A Nursing Civil War
It is hard to believe that when you read this, my term as your president will be more than half over. A year sounded like a very long time, way back in March!!!
This past July, the National Association of Clinical Nurse Specialists (NACNS) hosted a successful annual clinical nurse specialist (CNS) summit. For the last several years, NACNS has hosted an annual summit in Indianapolis to bring together key stakeholders and organizations interested in the education, licensure, and recognition of the CNS. In the past, summit topics have included the competencies necessary to be adequately educated as a CNS and the legislative and regulatory challenges for recognition as a CNS in each state. This year, we hosted 18 national nursing organizations that have an interest in developing and validating competencies for the doctoral preparation of the CNS. The key stakeholders from NACNS and other nursing specialty organizations in attendance began the work of developing curricular and competency recommendations for CNS education at the doctoral level.
When pondering the work of the CNS, I have said many times that our work can be distilled into efforts directed at safety and quality. These efforts include the safety and quality of patient care, staff satisfaction and retention, and ensuring the existence of the correct resources to provide excellent care. If we are in consensus in our understanding that this is the work of the CNS, then what are the minimum educational requirements or curricular competencies necessary to prepare future CNSs to do this work? The current educational requirement is a graduate degree at the master's or doctoral level.
As a successfully practicing CNS for over 10 years, I can confidently say that I know the work and have had a share of success in doing this work for a large integrated health delivery network. My degree, Masters in the Science of Nursing the Adult, with a specialty in critical care nursing, has prepared me to use the scientific method to approach the clinical quality improvement process and all other aspects of my role. Many CNSs use these methods to lead large-scale quality improvement projects focused on topics such as reducing nosocomial infections, eliminating medication errors, developing rapid response teams or nurse consultation models, providing patient education to reduce recidivism, and leading interdisciplinary teams to optimize the care of patients or clients in each area of clinical specialty or interest. These are just some of many exemplars demonstrating outcomes of CNS practice.
In doing an environmental scan of the broad array of issues facing the healthcare delivery system, there are many external forces currently facing the nursing profession. These forces include the shortage of nurses and faculty; Centers for Medicare and Medicaid Services regulations and indicators; the Institute of Medicine report; and the emphasis on the 6 elements of quality in healthcare: safety, effectiveness, patient centeredness, efficiency, timeliness, and being equitable. In addition, the profession receives mandates for clinical quality improvement from organizations such as the Institute for Healthcare Improvement and the Joint Commission. I know of many, many CNSs across the country who are leading quality initiatives in response to these mandates. Through this work, they are making a significant impact on the clinical and financial outcomes in their facilities. This is the work of the CNS, and it is perfectly matched to the needs of the healthcare delivery system and the public.
If a CNS has career aspirations that spur the desire to earn a doctoral degree in nursing, what outcomes would we expect from this person? How would outcomes differ from a doctorally prepared CNS compared with a CNS with "only" a master's degree? Would the doctorally prepared CNS be paid more? A graduate of a doctoral program should possess different, more complex thinking and problem-solving competencies. Wouldn't it be logical to assume that the outcomes would be different to account for the doctoral degree and additional salary?
Since at least the 1970s, the nursing profession has fought with itself, a "nursing civil war." Baccalaureate entry into practice as the minimal standard is still not resolved. This seems to be the result of some nursing leaders having put forth recommendations without getting consensus from the larger nursing community. It seems that the push by some nursing leaders for the doctorate of nursing practice as the entry into advanced practice nursing for all 4 advanced practice roles has occurred without thought of the broad consequences to the profession and without gaining consensus from the larger nursing community. Where are the data that support the need to make doctoral preparation entry into advanced practice? I would contend that the CNS can continue to be prepared at the master's level. If a CNS should choose to pursue a doctorate, then that CNS should determine the type of doctorate desired, whether that would be a research doctorate or a clinical doctorate, including a doctorate of nursing science or a doctorate of nursing practice.
