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Paradigms and Filters (or, Who is Protecting the Public and From What?)

Some years ago, in graduate school, I was first introduced to the notion of paradigms, most memorably with Thomas S. Kuhn's famous treatise, The Structure of Scientific Revolutions.1 Kuhn wrote the essay while he was a graduate student at Harvard and eventually earned a doctorate in physics. He is credited with popularizing the term paradigm, which he described as essentially a collection of beliefs shared by scientists or a set of agreements about how problems are to be understood. Because he used the term structure repeatedly in his essay, some people think of a paradigm as the structure of existing science. In the philosophy of science, a paradigm is a generally accepted model of how ideas relate to one another, forming a conceptual framework within which scientific research is carried out.


It is my belief that there is a pervasive attempt to reconfigure the paradigm of advanced practice nursing (APN) by select and limited groups without the input of stakeholders. Our sense of the structure of APN, and in particular, CNS practice, has been evolving for over 50 years. In the name of protecting the public and creating "regulatory ease," the National Council of State Boards of Nursing (NCSBN) is promoting the idea that a specialty in advanced practice is only one that has a "broad, population-based focus of study".2


Clinical nurse specialists clearly have a different concept of the paradigm of practice. As described by the National Association of Clinical Nurse Specialists (NACNS) and the American Nurses Association (ANA), one of the hallmarks of CNS practice is specialization-it is the S in CNS. We define specialization as a delimited or concentrated area of expert clinical practice with focused knowledge and skills. The area of specialization may be broadly or narrowly defined; it may be well established or emerging.3-5 A population-based focus is only 1 of 5 criteria that define specialization. A CNS specialty is typically identified in terms of 1, or more, of the following 5 criteria:


* population, such as gerontology, maternal child/obstetrics, pediatrics, adult health;


* type of problem, such as enterostomal/wound/ostomy/continence, pain, nutritional support;


* setting, such as community, critical care, perioperative, emergency/ trauma;


* type of care, such as rehabilitation, hospice/end of life; and


* disease/pathology/medical, such as oncology, burns, psychiatry, cardiovascular, diabetes, orthopedics.3-5



Recently, national attention has focused on Texas and the new rules proposed by the Texas Board of Nurse Examiners (TxBNE). At issue is the TxBNE decision to create its own paradigm of APN in Texas, in isolation of the stakeholders, and with a bit of a paternalistic flavor. The TxBNE has decided to no longer accept the oncology certification exams for CNSs or NPs for eligibility for advance practice status in Texas. They have also decided not to recognize palliative care, a new emerging and important area of APN, despite the existence of a new American Nurses Credentialing Center American Nurses Credentialing Center (ANCC) certification exam. Exams in both of these areas are psychometrically sound and legally defensible. The issues, from the perspective of the TxBNE, focus on what is specialization versus subspecialization. Many non-Texas stakeholders have communicated their concerns to me about the likely potential influence of the same issue going forth to the national level. Both CNSs and NPs are being and will be affected by their decisions.


Who has given them the authority to change the paradigm of APN and CNS practice in particular?


It is important to note that an ongoing work group has been convened to analyze some of the same issues and is composed of leaders from over a dozen of the national organizations that support APN practice (including NACNS, AONE, ANA, NONPF, AACN (both), ONS, NLNAC, and NCSBN). They met in June 2004 and will have met in October 2004 by the time this is published. The work of this group is being preempted by the TxBNE proposals. Why not wait for the outcome of this important work to shape the paradigm of APN and CNS practice?


The proposed APN changes are being made in the name of "regulatory ease" and for "protection of the public." Yet, there are several filters in place that already serve to protect the public. These filters include education, accreditation, and certification.


Education is delivered by nationally accredited programs with faculty who know how to design and implement curricula, including theory and clinical practice courses that do provide a broad foundation for APN. We are not suggesting a narrow focus to education nor is this common practice. The AACN Essentials document6 combined with the NACNS Statement on Clinical Nurse Specialist Practice and Education5 provide ample guidance for CNS curricula and for shaping the paradigm of APN. A minimum of 500 clinical practice hours are expected by both groups that accredit CNS and NP programs (CCNE and NLNAC) and serves as yet another filter. Certification is available by a variety of certifying bodies using exams that are reliable, psychometrically sound, and legally defensible (yes, I've used those twice now-very important concepts!!). NACNS supports validation through psychometric examination, portfolio, or other legally defensible alternative strategies that are congruent with the CNS specialty practice.


