AACN SCOPE AND STANDARDS FOR ACUTE CARE CLINICAL NURSE SPECIALIST PRACTICE

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1 AACN SCOPE AND STANDARDS FOR ACUTE CARE CLINICAL NURSE SPECIALIST PRACTICE

2 AACN Mission Patients and their families rely on nurses at the most vulnerable times of their lives. Acute and critical care nurses rely on AACN for expert knowledge and the influence to fulfill their promise to patients and their families. AACN drives excellence because nothing less is acceptable. AACN Vision AACN is dedicated to creating a healthcare system driven by the needs of patients and families where acute and critical care nurses make their optimal contribution. AACN Core Values As AACN works to promote its mission and vision, it is guided by values that are rooted in, and arise from, the Association s history, traditions and culture. AACN, its members, volunteers and staff will honor the following: Ethical accountability and integrity in relationships, organizational decisions and stewardship of resources. Leadership to enable individuals to make their optimal contribution through lifelong learning, critical thinking and inquiry. Excellence and innovation at every level of the organization to advance the profession. Collaboration to ensure quality patient- and family-focused care.

3 AACN SCOPE AND STANDARDS FOR ACUTE CARE CLINICAL NURSE SPECIALIST PRACTICE

4 Editor: Linda Bell, RN, MSN Graphic Design: Lisa Valencia-Villaire An AACN Critical Care Publication American Association of Critical-Care Nurses 101 Columbia Aliso Viejo, CA American Association of Critical-Care Nurses ISBN AACN Product # All rights reserved. AACN authorizes individuals to photocopy items for personal use. Other than individual use, no part of the book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, photocopying, recording or otherwise) without the prior written permission of AACN. Printed in the USA.

5 Table of Contents Acknowledgments - v Introduction - 1 Purpose of This Document - 1 The Consensus Process and Title Transitions From Acute and Critical Care CNS to Acute Care CNS - 1 Definition and Role of Scope - 1 Definition and Role of Standards - 2 Framework for This Document - 2 Need for the Role of Acute Care CNS - 4 Scope of Practice for the Acute Care CNS - 5 Introduction - 5 Definition of Acute Care CNS - 5 Role of the Acute Care CNS - 6 Practice Population - 6 Practice Environment - 7 Educational Preparation - 7 Clinical Practicum - 8 Regulation - 8 Ethics and Advocacy - 9 Conclusion - 9 The Standards - 11 Introduction - 11 Assessment - 12 Diagnosis - 12 Outcomes Identification - 13 Planning - 13 Implementation - 14 Evaluation - 15 iii

6 Standards of Professional Performance - 16 Introduction - 16 Professional Practice - 17 Individual Practice Evaluation - 17 Professional Developement - 17 Collegiality - 18 Ethics - 18 Collaboration - 19 Research/Clinical Inquiry - 19 Resource Utilization - 20 Leadership - 20 System Thinking - 21 Current Issues and Trends - 22 Glossary - 24 APRNs and Health Care - 22 Consensus Model for APRN Regulation - 22 CNS Recognition as APRN - 23 The CNS and Certification - 23 Appendices A Consensus Model for APRN Regulation Clinical Nurse Specialist Focus - 27 B Role Comparison: Acute Care NP and the Acute and Critical Care Clinical Nurse Specialist - 28 C Additional Foundational Resources - 31 D AACN Standards for Establishing and Sustaining Healthy Work Environments: Executive Summary - 32 iv

7 Acknowledgments acute care clinical nurse specialist scope and standards task force Kathleen Hill, MSN, RN, CCNS Task Force Chair Kathleen K. Peavy, RN, MS, CCRN, CNS-BC AACN Board of Directors Liaison Linda Bell, RN, MSN AACN Staff Liaison Task Force Members: Mary Gordon, PhD, RN, CNS-BC Gary M. Gusick, RN, PhD, CCNS Deborah Klein, RN, MSN, ACNS-BC, CCRN, CHFN, FAHA Nicole Kupchik, RN, MS, CCRN, CCNS, PCCN Lisa Soltis, MSN, APRN, CCRN-CSC, CCNS, FCCM Kathleen Stacy, PhD, RN, CNS, CCRN, PCCN, CCNS Paul Thurman, RN, MS, ACNPC, CCRN, CCNS Invited Guests: Nancy Brames, MSN, ACNS-BC American Nurses Credentialing Center Carol Hartigan, RN, MA AACN Certification Corporation Ginger Pierson, RN, MSN, CCRN, CNS National Association of Clinical Nurse Specialists Aran Tavakoli, RN, MSN, AOCNS Oncology Nurses Credentialing Center Acknowledgments A special thank you to the institutions that supported participants from the American Association of Critical-Care Nurses (AACN) and representatives of other nursing organizations who served on the Acute Care Clinical Nurse Specialist Scope and Standards Task Force. We are indebted to the clinical nurse specialist students, faculty and practitioners who provided thoughtful review and comment throughout the public comment period. v

