Transcript CNS Practice: Professional and Regulatory Issues

The Clinical Nurse Leader
(CNL) and the Clinical Nurse
Specialist (CNS): How Similar
in Scope and Competencies?
The National Association of Clinical
Nurse Specialists (NACNS)
For ANA Organizational Affiliates
June 8, 2005
NACNS Mission:
• To enhance and promote the
unique, high value contribution of
the clinical nurse specialist to the
health and well-being of
individuals, families, groups and
communities, and to promote and
advance the practice of nursing.
Beginnings…50 years ago
• The first CNS program was initiated at
Rutgers in 1954.
• It represented a fundamental shift in the
vision of education for nurses to
university-based knowledge
development and application of that
knowledge through expertise (Mick &
Ackerman, 2002).
Expert nurse!
• The CNS was initially conceptualized as
an expert nurse at the bedside, providing
specialized nursing care directly to
patients, and indirectly improving care by
focusing on nursing staff education and
system analysis (Boyd, et al, 1991; Fenton
& Brykczynski, 1993; Page and Arena,
1994).
CNSs advance nursing
practice…
• Over the years, CNSs continued as
expert nurses while expanding their
activities to influence other nurses and
nursing practice, as well as the
structure, processes and outcomes of
nursing care, thereby advancing the
practice of nursing.
Value of CNS Practice Examples
• The value of CNS practice was demonstrated
by an extensive research review published in
1993 (Naylor & Brooten) which examined
CNS effects on low birth weight infants,
children with chronic illnesses, acutely ill
adults, and hospitalized elderly.
• More recent 2005 publication of research and
other articles about CNS outcomes of care
Early 1990s--Healthcare system problems
resulting from cost-cutting and diminished
CNS influence in nursing and system spheres
• Increasing errors in patient care
• Lack of resource people for education and
coaching for staff
• Limited mentoring for inexperienced nurses
• Short staff in the acute care setting & increased
use of unlicensed assistive personnel
Resulted in a re-evaluation of the value of CNS
practice
Today, there is a strong, renewed
interest in CNS practice to improve
patient outcomes
• There is a national shortage of available
CNSs.
• Organizations are offering large sign-on
bonuses.
• Having CNSs on staff is a published
desirable characteristic for Magnet
Hospital status.
Today…
• CNSs are in high demand to advance the practice
of nursing in a variety of settings and are
recognized as valuable contributors to the health
care delivery system. At the recent AONE
meeting, 25+ states had requests for CNSs.
• CNSs number over 67,000 (US Dept.HHS, 2003).
• 40 new or re-opened CNS education programs in
the past 3–5 years.(Walker, Gerard, et al, 2002).
NACNS Standards
(AONE, NLN-AC endorsed)
NACNS Statement on CNS
Practice and Education,
2nd edition (2004)
includes core competencies
and clinical leadership
characteristics.
*2003 Survey reports
>50% of CNS programs
using NACNS educational
Recommendations.
Leadership Competencies in 3
spheres of influence (NACNS, 1998; 2004):
• CNS practice is conceptualized as clinical
expertise expressed in three domains (spheres
of influence)—
– patient/client,
– nurses and nursing practice, and
– organizations/systems.
• Leadership skills encompass communication,
disciplined inquiry, systems-level thinking,
and shared decision-making.
Specialty Practice
Patient/Client
Nurses &
Nursing Practice
Organizations &
Systems
Specialty Skills/Competencies
© J.S. Fulton 2003
Clinical nurse specialist practice conceptualized as core competencies in
three interacting spheres actualized in specialty practice and guided by
specialty knowledge and specialty standards.
Themes of CNS practice
(NACNS, 1998; 2004): how similar is
the CNL role to these themes?
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Evidence-based practice
Innovation in clinical care
Quality nurse-sensitive outcomes
Patient safety
Empowering nurses
Interdisciplinary collaboration; and
Nursing practice-delivery system interface.
CNL? Bottom line concern:too much
overlap between the roles and titles
• We were assured by AACN (Rossiter memo) that the title
CNL was simply a “placeholder” and a new title would
be sought to avoid confusion and overlap with the CNS
title.
• Then told too late to change it.
