1 AACN Statement of Support for Clinical Nurse Specialists The American Association of Colleges of Nursing (AACN) is committed to advancing professional nursing roles and highlighting the connection between well-educated nurses and quality health care. As a leading supporter of academic institutions that educate advanced practice registered nurses (APRNs), AACN is keenly aware of the direct link between graduate-prepared nurses and both patient safety and positive outcomes. Within the APRN community, Clinical Nurse Specialists (CNSs) play a unique role in the delivery of high quality nursing care. These clinicians are experts in evidence-based nursing and practice in a range of specialty areas, such as oncology, pediatrics, geriatrics, psychiatric/mental health, adult health, acute/critical care, and community health among others. In addition to direct patient care, CNSs also engage in teaching, mentoring, consulting, research, management and systems improvement. Able to adapt their practice across settings, these clinicians greatly influence outcomes by providing expert consultation to all care providers and by implementing improvements in health care delivery systems. AACN supports the full definition of the Clinical Nurse Specialist outlined in the American Nurses Association s 2004 publication titled Nursing: Scope & Standards of Practice. (See Attachment A). Further, the growing body of research on CNS outcomes shows a strong correlation between CNS interventions and safe, cost-effective patient care. CNS practice has been directly linked to reducing hospital costs and lengths of stay, reduced frequency of emergency room visits, improved pain management practices, increased patient satisfaction with nursing care, and fewer complications in hospitalized patients (Fulton & Baldwin, 2004). Given this strong connection to patient safety, AACN encourages hospitals and other health care providers to expand the use of Clinical Nurse Specialists and to engage these clinical experts to a greater extent throughout the health care arena. AACN believes that Clinical Nurse Specialists play an important role in the provision of nursing care that does not duplicate the emerging role of the Clinical Nurse Leader (CNL). In terms of focus, CNLs are educated as generalists while CNSs are prepared for specialty practice. The CNL operates primarily on the clinical microsystem level involving small, functional front-line units, while the CNS is engaged not only within the microsystem but also at the systems levels within three spheres of influence: client, personnel and organizational systems. The CNL coordinates and implements client care, while the CNS designs and evaluates patient-specific and population-based programs. The CNL evaluates and implements evidence-based practice while the CNS has the added responsibility of generating new evidence. The CNS and CNL roles are distinct and complementary (Spross et. al., 2004). AACN envisions that these clinicians will work collaboratively to ensure that patients receive the best care possible. (See Attachment B.) The health of our nation rests on having an adequate supply of highly qualified nurses ADVANCING HIGHER EDUCATION IN NURSING One Dupont Circle NW, Suite 530 Washington, DC tel fax
2 available to render care in many different capacities. Nurses are needed both at the point of care and in advanced practice roles to deliver care that is growing intensely more complicated. Essential within this nurse staffing mix is the Clinical Nurse Specialist whose role is fundamental to provide quality, safe and cost-effective specialty care across settings. Approved March 13, 2006
3 References American Nurses Association. (2004). Nursing: Scope & standards of practice. Washington, DC: American Nurses Association. Fulton, J.S. & Baldwin, K. (2004, January/February). An annotated bibliography reflecting CNS practice and outcomes. Clinical Nurse Specialist, 18(1), Spross, J., Hamric, A., Hall, G., Minarik, P., Sparacino, P., Stanley, J. (2004, December). Working statement comparing the Clinical Nurse Leader and Clinical Nurse Specialist roles: Similarities, differences and complementarities. Washington, DC: American Association of Colleges of Nursing.
4 Attachment A The American Nurses Association s definition of a Clinical Nurse Specialist: Clinical nurse specialists (CNSs) are registered nurses, who have graduate level nursing preparation at the master s or doctoral level as a CNS. They are clinical experts in evidence-based nursing practice within a specialty area, treating and managing the health concerns of patients and populations. The CNS specialty may be focused on individuals, populations, settings, type of care, type of problem, or diagnostic systems subspecialty. CNSs practice autonomously and integrate knowledge of disease and medical treatments into assessment, diagnosis, and treatment of patients illnesses. These nurses design, implement, and evaluate both patient-specific and population-based programs of care. CNSs provide leadership in advancing the practice of nursing to achieve quality and cost effective patient outcomes as well as provide leadership of multidisciplinary groups in designing and implementing innovative alternative solutions that address system problems and/or patient care issues. In many jurisdictions, CNSs as direct care providers, perform comprehensive health assessments, develop differential diagnoses, and may have prescriptive authority. Prescriptive authority allows them to provide pharmacologic and nonpharmacologic treatments and order diagnostic and laboratory tests in addressing and managing specialty health problems of patients and populations. CNSs serve as patient advocates, consultants, and researchers in various settings. Source: American Nurses Association. (2004). Nursing: Scope & standards of practice. Washington, DC: American Nurses Association, p. 15.