8 Purpose of This Document Current trends and developments in advanced practice nursing, in association with issues in health care delivery and an aging society, continue to drive the roles and responsibilities of the acute care clinical nurse specialist (CNS). The purpose of AACN Scope and Standards for Acute Care Clinical Nurse Specialist Practice is to describe the practice of the acute care CNS, whether trained and certified to care for neonatal, pediatric, or adult-gerontology patients. This purpose is accomplished by describing the Scope of Practice, the Standards of Clinical Practice, and the Standards of Professional Performance. This document is intended for use by all of those involved in the profession of the acute care CNS, including students, faculty, CNSs in practice, members of the interprofessional team, and other nursing colleagues. In addition, administrators, medical staff professionals, boards of nursing, policy makers, and insurers will benefit from the description and accountabilities of the acute care CNS. The authors and contributors have attempted to describe the most current functions of the role in a manner consistent with CNS education and training, licensure, and certification, recognizing that there are variations in scope of practice based on state and hospital regulations. The role will continue to evolve, based on the needs of patients, families, and society. the consensus process and title transitions from acute and critical care cns to acute care cns Clinical nurse specialists are essential in coordinating and measuring nursing efforts to improve quality care. Their continued existence is crucial to both the professional development of acute and critical care nurses and positive outcomes for patients and families. Implementation of the Consensus Model for APRN Regulation brings with it many changes that are affecting nurses, including changes to the traditional titles of several CNS and nurse practitioner (NP) designations. 1 Under consensus agreements reached during the development of the model, all CNSs will be educated and certified from wellness through acute care. There will no longer be any reference to critical care in any CNS role designation of graduates educated under the model, and the ability to care for complex, high acuity patients will be a common skill set among all CNSs. It continues to be of critical importance in the implementation of the new Consensus Model-based acute care NP and CNS that certification examination programs are compliant with the licensure tier as delineated in the model. In order to demonstrate congruence with the model, AACN has avoided any reference to critical care in the examination names and credentials awarded. The scope of practice will include the continuum from acute through critical care for both acute care nurse practitioners (ACNPs) and CNSs as it always has been. For this reason, AACN has changed the title of this scope and standards document from Scope and Standards for Acute and Critical Care Clinical Nurse Specialist Practice to Scope and Standards for Acute Care Clinical Nurse Specialist Practice. definition and role of scope Scope of practice defines the boundaries of the practitioner s license, ie, the role s procedures, actions, and processes for which the practitioner has received the education, training, licensure and, if required, certification, to practice in the state where they work. The exception to state rules and regulations occurs in 1

9 federal jurisdictions such as the Veterans Administration. Documents on the scope of practice should describe who, what, where, when, why, and how the CNS functions in the role. The boundaries of the CNS as an advanced practitioner should not be confined to historical subroles. The definition allows for exchange, expansion, and flexibility of the profession to meet the changing needs of patients, organizations, and society. 2 Due to the evolving nature of the CNS role, and the health care environment, a flexible scope of practice statement is essential. definition and role of standards Standards are authoritative statements that describe the level of care or performance common to the profession of nursing by which the quality of nursing practice can be judged. 3 AACN standards are examples of the roles and responsibilities the profession and society expect of the acute care CNS. The Standards of Clinical Practice describe a competent level of advanced nursing practice in the CNS role. The Standards of Professional Performance speak to the activities and behaviors expected of the CNS. All standards reflect the professional activities and behavior expected of the CNS based on education, training, licensure, and certification. The standards include performance expectations that are key indicators of competent advanced practice, building on Nursing s Scope & Standards of Practice 3 and AACN Standards for Acute and Critical Care Nursing Practice. 4 It is expected that the standards describing clinical practice and professional performance will remain stable over time. However, performance expectations will continue to be evaluated and revised to incorporate changes, as the number, use, and evaluation of CNSs increase, along with advances in scientific knowledge, the health care environment, and technology. As advanced nursing practice continues to evolve, performance expectations also must evolve to remain consistent with the development of scientific knowledge and technology to meet patient, family, and societal needs. 2 framework for this document Nursing Process The nursing process is a systematic means to organize professional nursing practice using critical thinking and diagnostic reasoning skills. In this update, the nursing process was adapted to reflect the advanced knowledge, skills, and abilities expected of the CNS, including advanced assessment, differential diagnosis, outcome identification, plan of care development, implementation of treatment, and evaluation of outcomes along the continuum of care from wellness to illness. Each step is predicated on the accuracy of the previous step; however, the process is dynamic and circular rather than linear. Ongoing assessment of patients and families, their responses to interventions described in the plan, critical review and evaluation of available outcome information, and a reformulation of diagnoses, interventions, and expected outcomes occur along a continuum of care. Communication and collaboration skills among interprofessional team members, patients, and families/caregivers are critical to achieve the desired outcomes. AACN Synergy Model for Patient Care The fundamental premise of the AACN Synergy Model for Patient Care is that when patient characteristics drive nurse competencies, optimal outcomes for patients and families will occur. Based on core char-