• Potential exists for confusion to public (patients,
families, legislators), profession, other health care
providers.
• CNSs have provided health care for 50 years and the
issue of trademarking the established title was never
considered necessary.
Who picked the CNL title and why?
CNS-CNL-CNS-CNL-CNS…
How is “microsystem level by CNL”
differentiated from CNS “delimited
area”?
CNSs specialize in a delimited area of practice and
typically, the specialty can be identified in terms of the
following (ANA, 2004; NACNS, 1998; NACNS,
2004):
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Population (e.g. pediatrics, geriatrics)
Type of problem (e.g. pain, wound)
Setting (e.g. critical care, ED)
Type of care (e.g. rehab, end-of-life)
Disease/pathology/med specialty (e.g. oncology,
diabetes, cardiovascular)
Nurse executives (Erickson & Dittomasi,
2005) have argued that the CNL will add further
role confusion about nurses for the public.
• They articulately provide support for the CNS
practice in saying: “What is it about this role (CNL)
that will catapult the nursing profession to a new
level that could not occur by advancing the
professional development of clinical nurses,
reinstituting the CNS role throughout the United
States, showcasing and adopting best practices in
care delivery and role implementation, and most
strategically, coming to consensus about entry into
professional nursing practice at the baccalaureate
level?” (March 2005 Journal of Nursing Education, p. 100).
CNL as entry into practice?
• Appears this was an original goal of CNL role.
• One of our main concerns--the potential demise
of the baccalaureate nurse and baccalaureate
programs at this time of a nursing shortage.
• Other leading nursing organizations (AONE,
NLN, STT) have recently concurred with ANA
and NACNS regarding the need to support the
baccalaureate degree as the entry into practice
and published/circulated statements in support.
AONE Statement,
April 18, 2005
• AONE: “The educational preparation
of the nurse of the future should be at
the baccalaureate level”.
• AONE: “Given that the role in the
future will be different, it is assumed
that the baccalaureate curriculum will
be re-framed”.
Stanley, et al (2004) paper comparing
scope for CNSs and CNLs
• Includes 3 main areas of discussion: one column
describes characteristics of the CNL, one describes
characteristics of the CNS, and the third is titled
“Shared Role Characteristics” and clearly identifies
areas of overlap.
• We remained concerned about several areas in
particular that are hallmarks of CNS practice,
including: integrating evidence-based practice into
health care, designing and developing innovative
nursing interventions and programs of care, and
providing leadership and education to nurses and
nursing practice (NACNS, 1998; 2004).
Examples of the overlap between the
CNS and the CNL roles….
• 1. “Both the CNL and CNS translate nursing
research findings into clinical practice” (Stanley,
et al, 2004, p. 3).
• 2. “The CNL and CNS use knowledge of
health organizations, systems, policy
leadership and change to develop and
implement/coordinate evidenced-based
standards, policies and procedures”. (Stanley, et
al.,2004, p. 3).
More overlap?
• 3. “Although both the CNL and CNS
work with multidisciplinary care teams,
the sphere of influence and focus may
differ” (Stanley, et al,2004, p 4).
• 4. “The CNL and CNS design and
provide health promotion and risk
reduction services for patients”. (Stanley, et
al, 2004, p. 3).
CNL Implementation
concerns
• Institutional and/or employers reassignment
of CNS and NP to the CNL title described at
recent VA meeting in Tennessee.
• No control over how role or scope of practice
is implemented.
• Curricula very different.
• Fear that duplicity in roles will harm CNSsno clear practice outcomes for CNL that are
different from CNS.
Conclusions
• Concern about the impact of the CNL on the CNS role
continues to be an issue, given the overlap in some of
the key competencies.
• Continued clarification of the differences between
CNSs and CNLs is critical. NACNS and AACN should
partner in this initiative.
• Influence against institutional/employer reassignment of
CNSs (and NPs) to CNL role is needed.
• Outcomes research of the CNL “pilot project” will be
evaluated thoughtfully.
Thank you to ANA and our
Organizational Affiliate colleagues
• ANA: for their continued support of CNSs
and NACNS
• ANA: for their willingness to dialogue with
stakeholders about this important issue
• OA colleagues: for support of CNS
contributions.