Scope of Practice for the Acute Care CNS. Introduction

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1 Scope of Practice for the Acute Care CNS Introduction The historical conceptualization of nursing delineates clinical practice dimensions according to the practitioner s role, the practice environment, a patient s diagnosis and a patient s physiologic and psychosocial systems. Today s challenging health care calls for the complexities and needs of patients to drive the competencies of nursing and advanced nursing practice and a reframing of clinical practice dimensions. The various points of competency reflect the integration of the knowledge, skills, and attitudes needed to meet the patients needs. (Curley, 2007) Special attention is currently focused on the utilization of advanced practice nurses in a health care environment where the patient s needs are increasingly complex and of higher acuity. Throughout this document, the term patient refers to the individual, family or caregiver, or group or community. Family is defined as the family of origin or significant others and surrogate decision makers. This definition also recognizes family as defined by the patient. Caregiver is defined as family, custodian, or legal guardian. Advanced nursing practice builds on the competencies of the registered nurse and is characterized by the integration and application of a broad range of theoretical and evidence-based knowledge that occurs as part of graduate nursing education. (Safriet, 2011) As a result of this advanced preparation, advanced practice nurses have a great range, breadth, and depth of competencies, which result in a broad repertoire of effective solutions for patient needs, patient populations, and system. This expansion makes the acute care CNS optimally suited for managing the more complex, uncertain, and resource-exhausting situations characteristic of patients and settings with high acuity.(safriet, 2011) Care is continuous and comprehensive and may be provided across the continuum of wellness to acute care and within the 3 spheres of clinical nurse specialist influence: patient, nursing and nursing practice, and organizations and systems. (NACNS, 2004) It is provided using a collaborative model involving patients, families, nurses, other healthcare providers, and healthcare executives and is based on the tenets of the AACN Synergy Model for Patient Care. Definition of Acute Care Clinical Nurse Specialist The CNS is a registered nurse who has completed an accredited graduate-level educational program that prepares him or her as a clinical nurse specialist and includes supervised clinical practice to acquire advanced knowledge, skills, and abilities. This education and training qualifies him or her to independently: Function as an expert clinician and patient advocate (patient sphere) Lead the advancement of nursing practice (nursing sphere) Identify opportunities for and lead organizational and system change. (organizations and systems sphere)

2 The CNS is responsible and accountable for diagnosis and treatment of health/illness states, disease management, health promotion, and prevention of illness and risk behaviors among individuals, families, groups, and communities. All APRNs are educationally prepared to provide a scope of services across the wellness-illness continuum to at least one population. (LACE, pg 8, 9; 2008) The Role of the Acute Care Clinical Nurse Specialist Within the patient sphere, he or she provides and oversees direct culturally sensitive patient care including assessing, diagnosing, planning, and intervening, which includes prescribing of pharmacologic as well as nonpharmacologic treatment of health problems. The CNS also focuses on health promotion, risk reduction, and preventive care. To influence the nursing sphere, the CNS uses the AACN Synergy Model (Curley, 2007) to lead the advancement of nursing practice at the micro and macro levels. Clinical judgment and collaboration are used to enhance nursing care and its impact on the unique characteristics of the patient in order to devise a plan of care that ensures advocacy. Translation of evidence into the care of patients will help to achieve safe, quality, and cost-effective outcomes. The CNS leads organizational and system change by using systems thinking to identify opportunities to improve outcomes and optimize resources. Clinical inquiry and systems thinking are employed to analyze and evaluate data for global outcomes that ensure practice is patient-centered, safe, timely, effective, and efficient. The CNS designs strategies and interventions to promote optimization within all 3 spheres of influence. Significant Elements of CNS Practice: Promoting patient safety and quality outcomes through clinical inquiry and clinical judgment Demonstrating specialty/advanced practice clinical expertise in caring for a diverse patient population Integrating resource utilization across the continuum of care Assisting patients and their families in safely navigating a complex healthcare system Advocating for the rights and concerns of patients and their families Creating and translating best evidence into clinical practice Identifying the root cause of issues to differentiate among failures in the system, educational needs, and/or compliance issues to continuously improve care. Collaborating successfully to facilitate interprofessional safe practice Creating and sustaining healthy work environments Assessing, educating, and providing referrals for the patient, family, and caregiver