10 acteristics, a patient differs in his or her capacity for health and vulnerability to illness. The skills and level of competency required by the nurse are driven by the patient s needs along the continuum of core characteristics. 5 This matching of nurse competencies and patient characteristics is equally as important for the advanced practice nurse as for the bedside clinician. The Synergy Model focuses on knowing the patient and understanding the perspectives of the patient and family. It integrates all dimensions of a patient s health status: physical, social, psychological, and spiritual. It reflects patient-driven and patient- and family-centered care that requires building relationships and achieves synergy when a healing environment is created. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (LACE) The Consensus Model for APRN Regulation reflects the need to align education, licensure, and certification for the 4 clinically based advanced practice nursing roles: certified registered nurse anesthetist, certified nurse midwife, CNS, and certified nurse practitioner (NP). One goal of Consensus Model development is to ensure consistent licensure and regulatory requirements so that APRNs can practice to the full scope of their education and training. The Consensus Model clarified that education must be provided by an accredited organization, that the education of the advanced practitioner is consistent with the role and the population being served, and that certification assesses the competencies of the role s core education. Licensure grants authority as a licensed independent practitioner (LIP) to practice in an advanced role in the population foci for which the person was educated and certified. 1 The Consensus Model informed the development of this scope and standards document by clarifying the required education and population foci of the neonatal, pediatric, or adult-gerontology acute care CNS. Spheres of Influence In 1998, the National Association of Clinical Nurse Specialists (NACNS) introduced the conceptual framework of spheres of influence to define the role of the CNS as an alternative to the subroles that previously classified CNS function (expert practitioner, educator, researcher, change agent and consultant). NACNS defined sphere of influence as a domain of CNS practice that encompasses the pertinent stakeholders or consumers of CNS services. 6 The 3 spheres of influence defined by NACNS are patient/family, nursing/nursing practice, and organizations/systems. Competency Documents The Acute Care CNS Scope and Standards Task Force used many documents to inform their work, including Clinical Nurse Specialist Core Competencies, 7 Adult-Gerontology Clinical Nurse Specialist Competencies, 8 Core Competencies for Interprofessional Collaborative Practice, 9 and Graduate Level QSEN Competencies: Knowledge, Skills and Attitudes. 10 At the time of this writing, neonatal and pediatric CNS competencies were not completed. These documents helped the task force view the complexity of the CNS role and its obligations to the patient/family, nursing/nursing practice, and organizations/systems. 3

