1. Nelson, Roxanne

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On February 17 the National Council of State Boards of Nursing (NCSBN) circulated a draft of Vision Paper: The Future Regulation of Advanced Practice Nursing to members of the nursing community. The paper proposes the regulation of all advanced practice registered nurses (APRNs) by state boards of nursing, as well as the development and administration of "a core nurse practitioner licensure examination"-a hot issue on its own. But perhaps what has generated the strongest backlash is the paper's assertion that the clinical nurse specialist (CNS) does not fit into the model of advanced practice nursing. (Read the draft of the vision paper at


And then there were three.

The paper proposes that APRN licensure include only the nurse anesthetist, the nurse midwife, and the NP. The paper differentiates the CNS from other APRNs because, it asserts, an APRN practices outside the scope of RN practice, whereas many CNSs do not. It acknowledges, however, that some CNSs, such as those who work with patients with diabetes, do a certain degree of prescribing, along with "the independent diagnosis and treatment of disease"; this group "will be grandfathered into the nurse practitioner licensure status and retain their prescriptive authority for the duration of their active license." In other words, a CNS would not be included in the category of advanced practice nursing unless she had prescription privileges.


"They have very cut-and-dried boundaries for what encompasses advanced practice nursing," says Christine Filipovich, MSN, RN, executive director of the National Association of Clinical Nurse Specialists. "It is our understanding that they have delineated medical practice as the defining characteristic for advanced nursing. That's the flawed logic."

FIGURE. With its res... - Click to enlarge in new windowFIGURE. With its resources strained, the Department of Veterans Affairs (VA) has taken an innovative, home-based approach to caring for elderly veterans. Above, VA advanced practice nurse Joan Trelease visits 66-year-old veteran Franklin Holden, who has had a stroke.

The NCSBN is a voluntary organization but includes all state boards of nursing. While the NCSBN itself has no statutory or regulatory authority, a recommendation from the national council carries great weight when it comes to decisions and actions taken by the state boards. The National Association of Clinical Nurse Specialists believes that if this vision becomes reality, it will prevent many CNSs from practicing in the role for which they have trained.


Good intentions?

"We understand that the proposal is intended to create administrative ease for boards of nursing," says Filipovich. "But we believe that the public's access to health care will suffer just to make it easier for boards of nursing to deal with the unique scopes of practice of all four groups of advanced practice nurses."


The NCSBN does not intend to undermine CNSs or devalue their role, says Nancy Chornick, PhD, RN, director of practice and credentialing at the NCSBN. "From a regulatory perspective, the activities performed by a CNS fall under the RN scope of practice and therefore do not warrant additional regulation. The intent is to avoid overregulating CNSs by requiring them to meet the same criteria, such as collaborative agreements, that are required of APRNs who practice outside of the RN scope of practice."


Chornick also contends that the purpose of the vision paper is to promote standardization and appropriate regulation for APRNs, which will in turn increase their mobility and improve access to health care. The idea of a second licensure also isn't a new idea; the NCSBN first proposed it in 1993 in Position Paper: The Regulation of Advanced Practice Nursing. In that paper, second licensure was recommended because of "the nature of the practice, which requires advanced knowledge, clinical proficiency, independent decision making, and autonomy."


In a letter to the APRN Advisory Panel at the NCSBN, Kelly Goudreau, DSN, RN, CNS, president of the National Association of Clinical Nurse Specialists, pointed out that uniformity in the scope of APRNs' practice currently does not exist-nor is it something that will be easily achieved, given the variance in state laws.


"While it would be ideal for APRNs to operate independently of the supervision of other health care providers, it is clear that in many states this may not easily occur," Goudreau wrote. "To try to modify or introduce new legislation to create this independent practice environment, nursing may run the risk of igniting a political battle that could result in loss of the current scope of practice for APRNs in some states."


It's not final.

The advisory panel of the NCSBN has been working on this proposal for three years, but they acknowledge that CNSs are engaged in a national effort to determine the scope of their practice in the future. These discussions, Chornick points out, will be considered when drafting the final paper.


Many nursing organizations have drafted statements in response to the vision paper and most disagree with much of what is proposed. The American Association of Colleges of Nursing (AACN) is working to facilitate a response from nursing organizations and has links to many of the response papers on its Web site (


Robert Rosseter, the AACN's associate executive director, says that "the AACN has respectfully asked the NCSBN to withdraw the paper and to fully commit to continuing its participation in the Advanced Practice Nursing Consensus Group, a coalition of more than 30 organizations working to iron out some of the issues raised in the paper." He adds that the general consensus is that the NCSBN vision paper shouldn't be endorsed as written.


"We are very pleased that the APRN advisory panel at the NCSBN indicated that the vision paper will be redrafted based on feedback from the nursing community," says Filipovich. "The National Association of Clinical Nurse Specialists and CNSs across the country have spoken clearly affirming that clinical nurse specialist practice is indeed advanced nursing practice and that no longer recognizing the CNS as an advanced practice nurse would be harmful to the profession and to the public."

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