3 Implementing transitions in the levels of care Diagnosing, treating, and managing patients with acute and chronic illnesses and disease Prescribing medications, durable medical equipment, and advanced therapeutic interventions Prescribes nursing therapeutics, pharmacologic and nonpharmacologic interventions, diagnostic measures, equipment, procedures, and treatments to meet the needs of patients, families and groups (NACNS Core Competencies, 2010) Practice Population The acute care CNS practice is based on education in a population focus: neonatal, pediatric, or adultgerontology. The population focus includes patients with acute, critical, and/or complex chronic illnesses who may be physiologically unstable, technologically dependent, and highly vulnerable for complications. The patient may be experiencing episodic critical illness, chronic critical illness, acute exacerbation of chronic illness, or terminal illness. By influencing nurses, other members of the healthcare team, and organization/systems, the CNS is able to facilitate the needs of diverse groups and to enhance quality and cost-effective patient-centered care. Practice environment The acute care CNS practices in any setting in which patients with acute, chronic, and/or complex chronic illnesses may be found. Needs may include complex monitoring and therapies, high-intensity interventions, or continuous vigilance within the range of high acuity care. Although many CNSs practice in acute care and hospital-based settings, including emergency care and intensive care settings, the continuum of acute care services spans the geographic settings of home, ambulatory care, long term acute care, rehabilitative care. The practice environment extends into the mobile environment and virtual locations, such as tele-intensive care units (tele-icus) and areas using telemedicine. From a systems perspective, this environment encompasses the continuum of acute care from tertiary care to home care and all systems and agencies of the practice environment and places the CNS in an optimal position to facilitate care transitions. Educational preparation Education of the acute care CNS takes place at the graduate or post-graduate level in nursing. The educational program assists the CNS to develop core competencies within each sphere of influence relative to a specific population focus. The defining factor for all CNSs is that a significant component of the education and practice focuses on direct care of individuals and includes wellness through acute care.

4 CNS education must prepare the graduate to practice within at least one of the 6 population foci: family/individual across the lifespan, adult-gerontology, neonatal, pediatrics, women s health/genderrelated, or psychiatric-mental health. The CNS graduate must be prepared to assume responsibility and accountability for health promotion and/or maintenance as well as assessment, diagnosis, and management of patient problems, which include the use and prescription of pharmacologic and nonpharmacologic (LACE 2008, NCSBN 2008) interventions. The curriculum is composed of, but not limited to, content to ensure attainment of the APRN core, role core and population core competencies. (LACE, 2008 pg16). These competencies are delineated by the American Association of Colleges of Nursing documents: Essentials of Master s Education in Nursing (AACN 1996) and The Essentials of Doctoral Education for Advanced Practice Nursing (AACN, 2006). 1. APRN Core Competencies a. Advanced Health or Physical Assessment b. Advanced Physiology and Pathophysiology c. Advanced Pharmacology 2. Role Core Competencies a. Background for Practice from Sciences and Humanities b. Organizational and Systems Leadership c. Quality Improvement and Safety d. Translating and Integrating Scholarship into Practice e. Informatics and Healthcare Technologies f. Health Policy and Advocacy g. Interprofessional Collaboration for Improving Patient and Population Health Outcomes h. Clinical Prevention and Population Health for Improving Health i. Advanced level Nursing Practice 3. Population Core Competencies (AACN, 2010 Adult-Gero CNS Competencies) a. Direct Care b. Consultation c. Systems Leadership

