1. Goudreau, Kelly A. PhD, RN, ACNS-BC, FAAN

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Some topics inspire that glazed-over, eye-roll look. For years, research topped the list of most likely to disengage an audience of practicing nurses. But times have changed, and Clinical Nurse Specialists (CNSs) now lead integration of research and evidence into practice. Slowly the twin barriers of "we always did it this way" and "we tried it once and it didn't work" are giving way to practice innovations for improved quality and safety.


Now imagine the same thing happening with engagement in health policy. Is it possible? Of course it is, provided we set aside the assumption that policy work belongs to people with time for such things. As advanced practice nurses and leaders in the profession, CNSs are responsible for shaping the laws, rules, and regulations defining nursing's practice authority and responsibility. Clinical Nurse Specialists must engage in understanding changes occurring not only at the individual state level, but also around the nation. What may seem distant and uninteresting in the halls of the state legislature will subsequently roll over to the halls of the state board charged with regulating the practice and culminate in a tremendous impact on daily practice with patients. Not convinced? Here's a story to illustrate the point. In my current job as a nurse administrator in the Veterans Health Administration (VHA), I reviewed the state rules and regulations related to standing medical orders and protocols with standing orders for medical treatments from a number of states-strategies for initiating medical treatments based on the nurse's judgment. In a federal system such as VHA, nurses work with licenses from many different states; the federal system honors all state licenses. The VHA facility where I work employs nurses with licenses from 6 different states, each with differing regulations for the use of standing medical orders. To facilitate nurses practicing to the full extent of their education and training, as recommended by the Institute of Medicine (The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011:85-183), the facility moved forward with physician-nurse collaborative protocols for managing some chronic diseases, a practice permitted in the state nursing regulations where the facility is located. However, in 5 of the 6 states where nurses were licensed, this practice would have been restricted by individual state regulations. It is pretty amazing to see the significant differences around the nation on this one simple topic. Even more amazing are the barriers to the public's access to CNS and other nurses' services created by variances in state policies.


Nurses licensed in states allowing use of facility-specific protocols with medical treatments based on a nurse's judgment are known to practice safely within the protocol parameters. Nurses licensed in states that require a prescriber's signature each and every time a protocol is initiated can be charged with practicing outside their license scope for initiating the very same protocol that a peer licensed in another state can use. Some states go beyond a signature for the protocol treatment and require patient evaluation by a physician or a licensed independent practitioner (LIP) (including APRNs in LIP roles) before protocol treatments can be written.


Cumbersome protocol procedures impact nursing practice and ultimately patient care outcomes. Unless a CNS is recognized by a facility as an LIP, specialty care initiatives can be restricted, and patients experience time delays in receiving needed services. Clinical Nurse Specialists need to be knowledgeable about licensing rules and regulations and should help staff understand their role in initiating an intervention initiated by a CNS. Know the regulations applicable to standing orders and medical protocols. New York and Florida are 2 examples of states where standing orders lack legal support for use in care facilities. Anyone working in states lacking support for protocols should begin an initiative to change the regulations.


How do you possibly find the time to pay attention to the state board and the legislature? Make time. It's important. Clinical Nurse Specialists need to be advocates for CNS practice in particular and nursing practice at all levels. Any nurse with licensure must pay attention to the rules, regulations, laws, and pending outcomes of your state legislature. In some instances, as in the case of those working in the federal systems such as the VHA, attention must be given to the rules and regulations in more than 1 state.


Awareness is the first step; next comes influencing change. Become engaged by listening, asking questions, attending meetings, reading bulletins, and checking out what's on the state board's Web page. Know the names and backgrounds of the board members. It is highly likely the minutes of the board meetings are posted on the Web. The meetings are open, so go to one. Just as research is now part of daily life for a CNS, so too should health policy become a part of daily life. Kudos to those who are actively engaged in educating legislators, peers, administrators, and colleagues about the importance of some small wording change that is needed. Kudos to those who are thinking about becoming engaged in the discussions and dialogues about changes in policy that are needed in order to improve the care of patients within your region, your state, your nation, or even other nations. Kudos to those who are early in your career and cannot see your way clear to addressing this one more issue but are supporting those who are doing so.


Together we can make a difference and we will[horizontal ellipsis] one state at a time.