1. Manning, Jennifer M. DNS, ACNS-BC, CNE

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The National Association of Clinical Nurse Specialists applauds the National Academy of Medicine for its recently released report, "The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity: A Consensus Study from the National Academy of Medicine." The new report builds on the recommendations from the "Future of Nursing Report: Leading Change, Advancing Health" released a decade ago. The 400+ page report recognizes the Robert Wood Johnson Foundation for sponsoring the consensus study, which aimed to explore essential nursing contributions in addressing social determinants of health and health equity in the United States.1 The report identified recommendations that call for change at the individual and system levels.



The National Academy of Medicine sought to release its findings in 2020, the year the World Health Organization commemorated the International Year of the Nurse and the Midwife. However, the onset of the COVID-19 pandemic resulted in a release delay to allow time to incorporate information based on the pandemic's impact on healthcare. The information gathered during the pandemic further highlighted what the report already concluded. There are clear challenges in achieving health inequity due to the disproportionate impact of the pandemic on those with low income, those living in rural communities, and people of color.2


The report's release in 2021 recognized the significant loss of life during the pandemic while also identifying the need to address the lessons learned, such as the nursing profession's commitment to healthcare, innovation in improving healthcare, and adaptation in the education of the future nursing workforce. The nursing profession admirably delivered a renewed hope during the pandemic, hopefully laying the groundwork for future lasting change.3



Clinical nurse specialists (CNSs) and advanced practice registered nurses (APRNs) are mentioned many times throughout the report. From a workforce perspective, the report cited a significant increase in CNSs nationwide for the past decade, increasing from 49 793 in 2008 to 70 737 in 2018.4 On the basis of the nation's healthcare needs, the increase in the number of CNSs is not enough to meet the nation's healthcare needs.5


From a demographic perspective, a wide gender gap remains among CNSs, with a large majority being female (96.7%). The report recognized the progress made in the past decade in expanding the APRN workforce. There are signs of increasing diversity, but CNSs have a long way to go in achieving a more diverse workforce.



The report cited the need to clearly define the value of the clinical care delivered by CNSs. As long as the profession remains dependent and lacks full practice authority, a clear understanding of CNS value will remain elusive and difficult to capture.6 There is a need to shift CNS value from the cost side to the revenue side of organizational earning statements. The report called on stakeholders in healthcare to change how the work of the CNS is measured, shift to value-based models, which measure outcomes such as clinical service provided, professional billing activity, and cost savings. Finding ways to ensure maximum CNS productivity with a health equity focus will benefit organizations and patients alike.7


The report called on APRNs to inform and implement policies impacting health equity. More freedom to practice to the full extent of CNS training is needed. The report cited the difficulty in assessing the impact of CNSs due to the wide variety of job titles and work settings. Clear metrics that account for CNS work are needed to fully understand their effects on health equity. Correcting the undervaluing CNSs by reimbursing at 80% to 85% of physicians' rates is required.8


There is a growing body of solid evidence citing that scope-of-practice restrictions decrease the quality of care and leads to higher health costs. A call to remove regulatory and institutional obstacles is needed. Until APRNs are permitted to practice based on the full extent of their advanced education and training, gaps in access to care will prevail. Millions of Americans who need healthcare will continue to be unable to obtain it, leading to delays in quality care and worsening symptoms and disease progression. Although there are many negative impacts from the COVID-19 pandemic, one positive was easing full practice authority in some states and creating an unprecedented opportunity for CNSs to reform healthcare and advocate for permanent full practice authority.



The report described the critical role of nurses in leading the work of creating and deploying advanced care models that are individual and population centered. A significant need to increase the number of CNSs was identified in perinatal care/women's health. Filling the CNS workforce gap in this area can significantly impact health equity in maternal health. At the current pace, if the supply of CNSs who specialize in perinatal care/women's health is not expanded, millions of women will continue to be excluded from critical APRN services. In addition, evidence supports that when a CNS is practicing with more autonomy, there is reduced use of unnecessary medically intensive procedures, putting mothers and infants at risk.9


Primary care, gerontology, mental, and behavioral specialties are additional projected shortage areas where population growth exceeds physician supply. Federally qualified health centers located in federally designated medically underserved areas that experience APRN role expansion also experience improved patient outcomes. The expansion of APRNs in federally qualified health centers can fill the gaps in individual access to quality care.


In education and practice settings, diversity, inclusion, and equity training is needed. There is widespread confusion for social determinants of health terms, and until APRNS understand them, goals and clear solutions cannot be achieved. Clinical nurse specialist practice must incorporate best practices in diversity, inclusion, and equity based on high-quality evidence. Prioritization of research in this field is needed to measure how the CNS can impact health equity outcomes across the 3 spheres of influence: patient, nurse, and system.



The National Association of Clinical Nurse Specialists is inspired by the extensive referencing to the CNS role in healthcare in the Future of Nursing Report. The support and recognition for the nursing profession and many references to CNSs and APRNs were inspiring. However, the report's reminder of the ongoing practice barriers highlights that much work is to be done. The largest healthcare workforce, nursing, is called to listen, engage, examine practice, collect data, and move the nation to greater health equity for all.




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