What is my point? In listening to the work groups at our summit, we discussed what doctoral education for the CNS should look like without focusing on the specific type of doctoral education such as a research doctorate or a clinical doctorate. We discussed what curricular components of doctoral programs would lead to outcomes that differ from outcomes achieved by CNS graduates of master's programs. However, regardless of the level of education, curricula need to include organizational learning and systems thinking. Both are needed for the CNS work of advancing the practice of nursing and practicing nursing at an advanced level. This is the safety and quality work of the CNS, and it is essential in today's healthcare delivery system. It is unclear why a doctoral degree would be required to do this work when the preparation for the work is already a component of master's education. Compelling reasons for requiring doctoral education as entry into advanced practice must be present or the danger of not being good stewards of the profession exists.
In being aware of the multiple forces in the healthcare delivery scene, our focus should be on working with and supporting each other in the safe, equitable delivery of care to the public. They have entrusted themselves to us and to the system. I am now convinced that we are being irresponsible if we mandate a change in minimum educational requirements without the evidence to do so. The expenditure of resources in rewriting curricula and changing state practice acts, is once again a sign that the nursing profession is battling within itself-a nursing civil war. We should be joining forces to provide exceptional care regardless of the setting or population instead of creating additional layers of educational requirements that have not demonstrated added value to the practice of the CNS.
Therefore, we will continue to develop consensus among the stakeholders in the advanced practice community regarding the development of CNS doctoral level education and practice competencies. Based on the work achieved at the summit, I believe that we will have a set of competencies that will attain this goal. But in looking at our overall responsibility to the nursing profession and to the public, doctoral education should remain an option for the CNS, unless and until there is a cogent argument to mandate doctoral level education as entry into advanced practice.
NACNS Updates
Last Chance to Nominate Your Colleagues for NACNS Awards
Now is the time to nominate your colleagues for one of several NACNS awards. Available awards include CNS of the Year, CNS Educator of the Year, CNS Preceptor of the Year, and CNS Researcher of the Year. All nominations are due by October 15, 2007. Further information and nomination materials are available at http://www.NACNS.org.
News From Our Affiliates
The California Clinical Nurse Specialist Network
The California affiliate is embarking on a challenging journey to explore the option for prescriptive authority. The affiliate board surveyed the membership and all clinical nurse specialists (CNSs) in California on the topic of prescriptive authority. As a result of the survey findings, and in light of our expanding scope of practice, we are focusing on this issue for our November educational activity. Our mental health CNSs have been spearheading a subgroup, chaired by Kevin McGirr, for some time. The survey was a result of a request from them to query our state membership and all CNS specialties.
For our November conference, we have secured Oregon CNS affiliate member and former National Association of Clinical Nurse Specialists (NACNS) president Sue Davidson to facilitate our discussions of how to proceed. Oregon obtained prescriptive privileges in 2005, and we will need to explore similarities and differences among state practices.
Our affiliate has more than 300 members, and we are challenged to stay connected over our large geographical area. Our newsletter editor, Dr Cheryl Westlake Canary, has always done an impressive newsletter that is distributed electronically and by mail to keep us all connected to activities and opportunities. In addition, we have recently changed our board meeting structure to a conference call process so that we can connect to our Northern and Central California regional directors. We are grateful to Dr Kathi Ellstrom, our research board member, for setting this up. We have had 2 board meetings using conference technology that have been very productive. We look forward to more expedient responses to challenges that our membership encounters as well as the ability to efficiently plan conferences and educational offerings.
I stepped down as chair of the California CNS network as of July 2007. It has been a very rewarding and growth-stimulating position. I will remain active as a board member and as a member of the NACNS affiliate advisory committee as I embark on my PhD in Nursing at the University of San Diego this fall. The new California CNS chair, Evelyn McLaughlin, has stepped up to the role and has established herself as a competent leader in a short time. I am most grateful to leave the affiliate in her (and our excellent board's) capable hands. It has been my pleasure to serve with such a superb group of CNS.
Submitted by Margaret Talley, RN, CNS, CWCN-AP.