11 need for the role of acute care cns The changing health care environment has accentuated the fragmentation that accompanies the delivery of episodic, specialized care across the continuum of acute and chronic care services for the neonatal, pediatric, and adult-gerontology patient populations. Limited access to care, the aging population, and chronic illness across the life span contribute to the number of vulnerable patients. Management of stable and progressive chronic illness in a care setting where episodic care is provided often results in lack of continuity and increased patient vulnerability. Transitions across the health care system are particularly susceptible to compromised care, breakdowns in communication, and issues of patient safety. The skill set of the acute care CNS includes addressing these needs across all 3 spheres of influence for his or her patient population. Patient needs are also unmet when care is limited to specialty treatment of an acute illness, with lack of attention to comorbidities and chronic health conditions, or the recognition and minimization of physiologic, psychological, and iatrogenic risks. Significant resources are expended on specialty care, both inpatient and outpatient, which also affects continuity of care. The result is an environment of uncoordinated use of resources and poorly defined holistic outcomes. Furthermore, there is an increasing mismatch between historical provider characteristics and patient needs. The need has emerged for a provider with unique knowledge, skills, and abilities to manage a patient s care across the full continuum of acuity and care services from wellness to illness. The acute care CNS in collaboration with his or her acute care NP colleagues is uniquely prepared to fill this need. In the Future of Nursing report, the Institute of Medicine advocates not only that nurses practice to the full extent of their education and training, but also federal and state action is needed to remove restrictions to make full use of APRNs in meeting health care needs. 2 references 1 APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education; Accessed March 4, Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; American Nurses Association. Nursing: Scope and Standards of Practice. Washington, DC: Bell L, ed. AACN Scope and Standards for Acute and Critical Care Nursing Practice. Aliso Viejo, CA: American Association of Critical-Care Nurses; Curly MAQ. Synergy: The Unique Relationship Between Nurses and Patients. Indianapolis, IN: Sigma Theta Tau; NACNS Research and Practice Committee. Statement on Clinical Nurse Specialist Practice and Education. 2nd ed. Harrisburg, PA: National Association of Clinical Nurse Specialists; National CNS Competency Task Force. Clinical Nurse Specialist Core Competencies: Executive Summary Harrisburg, PA: National Association of Clinical Nurse Specialists; American Association of Colleges of Nursing. Adult-Gerontology Clinical Nurse Specialist Competencies. Washington, DC: American Association of Colleges of Nursing; Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative; QSEN Education Consortium. Graduate-Level QSEN Competencies: Knowledge, Skills and Attitudes. Washington, DC: American Association of Colleges of Nursing; Accessed March, 4,

12 Scope of Practice for the Acute Care CNS Introduction The historical concept of nursing defines clinical practice dimensions according to the practitioner s role, the practice environment, the patient s diagnosis, and the patient s physiologic and psychosocial systems. In today s health care, the needs of patients drive nursing practice competencies and a reframing of clinical practice dimensions. Competency reflects integration of the knowledge, skills, and attitudes required to meet patients needs. 1 Special attention is currently focused on the use 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. 2 As a result of this preparation, advanced practice nurses have a great range and depth of competencies, which results in many effective solutions for patients and systems. This expansion makes the acute care CNS well suited to manage the more complex, uncertain, and resourceexhausting situations characteristic of patients in high acuity settings. Care is continuous and comprehensive and may be provided across the continuum of wellness to acute care within the 3 spheres of CNS influence: patient/family, nursing/nursing practice, and organizations/systems. 3 It is provided using a collaborative model involving patients, families, nurses, other health care providers, and health care executives and is based on the AACN Synergy Model for Patient Care. definition of acute care cns The CNS is a nurse who completed an accredited graduate-level educational program that prepares him or her as a CNS within a defined population 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/family sphere) Lead the advancement of nursing practice (nursing/nursing practice sphere) Identify opportunities for and lead organizational and system change (organizations/systems sphere) The CNS is responsible for diagnosis and treatment of health/illness states, disease management, health assessment, screening and promotion, and prevention of illness and risk behaviors among patients, families, groups, and communities. All APRNs are educationally prepared to provide a scope of services across the wellness to illness continuum for at least 1 population. 4 5

13 role of the acute care cns Within the patient sphere, the CNS provides and oversees direct culturally sensitive care, including assessing, diagnosing, planning, and intervening, which includes prescribing pharmacologic and nonpharmacologic treatment of health problems. The CNS also focuses on health assessment, screening and promotion, risk reduction, and preventive care. To influence the nursing sphere, the CNS uses the AACN Synergy Model for Patient Care 1 to lead the advancement of nursing practice at the micro and macro levels. Clinical judgment and collaboration 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 will help to achieve safe, quality, and cost-effective outcomes. The CNS leads organizational and system changes using systems thinking to optimize resources and improve outcomes. Clinical inquiry and systems thinking help the CNS analyze and evaluate data to ensure practice is patient-centered, safe, timely, effective, and efficient. The CNS designs strategies and interventions to promote optimization within the 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 and care coordination across transitions of care Helping patients and families safely navigate a complex health care system Advocating for the rights and concerns of patients and families Creating and translating best evidence into clinical practice Supporting a just culture by identifying the root causes of issues to differentiate among failures in the system, educational needs, and/or compliance issues to continuously improve care Collaborating to facilitate interprofessional safe practice Establishing and sustaining healthy work environments Assessing, educating, and providing referrals for the patient, family, and caregiver Implementing transitions in the levels of care Diagnosing, treating, and managing patients with acute and chronic illness and/or disease Prescribing medications, durable medical equipment, and advanced therapeutic interventions Prescribing nursing therapeutics, pharmacologic and nonpharmacologic interventions, diagnostic measures, equipment, procedures, and treatments to meet the needs of patients, families, and groups. 5 Practice Population Acute care CNS practice is based on education in a population focus across the wellness to illness continuum. Acute care populations are neonatal, pediatric, and adult-gerontology. The population focus includes patients with acute, critical, and/or complex chronic illnesses who may be physiologically unstable, technologically dependent, and/or highly vulnerable to complications. These patients may experience episodic critical illness, chronic critical illness, acute exacerbation of chronic illness, or terminal illness. By influencing nurses, other members of the health care team, and organizations/systems, the CNS facilitates the needs of diverse groups and enhances quality and cost-effective patient-centered care. 6

