On NBC's fictional television drama Dragnet, ace police detective Sergeant Joe Friday was adamant about getting the facts and just the facts. No embellishment, no frills, no side interest stories-just information relevant to solving the case. Over the past months, I have been invited to participate in discussions representing the National Association of Clinical Nurse Specialists (NACNS) positions on clinical nurse specialist (CNS) practice, education, certification, and regulation. With limited presentation time, it was necessary to focus on key points and salient issues-neatly packaged, summarized. Consistent with the journal's mission to bring you information, here are some of NACNS's positions packaged as information nuggets-Joe Friday style-with just a little interpretation.
WHO IS NACNS?
The NACNS was founded in 1995 and has enjoyed steady membership increases, including a 20% increase in 2003!! This continued growth is validation of NACNS's mission and message-the board has the organization on the correct course.
NACNS represents CNS interests regardless of specialty, across broad geographical areas, and in many settings and practice arrangements. Members practice in approximately 40 specialties. NACNS positions reflect the commonalities among its CNS members regardless of specialty.
NACNS has a diverse membership and represents both practice and education. Collaboration between active education and practice committees assures that each perspective is engaged and appreciated-an all too rare partnership between faculty and clinicians under one roof. The NACNS Board of Directors represents the diversity of its membership and includes CNSs in acute care, women's health, and adult health, 2 deans of schools of nursing, CNS faculty with specialty practices in cardiology, diabetes, gerontology, oncology, and adult health, and a nurse entrepreneur who founded and runs a business that provides services directly to patients on a fee-for-service basis as well as consultation for healthcare systems.
WHAT IS NACNS'S DEFINITION OF A CNS?
A CNS is defined by education and expertise. By education, a CNS is a licensed registered professional nurse with graduate preparation (earned master's or doctorate) from a program that prepares CNSs. A CNS may also be prepared in a post-master's certificate program that is recognized by a national nursing accrediting body as preparing graduates to practice as a CNS for a specialty population. By expertise, a CNS possesses advanced knowledge of the science of nursing with a specialty focus and applies that knowledge to the assessment, diagnoses, and interventions and the design of nursing interventions.1
WHAT IS NACNS'S DEFINITION OF AN ADVANCED PRACTICE NURSE?
NACNS's definition of an advanced practice nurse is consistent with American Nurses Association's long-standing position-advanced practice nursing is an umbrella term used to describe registered nurses (RNs) with educational preparation at the graduate level for a particular and unique focus of clinical practice-CNS, nurse practitioner, nurse midwife, nurse anesthetist.
WHAT IS THE LEGAL BASIS FOR CNS INDEPENDENT PRACTICE AUTHORITY?
CNSs function independently to provide theory and evidence-based care to patients/clients in the attainment of health goals. CNS advance the practice of nursing by revising standards of practice, influencing the practice of other nurses, and influencing the delivery system to create a climate where nursing practice leads to quality patient outcomes. CNSs practice autonomously under the statutory authority granted by the registered nursing (RN) license. State nurse practice acts grant nurses an autonomous scope of practice that differentiates the practice of RN from the practice of other licensed health professions, such as physician, physical therapist, and pharmacist. CNSs provide advanced nursing practice by expanding the depth and breath of autonomous nursing practice granted by state statute and described in the RN license. CNSs, like all licensed RNs, have an independent and autonomous scope of practice-we are just beginning to spread our wings and discover how much of that autonomous terrain is undeveloped. A graduate degree from a program that prepares CNSs is the way to acquire tools to explore the uncharted terrain.
WHAT ARE THE DEFINING CHARACTERISTICS OF CNS PRACTICE?
The defining characteristic of all CNSs is clinical expertise- expertise in the assessment, diagnosis, and treatment of illness (the experience of symptoms and functional problems) and the prevention or remediation of risk behaviors through nursing interventions. Illness can be experienced in the presence or absence of disease; the presence of illness does not preclude health. Likewise, health does not preclude illness.1-4 CNSs achieve quality cost-effective patient outcomes by 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. Additionally, CNSs contribute to knowledge development about specifics, how, when, and where, of implementing medical therapeutics.5
IS PRESCRIPTIVE AUTHORITY A DEFINING CHARACTERISTIC OF CNS PRACTICE?