5 d. Collaboration e. Coaching f. Research g. Ethical Decision Making, Moral Agency, and advocacy Note: The population core competencies listed are for the adult-gerontology patient focus only. As of publication date, neonatology and pediatric core competencies have not been developed) The curriculum prepares students to meet the criteria for eligibility to take the appropriate national certification examination consistent with the role and population focus and for state licensure/recognition as a CNS/APRN. (LACE, 2008; NCSBN, 2008; CNS education standards pg 18.) Clinical Practicum The CNS is considered to be a direct care provider and must receive sufficient clinical experience to provide comprehensive care for a specific population. When preparing a graduate who will provide direct patient care, establish differential diagnosis, prescribe, and assume accountability for clinical care, the educational program should provide the student with opportunity to build on existing clinical expertise, master clinical judgment of healthcare problems, and apply advanced skills in extensive clinical practice.(aacn, 2011; CNS Educational Program requirements) According to the American Association of Colleges of Nursing, all APRN students who will practice in a direct client role, make diagnoses, prescribe therapeutic regimens, and be accountable for these decisions should have a minimum of 500 hours in direct clinical practice in the role and population focus during the master s educational program.(aacn, 2011) With the current trend towards the Doctorate of Nursing Practice, the American Association of Colleges of Nursing recommends a minimum of 1000 postbaccalaureate hours in direct clinical practice for a doctoral educational program. (AACN, 2006) Optimally, practice experiences for CNS students will occur primarily with a CNS as the preceptor. The preceptor may also be a practicing physician or other licensed independent practitioner (LIP) with at least a graduate degree and comparable practice focus; however, physicians and LIPs cannot constitute a majority of the preceptors. These experiences should provide for the opportunity to collaborate with and receive feedback from nursing as well as other healthcare disciplines. Regulation Regulation of all advanced practice roles is accomplished through self-regulation, peer review, certification, statutes, and the rules and regulations of state nurse practice acts and employer credentialing and privileging. The board of nursing in each state, under the authority of the Nursing Practice Act, establishes statutory authority for licensure of registered nurses and licensure or

6 recognition for advanced practice registered nurses. This includes the use of a title, authorization for a scope of practice, standards of practice, and grounds for disciplinary action. All nurses exercise autonomy within their scope of practice. This autonomy is based on expert knowledge and the willingness to commit to self-regulation and accountability for practice. Such selfregulation includes the CNS performing an internal and PEER review of his or her own practice to ensure function within educational preparation, certification, and competencies. To maximize the effect that the CNS has on patient outcomes, nursing practice, and competencies, as well as system effectiveness, regular evaluation of performance and impact must be done at the organizational level. In conjunction with organizational leaders, the CNS should have significant input into the evaluation criteria used to guide performance goals. Goals should be focused on achieving optimal patient, nursing, organization, and system outcomes. Credentialing and privileging through an employer also impacts the scope of CNS practice and should be implemented. Certification of the clinical nurse specialist is a formal recognition of competence made about nurses who are clinically active in a population focus. One component of certification is eligibility that is related to the successful completion of the program of study, appropriate course content, and specified amount of supervised clinical practice. The other component of certification is knowledge, which is determined by passing a written (or computer-based) examination that tests the knowledge base for the selected area of advanced practice (ANA, 2010) The CNS s practice is regulated externally through licensure at the state level. Regulation in the state nurse practice acts is informed by the APRN Consensus Model and is administered under the authority of state governments to ensure public safety. The CNS is licensed as an advanced practice registered nurse to practice in the state in which he/she practices and is subject to the state s legal constraints and regulations. Some states have additional requirements that must be met to practice or be recognized as a CNS. The National Council of State Boards of Nursing (NCSBN) APRN Model Act states, APRNs are expected to practice as licensed independent practitioners within the standards established and/or recognized by the board. Each APRN is accountable to patients, the nursing profession, and the board for complying with the requirements of this Act, and the quality of advanced nursing care rendered; for recognizing limits of knowledge and experience, planning for the management of situations beyond the APRN s expertise; and for consulting with or referring patients to other health care providers as appropriate. 4(pp1,2) Ethics and Advocacy The acute care CNS bases clinical judgment on needs of patients and families consistent with the ANA Code of Ethics for Nurses with Interpretative Statements. (ANA, 2001) The CNS acknowledges a patient s and family s dignity, autonomy, cultural beliefs, and privacy within the framework of interprofessional collaborative practice.

7 The CNS works to promote an ethical practice environment, serving as an advocate for the patient and staff. He or she is obliged to demonstrate nonjudgmental and nondiscriminatory attitudes and behaviors toward patients, families, and other members of the health care team. (Interprofessional Education Collaborative,2011). The CNS enhances the patient experience, facilitates resolution of ethical and clinical conflicts with patients and other healthcare professionals, and promotes an environment for ethical decision-making and patient advocacy. Conclusion This document reflects the CNS s response to patients and families throughout the 3 spheres of influence. By defining, clarifying, and reviewing the Scope of Practice for the CNS, this statement to the advancement of clinical nursing practice in the current health care environment. In the Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine advocates that nurses be allowed to practice to the full extent of their education and training but, in addition, that federal and state actions are needed to remove the current restrictions to make full use of APRNs in meeting health care needs. (IOM, 2010)

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