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  • 1. National Association of Clinical Nurse Specialists Advanced Practice Nursing Consensus Conference June 9, 2004 An Invitational Meeting
  • 2. 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.
  • 3. 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.
  • 4. 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.
  • 5. 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).
  • 6. Definition of CNS: Independence  CNSs function independently to provide theory and evidence-based care to patients/clients in the attainment of health goals.
  • 7. 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.
  • 8. 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
  • 9. 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.
  • 10. 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.
  • 11. Give me an example Problems 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
  • 12. 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
  • 13. 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.
  • 14. 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.
  • 15. 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.
  • 16. 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.
  • 17. 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
  • 18. 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.
  • 19. 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
  • 20. 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).
  • 21. 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 Recommendations for CNS Curriculum See handout
  • 22. 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
  • 23. 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.
  • 24. 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.
  • 25. 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.
  • 26. Options for Modules  Psychometric examination  Portfolio  Other alternative strategies All options must be legally defensible
  • 27. 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
  • 28. 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.
  • 29. 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.
  • 30. 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
  • 31. Specialty Organizations  NACNS positions reflect commonalities among its CNS members regardless of specialty.  Specialty organizations develop standards of practice for the unique specialty population.
  • 32. Client Direct Care Nurses & Nursing Practice 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/Competencies SpecialtyStandardsofPractice SpecialtyKnowledge © J.S. Fulton, 2004
  • 33. 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.
  • 34. About Consensus…  Tyranny of Consensus Banister & 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
  • 35. Avoiding tyranny  Identify and examine values  State core principles  Address informal power (resources, position, experience) that can lead to coercion  Account for all perspectives
  • 36. 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.

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