5 Attachment B American Association of Colleges of Nursing Working Statement Comparing the Clinical Nurse Leader sm and Clinical Nurse Specialist Roles: Similarities, Differences and Complementarities December 2004 Judith A. Spross, PhD, RN, AOCN, FAAN Associate Professor University of Southern Maine Ann B. Hamric, PhD, RN, FAAN Associate Professor University of Virginia School of Nursing Geri Hall, PhD, ARNP, CNS, FAAN Clinical Professor University of Iowa College of Nursing Pamela A. Minarik, MS, APRN, BC, FAAN Professor of Nursing Director, Office of International Affairs Yale University School of Nursing Patricia S. A. Sparacino, MS, RN, FAAN Vice Chair, Department of Family Health Care Nursing University of California, San Francisco School of Nursing Joan M. Stanley, PhD, RN, CRNP Director of Education Policy American Association of Colleges of Nursing
6 The American Association of Colleges of Nursing (AACN) Board of Directors approved the Working Paper on the Role of the Clinical Nursing Leader sm in May In response to client care needs and to the health care delivery environment, the Working Paper, the report of the Task Force on Education and Regulation II, delineates a new role, the clinical nurse leader (CNL) sm role. To address questions that have been raised by the nursing community, a group of individual clinical nurse specialists, leaders in the field of nursing and CNS practice and education, were asked to work with AACN to develop a statement that would compare the CNL and CNS roles: the similarities, differences and complementarities. This statement represents the work of those individuals. Clinical Nurse (CNL) The Clinical Nurse Leader (CNL) is prepared at the master s degree level as a generalist. In addition to the competencies delineated in the AACN (1998) Essentials of Baccalaureate Education for Professional Nursing Practice i, the CNL is prepared with the competencies outlined in the AACN (2003) Working Paper on the Role of the Clinical Nurse Leader ii. The CNL functions as a generalist providing and managing care at the point of care to patients, individuals, families, and communities. The CNL is responsible for the management and coordination of comprehensive client care, for individuals and clinical cohorts. vii The CNL functions primarily within clinical microsystems which are small Shared Role Characteristics Both the CNL and CNS provide care in all types of health care settings, including acute, outpatient, home, school and community. develop a comprehensive and holistic view of patients. Both the CNL and CNS manage care Clinical Nurse Specialist (CNS) The Clinical Nurse Specialist (CNS) is an advanced practice nurse prepared in a clinical specialty at the master s, postmaster s or doctoral level as a specialist. The CNS, as an Advanced Practice Nurse (APN), is prepared with the AACN (1996) Essentials of Master s Education for Advanced Practice Nursing iii, including the Graduate Nursing and APN Clinical Core. In addition, the CNS is prepared in a specialty curriculum which includes those clinical and didactic learning experiences identified and defined by the specialty nursing organization for the particular area of advanced clinical practice. The CNS functions as an expert clinician in a particular specialty or subspecialty of nursing practice. iv, v, vi The CNS is responsible for designing, implementing, and evaluating patientspecific and population-based programs of care. viii,ix The CNS functions at both microsystem and system levels, within three spheres of
7 functional front-line units such as a hospital unit, outpatient clinic or home health agency. x The CNL assesses individuals and families to anticipate risks, design and implement plans of care, provide oversight of the care delivery and outcomes for a specified group of patients. The CNL implements principles of mass customization xiii to ensure consistency of clinical care within populations. The CNL also uses strategies for risk anticipation and risk assessment to design, implement and evaluate plans of care for a cohort of patients. that is responsive to the health care needs of individuals and families. provide highly skilled clinical patient care. serve as advocates for individual clients, families and communities in the health care system. use clinical knowledge and skill and a variety of information technologies, including clinical databases, to anticipate risk, perform risk assessments and other surveillance strategies to customize interventions and ensure achievement of health related outcomes. design and provide health promotion and risk reduction services for patients. influence: client, personnel and organizational systems. xi The CNS (even if unit-based) exerts influence on behalf of their specialty population at the system level. The CNS manifests a high level of expertise in the assessment, diagnosis, and treatment of the complex responses of individuals, families or special populations to actual or potential health problems, prevention of illness and injury, maintenance of wellness, and provision of comfort. xii As a consultant the CNS provides expert knowledge and skill in a specialized area of practice to other nurses and the multidisciplinary health care team, particularly for complex or critically ill patients. xiv The CNL is responsible for the delegation and oversight of care mentor nursing staff The CNS serves as a mentor to other nursing professionals to advance the