14 Practice Environment The acute care CNS practices in any setting where patients have acute, chronic, and/or complex chronic illnesses. Needs across the wellness to illness continuum 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, the continuum of acute care services spans the settings of home, ambulatory care, long-term acute care, rehabilitative care, the mobile environment, and virtual locations, such as tele-intensive care units (tele-icus) and areas using telemedicine. From a systems perspective, the environment encompasses the continuum of acute care from tertiary care to home care and all systems and agencies within these practice environments which 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 nursing level. The educational program helps the CNS develop core competencies within each sphere of influence relative to a specific population focus. A significant component of education and practice focuses on direct patient care from wellness to illness. Clinical nurse specialist education must prepare the graduate to practice within at least 1 of the 6 population foci: family/patient across the life span, adult-gerontology, neonatal, pediatrics, women s health/gender-related, or psychiatric/mental health. The CNS graduate must be prepared to assume responsibility 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 interventions. 4 The curriculum is composed of, but not limited to, content to ensure attainment of the APRN core, role core, and population core competencies. 4 These competencies are described in the American Association of Colleges of Nursing documents: The Essentials of Master s Education in Nursing 6 and The Essentials of Doctoral Education for Advanced Nursing Practice 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 Health Care 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 8 a. Direct Care 7

15 b. Consultation c. Systems Leadership 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 were not developed. The curriculum prepares students to meet the criteria to take the national certification exam consistent with the role and population focus and for state licensure/recognition as a CNS/APRN. 4 Clinical Practicum The CNS is a direct care provider and must receive sufficient clinical experience to meet the core role and population competencies to 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 the opportunity to build on existing clinical expertise, master clinical judgment of health care problems, and apply advanced skills in extensive clinical practice. 9 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. 4 With the current trend toward the doctorate of nursing practice (DNP), the American Association of Colleges of Nursing recommends a minimum of 1000 post-baccalaureate hours in direct clinical practice in a doctoral educational program. 7 Optimally, practice experiences for CNS students will occur primarily with a CNS preceptor. The preceptor also may be a practicing physician or other 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 the opportunity to collaborate with and receive feedback from nursing as well as other health care disciplines. Regulation Regulation of all advanced practice roles occurs through self-regulation, peer review, certification, statutes, state rules for nursing practice, 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 nurses and licensure or recognition for APRNs. This licensure includes the use of a title, authorization for scope of practice, standards of practice, and grounds for disciplinary action. All nurses exercise autonomy within their scope of practice, based on expert knowledge, and commit to self-regulation and accountability for practice. Such self-regulation includes the CNS performing an internal and peer review of his or her own practice to ensure 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 occur at the orga- 8

16 nizational level. In conjunction with organizational leaders, the CNS should have significant input for the evaluation criteria that guide performance goals. Goals should be focused on achieving optimal patient, nursing, organization, and system outcomes. Credentialing and privileging through an employer also impact the scope of CNS practice and should be implemented. Clinical nurse specialist certification is formal recognition of competence for nurses who are clinically active in a population focus. One component of certification is eligibility related to successful completion of the program of study, appropriate course content, and a specified amount of supervised clinical practice. The other component of certification is knowledge, which is determined by passing a written (or computer-based) exam that tests the knowledge base for the selected area of advanced practice. 10 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 APRN in the state in which he or she practices and is subject to the state s regulations. Some states have additional requirements to practice or to be recognized as a CNS. The exception is the APRN functioning in federal facilities such as the Veterans Administration. 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. 11 Ethics and Advocacy The acute care CNS bases clinical judgment on the needs of patients and families consistent with the ANA Code of Ethics for Nurses With Interpretive Statements. 12 The CNS acknowledges a patient s and family s dignity, autonomy, cultural beliefs, and privacy within the framework of interprofessional collaborative practice. The CNS promotes an ethical practice environment, serving as an advocate for the patient and staff. He or she must demonstrate nonjudgmental and nondiscriminatory attitudes and behaviors toward patients, families, and other members of the health care team. 13 The CNS enhances the patient experience, facilitates resolution of ethical and clinical conflicts with patients and other health care professionals, and promotes an environment of 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 supports the role and function of the CNS as an advanced nursing practitioner. In The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine advocates that nurses practice to the full extent of their education and training, and, in addition, federal and state actions are needed to remove the current restrictions to make full use of APRNs in meeting health care needs. 14 9