I am baffled by the logic that anyone is protecting the public interest by requiring emergency room NPs to write the family nurse practitioner certification exam, or requiring oncology CNSs to write the medical-surgical CNS certification exam for APN status. I listened to recent explanations by TxBNE representatives about a psychiatric mental health APN practicing with medical/surgical interventions in a thoracic surgery setting. This is clearly a scope of practice breech and should be treated as such. Don't penalize the other 99% of CNSs and NPs who are practicing in their scope, have a broad-based foundation in their master's education, and are safe. Amen.


NACNS Statement on Clinical Nurse Specialist Practice and Education, Second Edition, Newly Revised!!

This document articulates the core competencies requisite to CNS practice, outlines the outcomes of CNS practice, and provides direction to schools of nursing regarding the preparation of CNSs. Endorsed by the American Organization of Nurse Executives (AONE) as "a comprehensive reflection of the contemporary role that Clinical Nurse Specialists play in the delivery of quality nursing care," this new and updated version contains information for contemporary clinical nurse specialist practice and education. You can purchase your copy through the NACNS Office at a cost of $25 per copy for members of NACNS and $45 per copy for nonmembers. Discounts are offered on purchases of 15 copies or more. Contact the NACNS Office today to order your copy of the Statement.




1. Kuhn TS. The Structure of Scientific Revolutions. Chicago, Ill: University of Chicago Press; 1962. [Context Link]


2. APRN Definitions. National Council of State Boards of Nursing, NCSBN Meeting, Chicago, Ill; May 6, 2004. [Context Link]


3. American Nurses Association. Nursing: Scope and Standards of Practice. Washington, DC: American Nurses Association; 2004. [Context Link]


4. NACNS. Statement on Clinical Nurse Specialist Practice and Education. Harrisburg, Pa: NACNS; 1998. [Context Link]


5. NACNS. Statement on Clinical Nurse Specialist Practice and Education. 2nd ed. Harrisburg, Pa: NACNS; 2004. [Context Link]


6. American Association of Colleges of Nursing. The Essentials of Master's Education for Advanced Practice Nursing. Washington, DC: American Association of Colleges of Nursing; 1996. [Context Link]

NACNS Update

Awards and Recognition


You should have received a "Cool Snapshots" postcard reminder about these awards back in September. Don't forget!! Your nominations are needed for the following awards to be given at the Annual Conference that will be held in Orlando, Fla, March 9-12, 2005!!



The NACNS Board of Directors is sponsoring an yearly award that is specifically designed to acknowledge one of its affiliate members. Currently, there are more than 20 NACNS affiliates. This rotating award is given to an affiliate that illustrates one or more of the following:


- In the first 2 to 3 years, it has demonstrated sustained growth of the NACNS member component;


- Has offered an innovative, creative continuing education class, conference, or program that focuses on CNS practice;


- Has a leadership development effort that prepares CNSs for local, regional, and/or national office in a professional group;


- Has contributed to the growth and activities of NACNS, eg, cohosting an annual NACNS conference; and


- A member and/or members of the affiliate have contributed an article to the CNS journal on a topic of interest to CNSs in practice.



The deadline for submission of an affiliate's information is December 31, 2004. A subcommittee selected by the Board of Directors will review and select the winning affiliate.


Please submit all information and supporting material to NACNS, 2090 Linglestown Rd, Suite 107, Harrisburg, PA 17110.



The Fourth Annual NACNS Clinical Nurse Specialist of the Year Award will be presented during the 2005 Annual Conference in Orlando, Fla. The purpose of this award is to nationally recognize an NACNS member for outstanding professional achievement as a CNS in the 3 spheres of CNS influence. The award acknowledges a nurse who demonstrates CNS competencies and exemplary practice in patient care, nursing, and healthcare delivery systems.


Please review the criteria given below and submit a completed application with corresponding rationale for those individuals who you feel should be considered.


* Must be nominated by a nursing colleague and/or nursing supervisor.


* Maintain current membership in NACNS.


* Have at least 3 years of experience as a CNS.


