National Association of
Clinical Nurse Specialists
Advanced Practice Nursing
June 9, 2004
An Invitational Meeting
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.
A 15 Minute Summary of
Too little time to reach understanding
of CNS practice and related issues.
Leading to misunderstanding and
Brief overview will generate more
Definition of a CNS:
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.
Definition of a CNS:
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,
Definition of CNS:
CNSs function independently to
provide theory and evidence-based
care to patients/clients in the
attainment of health goals.
Definition of CNS:
CNSs practice autonomously under
the authority granted by the
registered nurse license.
CNSs expand the depth and breath
of nursing practice within existing
Advanced Nursing Practice
Consistent with ANA’s longstanding
APN is an umbrella term to describe RNs
with educational preparation at the graduate
with a unique focus of clinical practice
CNS, NP, CNM, CRNA
of CNS Practice
Clinical expertise in the assessment,
diagnosis, and treatment of illness
and the prevention or remediation of
risk behaviors through nursing
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
Illness problems are problems amenable
to autonomous nursing interventions.
Give me an example
Problems amenable to autonomous
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
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
Is NOT the scope of practice of a “generalist” RN
Outcomes of CNS Advanced
Decreased use of pain medication
Decreased length of stay
Shorter return to functional status
Return to work – decreased sick leave
Shorter return to social role status
Ability to maintain family
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
Should CNSs have
Prescriptive authority may be a
characteristic of some CNSs
Prescriptive authority is not the
defining characteristic of CNS
Prescriptive authority for CNSs is
Specialization is a division of a generic
field or a recombination of aspects of
different fields that occurs along some
Specialization focuses on a narrow piece
of a field, which allows for greater
development of the specialty.
CNS Specialty Practice
Specialty focus is the hallmark of
CNS specialty is built on generalist
preparation as an RN.
CNS specialties may be broad or
narrow, well established or
• Individual, family, community
• Pediatrics, geriatrics, women
Type of problem
• Pain, wounds, stress
• Emergency unit, burn unit,
Type of care
• Rehabilitation, palliative care, wellness
• Diabetes, oncology, psychiatry
CNSs’ 50 year
is identified by:
ANA Scope and Standards of Practice, 2004;
NACNS Statement on CNS Practice and
NACNS Statement on CNS
Practice and Education
for CNS education.
*2003 Survey reports
>50% of CNS programs
using NACNS educational
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
Described in Statement, 2004
Core competency statements describe
skills essential to fulfill outcomes of CNS
Core competencies in client sphere (direct
care) are basis of competencies in other
two spheres (nurses/nursing practice &
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.
for CNS Curriculum
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
Matching Certification to
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
Specialty practice cannot be constrained by a
requirement for a priori exams.
Certification: What Model of
American Nurses Credentialing Center
(ANCC): 5 sub-roles model.
American Association of Critical Care
Nurses (AACN): Synergy Model of
Oncology Nursing Society (ONS): Relies
on ANA scope and standards of practice.
A Modular Approach
NACNS supports a modular certification
Earned graduate degree in nursing with
a CNS clinical focus.
A module to validate core CNS practice
Specialty module options to address
Options for Modules
Other alternative strategies
All options must be legally
Regulation for CNSs
Definition of advanced scope of CNS
Additional regulation if prescriptive
authority is sought
NACNS does not support the
Uniform APRN Compact
Current CNS Regulation
Review of 48 states revealed 6 types of
Recognition in statute only
Document of recognition
Lyon, B.L. & Minarik, P. (2001). Clinical Nurse Specialist, 15(3) 108-114.
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
requiring CNSs to obtain a separate authority
to practice is over-regulation for the majority
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
NACNS positions reflect
commonalities among its CNS
members regardless of specialty.
Specialty organizations develop
standards of practice for the unique
NACNS positions were developed by the
board of directors in response to
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.
Tyranny of Consensus
Banister & Schreibner (2004). International Journal of Nursing
Education Scholarship, 1(1).
Consensus based on unanimous
Lingering bad feelings
Undermining of previous work
Identify and examine values
State core principles
Address informal power (resources,
position, experience) that can lead
Account for all perspectives
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.