No. Prescriptive authority may be a characteristic of some CNSs' individual practices however; prescriptive authority is not the defining characteristic of CNS practice. There is nothing particularly unique about prescriptive authority-in many states, pharmacists, clinical psychologists, and other providers have options for prescriptive authority.
HOW DOES NACNS DEFINE SPECIALTY PRACTICE?
A hallmark of CNS practice is specialization. Specialization is a division of the generic field or a recombination of aspects of different fields that occurs along some logical lines. Specialization focuses upon a narrow piece of the field, which allows greater development of depth in the specialty.6 Consistent with this definition, NACNS defines specialization as a delimited or concentrated area of expert clinical practice with focused knowledge and skills. The area may be broadly or narrowly defined; the area may be well established or emerging.1,4 Typically, a CNS specialty is identified in terms of population, like gerontology or maternal child health; type of problem, such as wound or pain care; setting, such as perioperative or emergency; type of care, like rehabilitation or palliative care; and disease/pathology, such as oncology, diabetes, and orthopedics.1,4
WHAT ARE NACNS'S RECOMMENDATIONS FOR CNS EDUCATION IN A SPECIALTY?
CNS education is built on the generalist nursing practice foundations of baccalaureate nursing education. CNS education moves a nurse from the generalist focus to an advanced level of nursing with a specialty focus. CNS programs include 500 hours of clinical experience with the specialty supervised by a CNS. Graduate education should include content that address core competencies and outcomes of CNS practice consistent with the conceptual framework for CNS practice-the 3 spheres of influence. Content (advanced theory and science) and supervised clinical experiences should support the specialty CNS practice for which the student is preparing. CNSs in some specialties, but not all specialties, chose/need to extend their scope of practice beyond that of the RN, often to obtain prescriptive authority, and therefore need content and experiences to prepare for this additional practice activity.
SHOULD CNSS SEEK PROFESSIONAL CERTIFICATION?
Yes, certification is an important professional credential. Professional validation of practice competency and expertise is the responsibility of professional organizations. Current certification options are limited and do not adequately reflect CNS specialty practices. Multiple mechanisms are needed to address the full range of specialty practices. Validation through psychometric examination, portfolio, or other legally defensible alternative strategies must be congruent with the CNS specialty practice. NACNS supports a modular certification model that includes earned graduate degree in nursing with a CNS clinical focus, examination module for CNS practice competencies, and specialty module options to address specialized knowledge-determined perhaps by exam, portfolio, or other legally defensible mechanism determined by the professional organization that is the recognized authority for that specialty knowledge.
WHAT STATUTORY/REGULATORY AUTHORITY IS NEEDED FOR CNS PRACTICE?
CNSs independently provide advanced nursing practice within nursing's existing autonomous scope of practice consistent with the RN license. Additional regulation of CNSs by states should include title protection and a definition of advanced scope of CNS practice within the autonomous scope of practice authorized for the RN license. An additional license is not required. When CNSs are providing pharmacologic interventions, then CNSs are practicing outside of the legally authorized scope of practice granted by the RN license; therefore, additional regulatory authority is needed to protect the public specifically for prescriptive authority. Licensing requirements for all CNSs beyond the RN license, when prescriptive authority is not a part of that practice, is overregulation, results in restraint of trade, and deprives the public of CNS services.
WHAT IS NACNS'S RELATIONSHIP TO SPECIALTY PRACTICE ORGANIZATIONS?
Specialty organizations develop the standards of practice for the specialty population. Specialty practice organizations with CNS members may choose to narrow or revise NACNS positions to reflect the CNS membership of the specialty. Among practice organizations with CNS membership, NACNS may agree because NACNS' and the specialty organization's positions are in alignment, disagree because there are fundamental differences between the assumptions and positions of NACNS and the CNS members of the specialty practice organization, and disagree because of misunderstandings of NACNS's assumptions and positions. NACNS has and will continue to "agree to disagree" with respect and professionalism and work to resolve our misunderstandings or misinformation
So there you have it-the facts. At the end of each Dragnet episode, after TV magic assured that the criminal was apprehended, an announcer would describe what happened at the subsequent trial. I have no TV magic and cannot announce what will happen as advanced practice nursing continues to evolve. You are invited to contribute your scholarly analysis, opinion, and political observations and join the national dialogue that is shaping that future. I am confident that NACNS will continue to advocate for CNSs and support educational, legislative, and policy positions that increase the public's access to the full range of CNS services. And that's a fact, ma'am.
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