* Must serve as a role model to nursing colleagues by



maintaining an outstanding level of skill and knowledge in his or her specialty area,


utilizing or demonstrating CNS competencies in all 3 spheres of influence,


demonstrating quality patient outcomes as a result of his or her practice,


supporting nurses in the delivery of patient care or the advancement of nursing practice, and


promoting change or collaboration at the system level to improve or impact patient care.


News From Our Affiliates


This installment of the column designed specifically for our affiliates welcomes 3 new affiliates to the ranks!! Welcome to the Central California, Virtual VA, and Montana Association of CNSs!! We look forward to hearing from you in this column in the near future. In the meantime, here is what some of our other affiliates are celebrating!!


Minnesota: Mary Fran Tracy, PhD, RN, CCRN, CCNS, has been inducted as a Fellow into the American Academy of Nursing. Mary Fran is a critical care CNS at Fairview-University Medical Center in Minneapolis and an adjunct faculty member of the University of Minnesota School of Nursing. Mary Fran was cofounder of the Minnesota Affiliate of NACNS. She has been active in national NACNS by serving on the Practice Committee as well as the Abstract Review Panel for the annual NACNS conference. Mary Fran has served as secretary of the national Board of Directors of the American Association of Critical-Care Nurses and is currently a director on the AACN Certification Corporation Board. Sue Sendelbach, Minnesota.


California: The California CNS Network has been busy. We revised our bylaws to change our name to the California CNS Network and include members statewide. Our membership is now at 166 CNSs!!!!!! This is our largest membership in many years. Paddy Garvin, our membership chair, is quite busy keeping track of us. We held an educational meeting in July at Huntington Hospital in Pasadena. Robin Gemmel was our guest speaker who addressed Evidenced-based Practice: The City of Hope Model for the over 20 nurses in attendance. Our annual all-day conference is Friday, October 29, at the UCSD Eucalyptus Point Conference Center. Our speakers will be Jan Fulton from NACNS, who will speak on publishing in the journal and provide an update about the NACNS, the Honorable Tricia Hunter, who will facilitate a discussion of legal issues for the CNS, Dr Dana Rutledge, who will speak about evidence-based practice for the CNS, and Drs Kathi Ellstrom and Cheryl Westlake Canary, who will lead a seminar to take CNSs from the clinical question to the research proposal. We are accepting proposals for student project poster presentations. With vendors and meals provided, this promises to be a full day. The board recently met to stuff, address, label, and stamp over 1,900 brochure and membership packets to our members and the approximately 1,750 CNSs certified by the state. We hope to have 100 CNSs in attendance. If you would like any information about the California CNS Network, please contact the Chair Cheryl Westlake Canary at


Oregon: The Oregon Council of Clinical Nurse Specialists is pleased to announce that the Association of Military Surgeons (AMSUS) Clinical Nursing Excellence Award will be presented to our immediate past-chair Ann M. Herbage Busch, MS, RN, CWOCN, APRN, BS, CNS. She will receive the award from AMSUS at its annual meeting in November. Congratulations, Ann, on winning this prestigious national nursing award!! AMSUS was established in 1891 as primarily a physician organization. Over time, it has evolved into an organization of professionals of all of the healthcare disciplines in the Army, Navy, Air Force, Public Health Service, Department of Veterans Affairs, Army Reserve, Navy Reserve, Air Force Reserve, Army National Guard, Air National Guard, and the Coast Guard. Annually, AMSUS recognizes practitioners with 22 awards in a variety of categories; the VA can apply for 21. There is only one clinical nursing award-and Ann is the recipient!! You can learn more about AMSUS and the award at Kelly Goudreau, chair OCCNS.



This portion of the newsletter offers an opportunity for various committee chairs to report on recent activities. This edition has contributions from our Research Committee and the Legislative/Regulatory Committee. Watch this space for other committee reports and upcoming activities in which you may want to become involved.

Research Committee


Work this summer included revising the annual NACNS demographic survey. This survey is designed to capture not only NACNS membership demographics but also areas of specialty and specialty populations served by our membership.


This fall the committee will be coordinating the distribution of a new NACNS competency and outcomes survey. This survey is based upon the 2nd edition of the Statement on Clinical Nurse Specialist Practice and Education. Please look for this survey late 2004 through early 2005.