Minnesota Affiliate News
The Minnesota Affiliate of the National Association of Clinical Nurse Specialists (NACNS) will hold its annual clinical nurse specialist (CNS) conference on Friday, October 12, 2007, in Rochester, Minn. The title of the conference is "State of the Clinical Nurse Specialist: Practice, Patient Care and Programs." The keynote speaker will be Judith Spross, PhD, RN, AOCN, FAAN, well-known speaker, author, and NACNS member. Doctor Spross will present the keynote lecture "The Virtuoso Practice of CNSs: Millennial Reflections." The conference will include plenary and concurrent sessions on topics relevant to CNS practice, such as evidence-based practice, national safety goals, quality measurement and reporting, and an update on National NACNS from NACNS board member Sue Sendelbach, PhD, RN, CCNS. Abstracts for poster presentations will be accepted through Friday, September 7, 2007. For more information, or to receive a brochure, please contact Julie Ponto, PhD(c), RN, APRN-BC, AOCN, at 507-285-7135 or [email protected].
Submitted by Julie Ponto, PhD(c), RN, APRN-BC, AOCN.
Oregon Council of Clinical Nurse Specialists: A Special Interest Group of the Oregon Nurses Association
Two clinical nurse specialists (CNSs) from Oregon participated in the American Nurses Association (ANA) 2007 Quadrennial Policy Conference entitled "Nursing Care in Life, Death, and Disaster" in Atlanta on June 20, 21, and 22. The team of Oregon Nurses Association representatives included the president of the Oregon Nurses Association, Bruce Humphreys, BSN, RN; Kelly Rae Taylor, BSN, RN, chair for Cabinet on Health Policy; Sue B. Davidson, PhD, RN, CNS, assistant executive director of Nursing Practice Education and Research; Jane Sawall, MS, MPH, RN, CNS-BC, representative from the Cabinet on Health Policy; and Donna Jensen, PhD, RN, professor emeritus at Oregon Health & Science University (OHSU) School of Nursing and manager of Health Services with American Red Cross, Oregon Trail Chapter, who served in NY 9/11.
The conference provided information related to first-hand experiences during the disasters related to Hurricanes Katrina and Rita. Most importantly, discussion and feedback sessions took place regarding the White Paper draft initiated by the ANA related to altered standards of care during disaster responses. It was an honor to participate in this conference and be able to review and comment on the drafted document guiding the future of nursing practice during extreme conditions.
It is the goal of the above mentioned attendees to provide this information to other registered nurses within Oregon in October 2007 at a conference to be held in Eugene, Ore.
Submitted by Jane Sawall MS, MPH, APRN-BC; Clinical nurse specialist and chair of the Oregon Council of Clinical Nurse Specialist.
News From the Clinical Nurse Specialist Foundation
The board met on Saturday, August 4, 2007, at the home of Jan Bingle, chair of the Clinical Nurse Specialist (CNS) Foundation Board of Trustees. Besides the usual business of scholarships and research priorities, the board discussed potential sources for funding projects that the National Association of Clinical Nurse Specialists (NACNS) has underway, the creation of a promotional video on the role and work of clinical nurse specialists, and plans for our annual fundraising event during the 2007 NACNS conference. The group has also been finalizing plans for the CNS Foundation Web site.
Member Recognition
Members Kathy M. Baldwin, PhD, RN, CNS, ANP, GNP, CEN, and Elizabeth A. Mann, MS, RN, received awards for their respective posters during the 2007 Summer Institute on Evidence-Based Practice Quality and Safety, sponsored by The University of Texas Health Science Center at San Antonio Academic Center for Evidence-Based Practice. The conference was held in San Antonio from July 11 until July 14. Doctor Baldwin and colleague Linda Harrington, PhD, RN, CNS, CPHQ, won a first place award at the Educators Preconference. Their poster, entitled "Development and Implementation of a Clinical Nurse Specialist Master's Program Using Evidence-Based Practice as a Framework," described how the adult health clinical nurse specialist (CNS) program at Texas Christian University was designed to thread evidence-based practice concepts into every course. Major Mann, currently the chief of education for the Army Institute of Surgical Research Burn Center in San Antonio, Tex, along with copresenters Heather F. Pidcoke, MD, Charles E. Wade, PhD, Jose Salinas, PhD, Joel Michalek, PhD, John B. Holcomb, MD, and Steven E. Wolf, MD, won a second place award for their poster, entitled "Glucometer Correction Factor for Hematocrit Effect in the ICU." Their poster, chosen from among more than 100 submissions, described a mathematical correction that can be applied to glucometer values that approximates serum glucose measurements in patients with low hematocrit.
