1. Ray, Melinda Mercer MSN, RN
  2. Mittelstadt, Pamela MPH, RN

Article Content

Clinical nurse specialists (CNSs) comprise the second largest of the 4 advanced practice registered nurse (APRN) roles. The National Association of Clinical Nurse Specialists (NACNS), the American membership association for CNSs, contracted for a review of the status of 2 specific scopes of practice issues-prescriptive authority and independent practice-in the states since 2010. The timeline was selected based on the Institute of Medicine consensus report, "The Future of Nursing: Leading Change, Advancing Health,"1 published in October 2010. Among other recommendations, this report spoke to the importance of full scope of practice for APRNs.


Clinical nurse specialists are licensed registered nurses who have graduate preparation (master's or doctorate) in nursing. They have unique and advanced level competencies that can meet the increased needs of improving quality and reducing costs in a healthcare system. Growing numbers of CNSs provide Medicare part B services to beneficiaries and have prescriptive privileges in most states. Tracking the changes in state law that allows the CNS to practice to their full scope of practice is important information for regulators, legislators, and other public policy leaders.


These changes in prescriptive authority and independent practice legislation are the result of the demanding work of APRN and CNS coalitions in the state. Working for full scope of practice for the CNS is a challenging work and takes strong leadership from CNSs in the state. Any effort to increase the scope of practice can be met with strong opposition from medical societies and misunderstanding of the role by legislators. In many states, coalitions have worked for years to develop and move this important legislation through the state legislative and regulatory hurdles. The NACNS, as a national organization, relies on the efforts of these outstanding leaders to move the CNS to full scope of practice. It is important that all CNSs keep connected to their state NACNS affiliate or APRN coalition so that they can contribute to the state advocacy work.



Before 2010, 31 states provided some level of prescriptive authority (independent and collaboration required) for the CNS. On the basis of the NACNS review completed in 2016, there has been a 62% increase in independent prescriptive authority and a 29% overall increase. Prescriptive authority is part of the scope of practice of all APRNs; having the authority to prescribe does not require the provider to use this authority in their practice setting. Clinical nurse specialists have made excellent progress in 5 years, with a 62% increase in prescriptive authority recognition without supervision and/or an agreement with a physician. Another 19 states allow the CNS to prescribe with supervision and/or an agreement with a physician. This brings the total number of states that allow prescriptive authority of some type for the CNS to 40.



Independent practice authority describes the ability of a CNS to provide services and be reimbursed for those services as a free-standing healthcare provider. Many CNSs are employees of healthcare systems. Independent practice authority becomes important if you are a CNS who wishes to open your own practice or join a practice and bill for your services and/or seek medical privileges within a healthcare system or hospital. Since 2010, the recognition of CNS independent practice has increased 53%. Before 2010, only 19 states had independent practice authority for CNSs. The number of states with independent practice authority increased to 29. An additional 13 states recognize CNSs as an APRN but require a collaborative practice agreement with a physician.


The state maps and charts2 below document the results of the NACNS review. These charts are updated periodically, so make sure you access the NACNS Web site to view any recent changes.

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1. Institute of Medicine. The future of nursing: Leading change, advancing health. Accessed April 10, 2016. [Context Link]


2. National Association of Clinical Nurse Specialists. CNS scope of practice and prescriptive authority. Accessed April 14, 2016. [Context Link]