17 references 1 Curley, MAQ. Synergy: The Unique Relationship Between Nurses and Patients. Indianapolis, IN: Sigma Theta Tau; Safriet BJ. Federal options for maximizing the value of advanced practice nurses in providing quality, cost-effective health care. In: Institute of Medicine Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. Washington, DC: National Academies Press; NACNS Research and Practice Committee. Statement on Clinical Nurse Specialist Practice and Education, 2nd ed. Harrisburg, PA: National Association of Clinical Nurse Specialists; APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education; Accessed March 4, National CNS Competency Task Force. Clinical Nurse Specialist Core Competencies: Executive Summary Philadelphia, PA: National Association of Clinical Nurse Specialists; American Association of Colleges of Nursing. The Essentials of Master s Education in Nursing. Washington, DC: American Association of Colleges of Nursing; Accessed March 4, American Association of Colleges of Nursing. The Essentials of Doctoral Education for Advanced Nursing Practice. Washington, DC: American Association of Colleges of Nursing; Accessed March 4, American Association of Colleges of Nursing. Adult-Gerontology Clinical Nurse Specialist Competencies. Washington, DC: American Association of Colleges of Nursing; Validation Panel of the National Association of Clinical Nurse Specialists. Criteria for Evaluation of the Clinical Nurse Specialist Master s, Practice Doctorate, and Post-Graduate Certificate Educational Programs. Philadelphia, PA: National Association of Clinical Nurse Specialists; American Nurses Association. Nursing s Social Policy Statement: The Essence of the Profession ed. Silver Spring, MD: Nursesbooks.org; National Council of State Boards of Nursing. APRN Model Act/Rules and Regulations. Chicago, IL: National Council of State Boards of Nursing; American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Washington, DC: American Nurses Association; Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative; Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington DC: National Academies Press;

18 The Standards Introduction The standards are intended to be used with the Scope of Practice, which addresses the role and boundaries of practice for the acute care CNS. The standards apply to all care the acute care CNS provides. The performance expectations describe how each standard is met. The professional practice of the acute care CNS is characterized by the application of relevant theories, research, and evidence-based guidelines to explain human behavior and related phenomena. Such application also provides a basis for advanced nursing interventions and evaluation of the patient, nursing and nursing practice, and organizations and systems-oriented outcomes. Using the foundations of clinical judgment and clinical inquiry, theoretical knowledge and research, the CNS provides a comprehensive assessment and diagnosis for a given population. Theory and translation of research also guide the acute care CNS in the synthesis of data, intervention choices, methods of implementation, and evaluations of outcomes for the patient, nursing and nursing practice, and organizations and systems. To sustain and build on research and evidence-based practice, the acute care CNS requires resource materials in practice settings, support for and access to continuing education programs, and a philosophy that is congruent with clinical inquiry and evidence-based nursing actions. Standards of Clinical Practice The Standards of Clinical Practice are not intended to stand alone but must be used with the other sections of this document: Scope of Practice, and the Standards of Professional Performance. The Standards of Clinical Practice for the acute care CNS build on the American Nurses Association s Nursing: Scope and Standards of Practice 1 and AACN Standards for Acute and Critical Care Nursing Practice. 2 The Standards of Clinical Practice apply to the care that acute care CNSs provide to patients/families, nurses/nursing practice, and organizations/systems within the population focus of his or her educational preparation. The nursing process is a framework; however, in this update the standards also incorporate competencies specific to acute care CNS practice. The focus of acute and critical care CNS practice is to integrate care across a continuum and throughout the 3 spheres of influence based on patient needs. 11

