ignore the power of independence and autonomy described in statutes as the basis of the RN license. The NACNS Board supports CNSs who choose to supplement their advanced nursing practice with the ability to prescribe pharmacological agents and recognizes that these activities are outside of the RN license and may require additional statutory authority. However, prescriptive authority for CNS practice should be discretionary and not the defining practice characteristic. Because the advanced practice of CNSs is within the statutory definition of nursing, the public receives the benefits of illness care and resulting improved functioning, diminished symptoms, and resolution of risk behaviors, in addition to leadership for evidence-based nursing practice.
NACNS's positions articulated in this journal's articles and letters are congruent with the American Nurses Association (ANA). In the Nursing's Social Policy Statement, ANA defines expansion of practice as "the acquisition of new practice knowledge and skills, including the knowledge and skills that authorize role autonomy within areas of practice that may overlap traditional boundaries of medical practice." 1(p9) The ANA definition of expansion into medical practice is discretionary, that is, may (not shall, which indicates a mandatory rule, regulation, or requirement). In the ANA Scope and Standards of Practice2 the definition of CNSs is that they "[horizontal ellipsis]may have prescriptive authority."(p15) Our position is clearly consistent with that of ANA; CNSs acquire new practice knowledge and skills that authorize role autonomy. All CNSs are advanced practice nurses using the autonomous authority of the RN license; some CNSs may expand to overlap the traditional boundaries of medical practice. NACNS' positions reflected in journal articles are also consistent with the ANA Scope and Standards of Practice, 2(pp14-16) "Advanced practice registered nurse (APRN) is an umbrella term[horizontal ellipsis]"; "[horizontal ellipsis]the scope of practice for each of these advanced practice registered nurses is distinguishable from the others[horizontal ellipsis]" One of the distinguishing differences between CNSs and nurse practitioners (NPs) is that for CNSs prescriptive authority is discretionary, for NPs prescriptive authority is required in that they [horizontal ellipsis] "prescribe pharmacology and nonpharmacological treatments in the direct management of acute and chronic illness and disease." 2(p16)
The second area of disagreement focuses on the definition of specialty and the resulting issues regarding certification. CNSs have a long history as specialists in areas such as diabetes, rehabilitation, wound/ostomy, palliative care, and many others. The number of specialties evolved in response to needs of the public and at the request of healthcare system for CNS services. Master's education prepares CNSs to meet existing and emerging healthcare needs. It appears that NCSBN's position is to set aside this tradition through statute and recognize only those areas for which there is a current psychometric certification examination. Protection of the public from incompetent or fraudulent providers occurs when competency validation is aligned with specialty competencies. It is counter intuitive to argue that the public is protected when a CNS in wound/ostomy or palliative care or rehabilitation or any number of other adult specialties takes a broad-based "adult health" CNS examination where there may be no questions testing specialty knowledge and competencies. General examinations cannot verify competencies for advance practice in the specialty. To believe that general certification exams attest to specialty practice does not have merit and further denies the existence of specialty practice. ANA 2(p19) recognizes "more than 100 specialty nursing organizations[horizontal ellipsis]," and many of these organizations exist to foster and promote specialty clinical practice. The NACNS's position, as reflected in journal publications, proposes that if verification of competencies of advanced practice as a CNS is needed, NACNS supports a modular certification model that would include (a) earned graduate degree in nursing with CNS clinical focus, (b) exam module for CNS practice competencies, and (c) specialty module options to address the specialty practice competencies. NACNS further supports alternative mechanisms for validating specialty competencies, such as a systematic portfolio, when a psychometric exam is not feasible.
For NCSBN to take a position that valid APRN specialty areas have a certification program, and that certification exams with "low numbers" of takers represent subspecialties is not logical. There are many CNS specialty areas such as Maternal-Child Nursing that lack certification exams, yet the public need for expertise in these areas is apparent. Over 67,000 CNSs practice in the United States. 3 There is evidence that new CNS programs are opening. 4 Some of the new programs are preparing CNSs in specialties for which there is no current certification examination because schools are responding to a public health need and requests from healthcare systems for CNS services. We are seeking your collegial support to help remove certification barriers to CNS practice.
NACNS shares NCSBN's concerns about providing the best nursing care for patients, and is very interested in any NCSBN data about safety issues, particularly the study results reported by the "Commitment of Public Protection Through Excellence in Nursing Regulation" project noted in your letter. Sharing information about safety issues will assist NACNS and other organizations supporting advanced practice nursing to better address public safety concerns.
CNSs have existed as master's prepared advanced practice nurses for 50 years. NACNS is committed to supporting the unique scope of CNS practice and to further articulating that which makes CNS practice distinguishable from the other 3 categories of advanced practice nurses, and to assure that CNSs are not restrained in their ability to provide safe advanced nursing care to the patients. As evidence that NACNS's positions are consistent with those of practicing CNSs, we proudly note that our membership has increased 20% in the past year. We look forward to working with NCSBN and other organizations using our common areas of agreement as a platform to find creative solutions to our differences. Thank you for your very thoughtful letter to the editor of the journal as one vehicle to begin finding the solutions.
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