Janice Buelow, PhD, RN, was awarded an R 21 from the National Institute of Nursing Research to pilot test an intervention for parents of children with epilepsy and learning problems. The intervention, entitled "Creating Avenues for Parent Partnership (CAPP)," is designed to help parents problem solve when working with healthcare professionals and school professionals. This study was first funded by the Epilepsy Foundation for feasibility testing. Doctor Buelow is an assistant professor of nursing at Indiana University and teaches research in the CNS program.
Patti Rager Zuzelo, EdD, APRN-BC, CNS, a faculty member at La Salle University, received the 2007 Lindback Award for Distinguished Teaching at the university's recent commencement ceremony. The Christian R. and Mary F. Lindback Award for Distinguished Teaching is supported by the Lindback Foundation. One full-time faculty member is selected to receive the award each year by a committee consisting of students, faculty, and administrative representatives.
News Briefs
New Report: Tracking National Quality Forum Endorsed Consensus Standards for Nursing-Sensitive Care
In 2004, the National Quality Forum (NQF) published a report documenting the development of consensus standards for nursing-sensitive care. However, the degree to which these consensus standards have been adopted has been unclear. To address this question, the NQF has now completed a subsequent study, funded by the Robert Wood Johnson Foundation. The report of this work describes the use of nursing performance measures. The report also presents recommendations to accelerate the implementation of the performance measures and the adoption of NQF's endorsed consensus standards. The report is available only in electronic format and can be downloaded for free from http://www.qualityforum.org/publications/reports/nurse_tracking.asp.
Pennsylvania Clinical Nurse Specialists Receive Title Protection
July 20, 2007, will be a date to remember for clinical nurse specialists (CNSs) in Pennsylvania. Governor Edward Rendell signed House Bill 1254 into law-Title Protection for Clinical Nurse Specialists. Clinical nurse specialists in Pennsylvania have been working on the bill for approximately 10 years. The process began with the formation of the Alliance of Advanced Practice Nurses. The group was composed of representatives from the 4 advanced practice groups: CNSs, nurse anesthetists, nurse midwives, and nurse practitioners. Legislation affecting nurse practitioners was developed, introduced, and passed first. Then, the time came to write the Title Protection Bill for CNSs. The language of the bill was adopted from the NACNS Statement on CNS Practice and Education. Numerous meetings with legislators were held over the years to first explain what a CNS was and then why title protection was necessary. The bill was introduced into the House the past 2 years, with no success. But this year was different. Governor Rendell introduced the Healthcare Reform Agenda for Pennsylvania, which included HB 1254, among other advanced practice nursing bills. This time, it was successful. The law took effect 60 days after the bill was signed. The State Board of Nursing will be responsible for promulgating rules and regulations regarding the new law.
Section Description
NACNS Statement on Clinical Nurse Specialist Practice and Education,Second Edition.
This document articulates the core competencies requisite to CNS practice, outlines the outcomes of CNS practice, and provides direction to schools of nursing regarding the preparation of CNSs. Endorsed by the National League For Nursing and American Organization of Nurse Executives (AONE) as "a comprehensive reflection of the contemporary role that Clinical Nurse Specialists play in the delivery of quality nursing care," this updated version contains information for contemporary clinical nurse specialist practice and education. You can purchase your copy through the NACNS Office at a cost of $25 per copy for members of NACNS and $45 per copy for nonmembers. Discounts are offered on purchases of 15 copies or more. Contact the NACNS Office today to order your copy of the Statement.