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The National Association of Clinical Nurse Specialists (NACNS) supports the 4 overarching key messages identified by the Institute of Medicine (IOM) report, The Future of Nursing.1 A reformed healthcare system aimed at improving the health of all Americans will require nurses practicing to the full extent of their professional education and training, functioning as full partners with physicians and other healthcare professionals, and achieving higher levels of education and training. Strengthening an information infrastructure for improved data collection will lead to more effective workforce planning and policy making. Clinical nurse specialists (CNSs) play an important role in leading healthcare change in the United States. The purpose of this position paper is to identify and communicate NACNS's recommendations for ensuring CNS engagement in and contributions to accomplishment of the 8 overarching recommendations made by the IOM. Not all IOM recommendations are addressed, only those most aligned with NACNS goals.
Removing regulatory scope-of-practice barriers restricting the ability of CNSs to provide services that they are educationally prepared to provide will expand access to care and reduce costs while contributing to improved patient outcomes in a reformed healthcare system. National and international research has demonstrated that advanced practice registered nurses (APRNs), in particular CNSs, effect positive change and reduce costs through increased emphasis on evidence-based practice.2 Advanced practice registered nurses have improved outcomes in the area of chronic disease management by reducing fragmentation of care and improving patient self-care abilities.3 Specific strategies recommended by NACNS to remove scope-of-practice barriers include the following:
* Amend Nurse Practice Acts to allow CNSs to diagnose and treat health conditions.
* Eliminate requirements for physician "collaborative practice agreements."
* Remove prescribing restrictions or limitations imposed by required physician oversight, collaboration, or signature.
* Amend requirements for hospital participation in the Medicare program to ensure that CNSs are eligible for clinical privileges, admitting privileges, and membership on medical staffs.
* Advocate for all insurers, including but not limited to, Medicare, Medicaid, and third-party insurers, to include coverage of CNS services that are within their scope of practice under state law.
* Amend the Medicare and Medicaid programs to authorize CNSs to perform admission assessments, to certify patients for home healthcare services, and to admit patients to hospitals, hospice, and skilled nursing facilities.
The CNS is an APRN uniquely prepared to contribute to and lead collaborative improvement teams. Clinical nurse specialists are prepared at the graduate level with master's degrees, practice doctorates (doctor of nursing practice [DNP]), or research doctorates (doctor of philosophy [PhD]). Clinical nurse specialists with master's and DNP degrees are skilled in working collaboratively for dissemination of knowledge and sustaining change. PhD-prepared CNSs are additionally prepared to conduct research, lead research teams, and design and evaluate interventions for improved clinical and financial outcomes. Clinical nurse specialists improve clinical practices, develop appropriate use of current and new technologies, and create innovative models of care. All CNSs use systems thinking to develop and implement improvements across the healthcare continuum for specialty groups of individuals, families, and communities.
Specific recommendations to ensure expanded opportunities for CNSs include the following:
* Promote interdisciplinary education at the graduate level to optimize collaboration skills.
* Support entrepreneurial opportunities for CNSs in the design, implementation, and evaluation of innovative care models.
* Optimize education related to technology and technology evaluation.
* Revise or amend regulatory language to recognize CNSs as primary care providers for patients with chronic health problems related to medical diagnoses such as diabetes, heart failure, and mental health or to chronic conditions such as chronic wounds, chronic pain, or impaired mobility.
* Actively engage CNSs in healthcare policy decisions.
* Advocate for organizational support to increase CNSs' responsibility in implementing system improvements.
Expanded healthcare services, including prevention and intervention, have enabled people with health problems to live longer. As a result, patient health needs are often complicated by multiple comorbid diseases, resulting in increasingly complex care management. The healthcare system is challenged to meet multiple, simultaneous demands. Clinical nurse specialists are providing services and developing innovative care models to improve outcomes for relatively sicker and frailer patients in addition to managing the care of patients with complex and multiple chronic diseases across different practice settings. Clinical nurse specialist practice competencies are grounded in lifelong learning, including advanced academic degrees. With ever-expanding scientific and technological advances, graduate doctoral degree options for CNSs must be available-both the DNP and PhD. Clinical nurse specialist students should be encouraged to seek doctoral degrees for initial preparation, if feasible. Master's degree-prepared CNSs should be encouraged to pursue doctoral degrees.