Research Committee members for 2004 include Ann Mayo, chair; Sue Davidson; Kathi Ellstrom; Barbara Goldberg-Chamberlain; Gay Goss; Juanita Keck; Aleta Lazur, NACNS business administrator; and Nancy Dayhoff, NACNS board liaison. For more information about the NACNS Research Committee, contact Ann Mayo at Watch for us at the 2005 Annual Convention, March 9-12!! Ann Mayo, chair.

Legislative/Regulatory Committee


On July 14, 2004, NACNS convened a meeting to discuss ongoing issues surrounding CNS practice, licensure, and regulation. It was held at the Sigma Theta Tau headquarters located in Indianapolis, Ind. Over 10 nursing organizations attended.


NACNS Model Language for state practice acts was reviewed by Angela Clark, president NACNS. Alternative mechanisms to certification when an exam does not exist were also discussed.


Brenda Lyon, cochair of the NACNS Legislative/Regulatory Committee, presented an overview of the history of advanced practice recognition and the viewpoints of NACNS and NCSBN, highlighting where the 2 organizations' positions are in disagreement. At this point in time, NACNS and NCSBN views remain in conflict although both organizations share the goal of protecting the public. NCSBN views medical diagnosis and prescribing as the functions that "legitimize" advanced nursing practice. NACNS views the CNSs advanced practice of nursing within the autonomous and delegated authority domains of nursing practice.



Jo-Ellen Rust, cochair of the Legislative/ Regulatory Committee, led the group in summation of recommendations, which included identifying one strong message about appropriate regulation, communicating that message to licensing boards, importance of CNSs' awareness of plans and activities of their state boards, collaborative work among CNS organizations upon issues in which there is agreement, and importance of communicating activities related to these items to CNSs and interested organizations.


Potential methods to operationalize the above will be shared in this newsletter as plans are finalized. NACNS leadership welcomes ongoing dialogue with individuals and organizations who would like to discuss these important issues. Rebecca Long, MS, RN, CCRN, CMSRN, committee member.

Press Releases!!

New Web Site Fills Gaps in Geriatric Nursing Knowledge


Nurses and patients will benefit from the information and tools available through a new Web site,, that seeks to fill a gap in geriatric nursing knowledge. The Web site is a sophisticated resource for nurses who wish to learn more about geriatric syndromes, their possible causes, and treatments, and to translate that knowledge for the immediate benefit of their patients. A one-of-a-kind Web site, was launched in July 2004 by the Nurse Competence in Aging initiative, a collaborative of 3 major nursing organizations.


"Our goal is to share geriatric best practices with all nurses," says Linda Stierle, MSN, RN, CNAA,BC, chief executive officer of the ANA, 1 of the 3 partners that make up the Nurse Competence in Aging initiative. "This Web site is a resource for nurses nationwide and will help enhance nursing practice and improve patient outcomes for older adults."


Users of GeroNurseOnline may search the Web site in 3 ways: by patient clinical signs and symptoms, specific geriatric topics, or specialty nursing practice areas. Through the clinical signs and symptoms entry function, a nurse can look up a patient's particular behavior, such as agitation, and be directed to possible causes. A nurse may also come to the Web site to learn more about a specific geriatric topic, such as medication, pressure ulcers, delirium, falls, pain, or urinary incontinence. A nurse might also seek information that is most relevant to her nursing specialty, such as oncology, rehabilitation, or psychiatry. In all of these scenarios, the user finds a tremendous amount of useful, well-organized information.


"There has never been a resource like this before," says Mathy Mezey, EdD, RN, FAAN, director of the Hartford Institute. "Although this information appears in books, journals, and scattered throughout the Web, nurses need quick, easy, and centralized access to this kind of information so they can best assess needs and help their patients in a critical moment."


As it grows, GeroNurseOnline will increasingly incorporate the intersection of specialty practice and care of older adults. The goal of the Nurse Competence in Aging initiative is for 60 specialty nursing associations to designate "Web Fellows," who will be responsible for providing content to GeroNurseOnline in relation to that specialty area.

New Board Member Introductions


Because of space constraints, we are deferring this section until next edition. Be on the lookout for Dr Barbara Munro next time!!

What Would You Like to See?


If there is anything else you would like to see or hear about from the board or other committees, please do not hesitate to contact me at kagoudreau@