8 delivery by other staff on a daily basis. The CNL has the ability and primary responsibility for providing the necessary coordination and communication with other team members within the microsystem to affect improved patient outcomes for individual patients or a specified cohort of patients in a unit or care setting. The CNL coordinates care, decreasing the fragmentation and ensuring seamless, safe care. The CNL evaluates evidence for practice, implements evidence-based practice, and uses quality improvement strategies to affect improved outcomes at the microsystem level. The CNL identifies problem areas and participates in the implementation of clinical research. The CNL identifies the need for new policies and practices, participates in their development and provides leadership in implementation and evaluation of guidelines, professional standards and policies that impact patient care at the microsystem level. The CNL coordinates human, environmental and material resources and other care providers. Both the CNL and CNS translate nursing research findings into clinical practice. use knowledge of health organizations, systems, policy leadership and change to develop and implement/coordina te evidence-based standards, policies and procedures. practice of nurses and nursing. The CNS has the ability and responsibility for communication within and across the organization or systems to affect improved patient outcomes for the specialty population. A critical component of the CNS role is to generate and evaluate evidence for practice. The CNS advances nursing practice through innovative evidence-based interventions, best practice guidelines and modification of professional standards, organizational policies that direct the care of nursing personnel and other providers of health care to improve outcomes. xv,xvi The CNS identifies the need for new standards, policies and procedures within the organization and across systems. The CNS leads in the development, implementation and evaluation of innovative evidence-based interventions, best practice guidelines and modification of professional standards and organizational policies that direct the care of nursing personnel and other health care providers to improve outcomes. xvii The CNS demonstrates professional leadership by taking an active role in the formulation and implementation of such policies at the community, state and national levels. The CNS interprets the dimensions of nursing care requiring resources at the
9 within the microsystem to ensure costeffective care. xviii The CNL works with the multidisciplinary care team to provide quality care to a cohort of patients at the microsystem level. As a member of the professional staff, the CNL is responsible administratively to the unit administrator/nurse manger or equivalent depending upon the type of health care setting/unit. Key activities of the CNL include: The CNL is the health professional to whom other care providers go for day-today information or issues related to the care of the specified patient cohort. Performing a comprehensive assessment of the client and family/caregiver upon initial contact. Responsibility for the ongoing assessment and modification, if necessary, of the care plan. Responsibility and accountability for care delivered and the outcomes of care for the specified cohort of clients. Responsibility for patient education, including individuals, families and other caregivers. Although both the CNL and CNS work with multidisciplinary care teams, the sphere of influence and focus may differ. are involved in the interdisciplinary decision-making and planning processes in respect to the patient s plan of care. each develops an interpersonal relationship with individual patients and families and/or other caregivers. system level and provides leadership to assure that the system adequately supports the delivery of nursing care. xix The CNS works with multidisciplinary care teams within and across systems. The CNS may be responsible administratively to the specialty area administrator or chief nursing officer within the organization. Key activities of the CNS include: Using the core competencies of advanced practice nursing to design, implement, and evaluate programs of care to enhance patient outcomes, particularly for complex patients and across systems of care. 1 xx CNS involvement in care delivery and planning depends on a variety of factors, e.g. the assessed needs of patients and learning needs of staff. Leading multidisciplinary groups in designing and implementing innovative solutions that address system problems and patient care issues. xxi, xxii Serving as a leader, consultant, mentor and change agent to achieve quality cost-effective outcomes. xxiii Developing differential diagnoses and interventions to treat or prevent illness. xxiv Developing criteria for and 1 The APN competencies include: direct care, expert coaching and guidance, research, ethical decisionmaking, collaboration, consultation, and leadership.