19 standard 1 Assessment The acute care CNS collects data through interaction within the 3 spheres of influence: the patient/family, nursing/nursing practice, and organizations/systems. Performance Expectations: Conducts comprehensive, holistic wellness to illness assessments using evidence-based techniques and tools Assesses patient and family barriers in receiving, understanding, and giving information Uses reliable and age-appropriate assessment instruments to evaluate acute and chronic health concerns for the patient population Conducts a pharmacologic assessment including polypharmacy, drug interactions, and overthe-counter and herbal products Elicits comprehensive history, and performs physical exams assessing physiological and functional changes associated with growth and development across the population served Obtains necessary data to formulate differential diagnoses Recognizes the presence of comorbidities and psychosocial issues that may impact health, developmental level, and illness Identifies potential risks to patient safety, autonomy, and quality of care Performs patient care, nursing practice, and system-level assessments to identify variables that influence health care outcomes Assesses interprofessional practice for collaboration and use of evidence-based practice to optimize clinical outcomes standard 2 Diagnosis The acute care CNS analyzes and synthesizes assessment data to determine needs across the 3 spheres of influence: the patient/family, nursing/nursing practice, and organizations/systems. Performance Expectations: Obtains necessary data to formulate differential diagnoses/plans of care, and evaluate outcomes Synthesizes data with advanced knowledge and experience Uses critical thinking to formulate differential diagnoses Determines diagnoses considering o physiology/pathophysiologic changes 12

20 o morbidities/comorbidities o events across the life span o patient s pharmacologic history with particular attention to issues of polypharmacy Collaborates with patients, families, and other disciplines to prioritize diagnoses Uses data and trends in decision making to optimize patient safety, nursing practice, and systems function Identifies gaps in translation of evidence into practice Leads and participates in interprofessional teams examining data and trends to identify system opportunities Analyzes benefits and costs of care for programs, organizations, and society standard 3 Outcomes Identification The acute care CNS formulates goals and expected outcomes in each of the 3 spheres of influence: the patient/family, nursing/nursing practice, and organizations/systems. Performance Expectations: Identifies expected outcomes that incorporate scientific evidence and translational research and are achievable through evidence-based practices Collaborates with patients and other health care team members to identify expected outcomes that are consistent with the patient s present and potential capabilities, as well as the patient s values, culture, and environment Establishes incremental indicators of progress in achieving expected outcomes Identifies and analyzes factors that enhance or hinder expected patient and nurse-sensitive outcomes Identifies and prioritizes clinical and systems opportunities through education, evidence, expertise, and experiential knowledge Differentiates between outcomes that require care process modification at the patient level and those that require modification at the system level standard 4 Planning The acute care CNS develops and facilitates a plan that prescribes interventions to attain expected outcomes within the 3 spheres of influence: the patient/family, nursing/nursing practice, and organizations/systems. 13

21 Performance Expectations: Determines when evidence-based guidelines, policies, procedures, and plans of care need to be tailored to the patient and family Designs evidence-based strategies to meet the multifaceted needs of complex patients/populations (eg, safety, quality, cost) Communicates directly with nursing staff to determine which strategies would best meet a patient s needs Develops age- and population-specific clinical standards, algorithms, policies, procedures, protocols, and guidelines Coordinates education within the 3 spheres to improve health care outcomes Develops, implements, and modifies plans of care or system initiatives within the spheres of influence standard 5 Implementation The acute care CNS effectively implements interventions within the 3 spheres of influence: the patient/family, nursing/nursing practice, and organizations/systems. Performance Expectations: Provides direct care to selected patients based on the needs of patients and the CNS s specialty knowledge and skills Prescribes and/or implements pharmacologic and nonpharmacologic interventions, diagnostic measures, durable medical equipment, procedures, and treatments as identified in the plan of care Coordinates implementation of an individualized plan of care collaboratively with patients and the health care team Uses behavioral, communication, and environmental modification strategies with patients who have cognitive and/or psychiatric impairments Documents consultations, assessments, recommendations, interventions, and evaluations in the patient s record Initiates appropriate referrals, and performs consultations Implements evidence-based clinical guidelines, care paths, policies and procedures, and tailors them to specific populations Coordinates services to optimize transitions of care Intervenes to prevent and/or minimize iatrogenesis and ensure patient safety Implements strategies, and uses online guidelines to identify and/or manage age-related syndromes Facilitates learning among patients, staff, other disciplines, and organizational leaders Implements technology and treatments in an appropriate and ethical manner 14

