The Clinical Nurse Specialist: Under the Magnifying Glass

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by Tyler Sturdivant, MSN, RN, AGCNS-BC, SCRN and Chondra Butler, DNP, RN, AGCNS-BC

The clinical nurse specialist (CNS) is an advanced practice nurse (APN) who serves as a clinical expert within a specialty population. Like other APNs, (nurse practitioner, nurse midwife, and certified registered nurse anesthetist) the CNS is educationally prepared with either a master’s or doctoral degree. While the other APNs function primarily as providers, the CNS role encompasses a multitude of healthcare practices. The CNS focuses on treating and managing health concerns of patients and populations through practice in three spheres of influence which include the patient, the nurse, and the system spheres.

Within these spheres, the CNS functions as a direct care provider for patients and families, as an educator, mentor, and coach to nursing personnel, and as a change agent to impact outcomes within the healthcare system. Serving as a direct care provider is a distinguishing role of the CNS; however, performing actions within the nursing and system spheres indirectly impacts the quality of care provided to patients as well. Though each sphere encompasses separate and specific practice interventions, the CNS often engages within each sphere simultaneously and moves fluidly between each sphere seamlessly, offering a unique and global view to improving patient outcomes that cannot be performed solely through the direct care provider roles of other APNs.

CNSs have been named the APN leader in preventing hospital-acquired conditions (HACs) that include pressure injuries, falls, central line associated blood stream infections, and catheter-associated urinary tract infections in the United States. This reduction in HACs not only improves the quality of care provided to patients, but also saves institutions on average $45,500 per case that would otherwise not be reimbursable by the Centers for Medicare and Medicaid Services. Not only have CNSs shown significant impact on the number of HACs, CNSs often serve on interdisciplinary teams that drastically reduce readmission rates, lengths of stay, and psychiatric patient events that have direct care and fiscal implications for the patient, nurse, and system alike.

Traditionally, the CNS only practiced within the acute care setting; however, CNSs are now being utilized in outpatient primary care settings to treat patients and impact outcomes that are focused on disease prevention, health promotion, and wellness care. National CNS certifications are based on a specialty population area and include adult-gerontology, pediatric, and neonatal.  These certifications are offered through either the American Association of Critical-Care Nurses or the American Nurses Credentialing Center. Within the specialty population, CNSs can narrow their focus based on practice setting, such as the emergency department or critical care unit, or based on specific disease processes such as psychiatric, cardiovascular, or oncology.

The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education aimed to create uniformity between states regarding all APN roles and the requirements necessary to practice by the year 2015. All except three states recognize the CNS as an APN. Today, many states have adopted portions of the model, but there are still wide variations from state-to-state regarding APN scope of practice and licensure requirements, especially for the CNS. Some states allow CNS licensure and practice without national certification while others require national certification to obtain licensure. Practice and prescriptive authority for the CNS varies greatly among states. Many states allow the CNS to practice and prescribe with oversight from a collaborating physician, while some states allow the CNS to practice and prescribe independently without the use of a collaborating physician. Unfortunately, some states do not grant prescriptive authority to the CNS at all. Prescriptive authority is not exclusively related to medications, but more so, the ability to write orders for laboratory studies, diagnostic tests, durable medical equipment, and even discharge instructions. The lack of prescriptive authority in this regard can greatly limit the CNS’s scope of practice and prevent them from practicing to the full extent of their educational training. With the versatility of CNS practice and the variability of each state’s practice requirements, CNSs face an uphill battle with role confusion, fiscal reimbursement allowances, and justification of employment positions. In fact, the CNS is the only APN role decreasing in numbers nationally with direct relation to lack of understanding and utilization of the unique role.

In Alabama, the CNS is considered an APN and must submit proof of national certification to be licensed. The CNS technically has independent practice authority as no collaborating physician is required to practice, and the role is title protected. However, this practice authority is not as it seems. The CNS in Alabama does not hold prescriptive authority, even for durable medical equipment or laboratory studies, and “may not perform any of the functions” of the other APNs according to Article 5 of the Nurse Practice Act. Essentially, the CNS can be used in specific areas as an expert clinician but cannot use the APN skills and education obtained to practice in a direct care provider role. Because of this restricted practice authority, many CNSs fail to license in Alabama as they cannot practice to the full extent of training; to date, there are only approximately 80 licensed CNSs in the state with far more educationally prepared in the role of the CNS.

To add insult to injury, CNS educational programs are closing at an alarming rate with only one remaining in Alabama, and until recently, there was no professional organization for the CNS in the state. In addition, the four APN roles lack cohesion and true understanding of each other’s scope of practice, creating a conflicting and competitive environment regarding advocacy for full practice authority. Program closings, lack of a professional voice, and other APN competition aids to promote lack of necessity of the CNS role in the state and nationwide.

As of February 2018, a total of 18 states and Washington, D.C. allow the CNS to prescribe without the oversight of a collaborating physician, and a total of 20 states allow prescriptive authority with a collaboration agreement. Of the states that recognize the CNS as an APN, Alabama is one of only 10 states that does not allow the CNS to prescribe at all. In stark contrast to Alabama, Oregon allows CNSs to practice and prescribe non-pharmacological and pharmacological treatments without a collaborating physician and does not require national certification to be eligible for CNS licensure. With this authority, the CNS practices to the full extent of training and scope, enabling superior healthcare outcomes known to be produced by a CNS professional. Although not in full compliance with the Consensus Model related to licensure, the Oregon Association of CNSs is investigating possible ways to mitigate this issue.

To assist in creating a professional CNS voice in Alabama, the Alabama Association of Clinical Nurse Specialists (AACNS) was established in August 2017. AACNS serves to promote the CNS role, provide a network for CNSs within the state, and to provide organizational support for any policy initiatives that will impact healthcare and CNS practice authority in Alabama. Membership of AACNS is open to any individual educationally prepared as a CNS; licensure and certification are not required.

AACNS is currently applying as an affiliate of the National Association of Clinical Nurse Specialists to gain national support for CNS role promotion and resources for policy initiatives. Many AACNS members serve on the Alabama Board of Nursing (ABN) in either leadership roles or on special APN taskforces designed specifically to examine current APN practice and develop plans to allow each APN role to practice to the full extent of training. For the CNS role, the taskforce aims to improve practice authority through development of ABN-approved standardized procedures, communication of the CNS role throughout the state, addition of pharmacology educational requirements similar to other APNs, exploration of billing restrictions, and collaboration with other APNs to improve nursing practice in Alabama. With state-level and national organizational support, the CNSs in Alabama will have assistance in overcoming the hindrances that stagnate role promotion, employment, and scope of practice of the CNS.

The first step of role promotion starts with true understanding and outreach. Whether a bedside nurse, APN, or nurse executive, there is knowledge to gain regarding healthcare and the roles of nursing professionals. As an APN, CNSs should be privy to the same educational-based practice standards and role recognition as the other APNs. With the availability of full practice and prescriptive authority for the CNS, superior outcomes for the patient, nurse, and system can be achieved. As an overarching nursing goal to provide the highest quality of care to patients, all nurses should strive to promote nursing practice to the full extent of educational training. With the help of all, education on the role and value of the CNS can be disseminated and promoted throughout the state and nation.


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