10 evaluating the quality and effectiveness of nursing practice and organizational systems. Providing consultation to other nursing and health professional staff in an area of specialization, particularly for complex or critically ill patients. Planning and implementing educational opportunities for health professional staff, patients and communities. i American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. ii American Association of Colleges of Nursing. (2004). Working Paper on the Role of the Clinical Nurse Leader. 3 American Association of Colleges of Nursing. (1996). The Essentials of Master s Education for Advanced Practice Nurses. Washington, DC: Author. 4 American Nurses Association. (2004). Nursing scope & standards of practice. Washington, DC: Author. v National Association of Clinical Nurse Specialists. (2004). Statement on clinical nurse specialist practice and education. Harrisburg, PA: Author. vi Sparacino, PSA. (2005). The clinical nurse specialist. In AB Hamric, JA Spross & CM Hanson (Eds.), Advanced Practice Nursing: An Integrative Approach, 3 rd edition, p Philadelphia, PA: Elsevier Saunders. 7 American Association of Colleges of Nursing. (2004). Working Paper on the Role of the Clinical Nurse Leader. p.10 viii American Nurses Association. (2004). Scope & Standards of Practice. Washington, DC: Author. p.15. ix National Association of Clinical Nurse Specialists. (2004). Statement on clinical nurse specialist practice and education. Harrisburg, PA: Author. p Mohr JJ. Barach P. Cravero JP, Blike GT, Godfrey MM, Batalden PB, Nelson EC. (2003). Microsystems in health care: Part 6. Designing patient safety into the microsystem. Joint Commission Journal on Quality and Safety, 29(8) , August xi National Association of Clinical Nurse Specialists. (2004). Statement on clinical nurse specialist practice and education. Harrisburg, PA: Author. xii American Nurses Association. (2004). Nursing scope & standards of practice. Washington, DC: Author. xiii Institute of Medicine. (2001). Crossing the quality chasm, A new health system for the 21 st century. Washington, DC: National Academy Press. p
11 14 Sparacino, PSA. (2005). The clinical nurse specialist. In AB Hamric, JA Spross & CM Hanson (Eds.), Advanced Practice Nursing: An Integrative Approach, 3 rd edition, p Philadelphia, PA: Elsevier Saunders. 15 National Association of Clinical Nurse Specialists. (2004). Statement on clinical nurse specialist practice and education. Harrisburg, PA: Author. xvi Sparacino, PSA. (2005). The clinical nurse specialist. In AB Hamric, JA Spross & CM Hanson (Eds.), Advanced Practice Nursing: An Integrative Approach, 3 rd edition, p Philadelphia, PA: Elsevier Saunders. 17 National Association of Clinical Nurse Specialists. (2004). Statement on clinical nurse specialist practice and education. Harrisburg, PA: Author. p American Association of Colleges of Nursing. (1996). The Essentials of Master s Education for Advanced Practice Nurses. Washington, DC: Author. p National Association of Clinical Nurse Specialists. (2004). Statement on clinical nurse specialist practice and education. Harrisburg, PA: Author. p Hamric AB. (2005). A definition of advanced practice nursing. In AB Hamric, JA Spross, CM Hanson (Eds.) Advanced Practice Nursing: An Integrative Approach, 3 rd edition. Philadelphia: Elsevier Saunders. 21 National Association of Clinical Nurse Specialists. (2004). Statement on clinical nurse specialist practice and education. Harrisburg, PA: Author. 22 Sole, M L. (2004). How do You Define the Clinical Nurse Specialist? AACN News, 21,1. 23 National Association of Clinical Nurse Specialists. (2004). Statement on Clinical Nurse Specialist Practice and Education. Harrisburg, PA: Author. p National Association of Clinical Nurse Specialists. (2004). Statement on Clinical Nurse Specialist Practice and Education. Harrisburg, PA: Author. p.14.
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