Specific recommendations to increase the number of CNSs with doctorates include the following:
* Advocate for academic institutions to offer research and practice doctorates that support CNS specialty-focused advanced practice nursing.
* Advocate for CNS-focused courses in doctoral programs.
* Develop BSN-to-PhD and BSN-to-DNP programs for CNSs to streamline the process for preparing research and clinical scholars.
* Recommend options for seamless progression to practice doctorate (DNP) preparation for CNSs.
The ability of healthcare systems to more effectively use APRN skills and knowledge is central to achieving more efficient and effective healthcare in America. Clinical nurse specialists are the only APRNs prepared with both systems and specialty knowledge and are therefore well suited to lead the newly emerging interprofessional efforts addressing population-focused healthcare needs. National Association of Clinical Nurse Specialists recognizes the value of CNS membership on professional and public boards and challenges its membership to maximize use of systems thinking skills and experience by participating in developing innovative approaches to healthcare improvements.
Specific recommendations to increase CNS leadership in advancing health include the following:
* Encourage accountable care organizations to include CNS services among all the services provided.
* Facilitate the delivery of CNS specialty services in novel healthcare delivery systems.
* Foster the use of CNS leadership skills in the redesign of healthcare delivery across settings.
* Encourage CNSs to design, implement, and evaluate new systems of providing care to specialty populations.
* Advocate for CNS opportunities for continued development of leadership skills (lifelong learning).
* Encourage and mentor CNSs to participate in policy and regulatory bodies.
As the primary federal agency responsible for providing information and analysis related to the supply and demand for health professionals, including nurses, the National Center for Health Workforce Analysis ("National Center") helps promote a supply and distribution of well-prepared health professionals and other workers to ensure access to high-quality, efficient care for the nation. National Association of Clinical Nurse Specialists recommends that, in order to fully understand the advanced practice nurse workforce, the National Center must systematically collect and analyze data about the CNS workforce and practice. In addition, the Government Accountability Office should ensure that the Workforce Commission membership includes adequate nursing expertise that includes CNSs as part of this commission. Clinical nurse specialists must provide input into the process of data collection methodologies designed to collect data on both APRN and interdisciplinary practice. This would include future work proposed by state licensing boards for nursing, medicine, dentistry, and pharmacy. Clinical nurse specialists' expertise is needed for the development of a standardized minimum data set (MDS) across states and professions, deliberately planned to assess healthcare workforce needs by demographics, numbers, skill mix, and geographic distribution.
Specific recommendations to support an infrastructure for work force data collection and analysis include the following:
* Ensure that the criteria for all future survey designs include CNSs. For example, the Workforce Commission and the Health Resources Services Administration may want to develop an APRN survey focusing on the underserved and vulnerable populations. It is critical that CNSs provide the necessary consultation to ensure that CNS-sensitive outcomes are captured within such a survey.
* Include CNSs in the design of all workforce standardized MDSs, including work by state licensing boards.
* Increase the sample size and fielding the survey to every other year, facilitating expanding the data collected on APRNs, and release survey results more quickly.
* Include recommendations by CNSs when establishing a monitoring system that uses data from the MDS to systematically measure and project nursing workforce requirements by role, skill mix, region, and demographics.
* Integrate CNSs when coordinating workforce research efforts with the Department of Labor, state and regional educators, employers, and state nursing workforce centers to identify regional healthcare workforce needs and when establishing regional targets and plans for appropriately increasing the supply of health professionals.
1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. October 2010. http://iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Healt. Accessed May 21, 2012. [Context Link]
2. Gurzick M, Kesten KS. The impact of clinical nurse specialists on clinical pathways in the application of evidence-based practice. J Prof Nurs. 2005; 26: 42-48. [Context Link]
3. Koskinen L, Mikkonen I, Graham L, et al.. Advanced practice nursing for enduring health needs management: a global perspective [published online ahead of print March 17, 2012]. Nurse Educ Today. [Context Link]
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