22 Leads system change to promote health outcomes, system efficiency, and a healthy work environment through evidence-based practice standard 6 Evaluation The acute care CNS evaluates and communicates progress toward attainment of expected outcomes within the 3 spheres of influence: the patient/family, nursing/nursing practice, and organizations/systems. Performance Expectations: Revises diagnoses, expected outcomes, and interventions based on information gained in the evaluation process Bases the evaluation process on advanced knowledge, evidence, expertise, quality indicators, benchmarking, and research Evaluates evidence-based algorithms, clinical guidelines, protocols, and care paths for appropriateness to patient population Evaluates all 3 spheres to ensure care is patient centered, safe, timely, effective, efficient, and equitable Evaluates the clinical practice of health care team members (eg, nursing staff, medical staff, other health care providers) Evaluates impact of CNS interventions and nursing practice changes on systems of care using nurse-sensitive outcomes Evaluates effect of CNS practice on health care outcomes within the 3 spheres Evaluates impact of legislative and regulatory polices as they apply to nursing practice and patient or population outcomes references 1 American Nurses Association. Nursing Scope and Standards of Practice. Washington, DC; Bell L. ed. AACN Scope and Standards for Acute and Critical Care Nursing Practice. Aliso Viejo, CA: American Association of Critical-Care Nurses;

23 Standards of Professional Performance Introduction The Standards of Professional Performance are not intended to stand alone but must be used with the other sections of this full document: The Scope of Practice and Standards of Clinical Practice. Standards of Professional Performance describe a competent level of behavior in the professional role, including quality of professional practice, individual practice evaluation, professional development, collegiality, ethics, collaboration, research/clinical inquiry, resource utilization, leadership, and systems thinking. Some activities included are not unique to the acute care CNS; rather, they cross all roles of the APRN and describe the responsibilities of advanced nursing practice. CNSs should be self-directed and purposeful in seeking the necessary knowledge and skills to enhance their career goals. Membership in professional organizations, certification, continuing education, and advanced degrees are desirable methods of enhancing professionalism. 16

24 standard 1 Professional Practice The acute care CNS develops criteria for and evaluates the quality, safety, and effectiveness of practice within the 3 spheres of influence: the patient/family, nursing/nursing practice, and organizations/systems. Performance Expectations: Leads clinical inquiry through quality improvement activities Obtains and maintains professional certification Identifies and develops strategies to enhance quality care and promote healthy work environments Synthesizes data, and formulates evidence-based recommendations to improve quality care, practice, and health care outcomes within the 3 spheres Uses appropriate coding and billing to reflect the level and type of service delivery in practice Disseminates benefits of the CNS to the organization, system, and community through presentations, publications, and/or involvement in professional organizations standard 2 Individual Practice Evaluation The acute care CNS is accountable for maintaining competence in clinical practice across all 3 spheres of influence: the patient/family, nursing/nursing practice, and organizations/systems. Performance Expectations: Engages in self-reflection, performance appraisal, and peer review to ensure competent professional practice Complies with the credentialing and privileging process within the organization or system Evaluates role performance according to professional practice standards, institutional guidelines, and relevant statutes and regulations standard 3 Professional Development The acute care CNS is a lifelong learner who acquires and maintains current knowledge and competency in advanced nursing practice. Performance Expectations: Is accountable for self-engagement in educational activities related to professional practice and patient population across the 3 spheres of influence 17

25 Uses information gained in educational activities to improve professional performance Maintains competence in information and patient care technologies appropriate to role and patient population standard 4 Collegiality The acute care CNS promotes a healthy work environment for the development of peers, colleagues, and other professionals. Performance Expectations: Contributes to the advancement of the profession as a whole by disseminating outcomes of practice through presentations and publications Promotes career development for students, nurses, and other health care providers Promotes the role and scope of practice of the CNS (eg, to legislators, regulators, other health care providers, and the public) Facilitates development of clinical judgment in health care team members through role modeling, teaching, coaching, and/or mentoring standard 5 Ethics The acute care CNS makes decisions and implements actions to ensure the delivery of safe, competent, and ethical care that is age appropriate and congruent with patient and family needs and values. Performance Expectations: Fosters the establishment and maintenance of an ethical environment Facilitates resolution of ethical conflicts and moral distress using ethical principles to promote a healthy work environment Implements interventions that consider the impact of scientific advances, cost, clinical effectiveness, patient values and preference, diversity, and other external influences on health care Serves as a mentor and role model to others in developing moral agency by fostering professional accountability in self and others Facilitates ethical, noncoercive decision making for patients to maintain activities of daily living, receive treatment, initiate advance directives, and implement end-of-life care 18

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