AACN SCOPE AND STANDARDS FOR ACUTE CARE CLINICAL NURSE SPECIALIST PRACTICE

Transcription

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

26 standard 6 Collaboration The acute care CNS effectively partners with interprofessional colleagues in the care of patients and patient populations to improve patient outcomes. Performance Expectations: Facilitates the provision of clinically competent care through education, role modeling, team building, and quality monitoring Fosters an interprofessional approach to safety, quality improvement, evidence-based practice, research, and translation of research into practice Uses communication practices that minimize risks associated with handoffs among providers and across transitions of care Implements outcome-focused patient care programs Mentors health care team members to understand and use the expertise of others Establishes collaborative relationships within and across disciplines that promote patient safety, culturally competent care, and clinical excellence Leads and participates in activities such as interprofessional rounds and community healthrelated activities standard 7 Research/Clinical Inquiry The acute care CNS identifies research priority in practice, participates in research, translates scientific evidence, and promotes evidence-based practice. Performance Expectations: Identifies clinical opportunities amenable to research Conducts research to advance the science of nursing practice Participates with other health care professionals in conducting and implementing research/clinical inquiry Analyzes research findings and other evidence for application to clinical practice Synthesizes and translates research findings to determine the need for changes in practice Evaluates patient care practices based on research and experiential knowledge, and integrates changes into practice to improve safety, efficiency, reliability, and quality Role models and mentors staff regarding the dissemination, implementation, and evaluation of research findings Communicates research results, and develops a process to incorporate research findings into practice 19

27 Evaluates and facilitates incorporation of new products, techniques, and technologies into practice standard 8 Resource Utilization The acute care CNS influences resource utilization in order to promote safe, quality, and cost-effective patient care. Performance Expectations: Leads clinical inquiry through quality improvement activities Considers fiscal and budgetary implications in decision making regarding practice and system modifications Assists staff in the development of innovative, cost-effective programs or protocols of care Conducts cost/benefit and cost avoidance analysis of programs, processes, and technologies Evaluates impact of introduction or withdrawal of products, services, and technologies Facilitates access for patients to appropriate health care services Facilitates safe and effective transitions across levels of care, including acute, community-based, and long-term Utilizes resources/programs to promote functional, physical, and mental wellness for patient population Interprets and facilitates integration of organizational mission, goals, and systems into patient care practices Role models and mentors innovative systems thinking and resource use among the health care team Develops strategies to facilitate transition of patients through the health care system Assesses, facilitates, and advocates the impact of social, political, regulatory, and economic forces on delivery of care standard 9 Leadership The acute care CNS manages change and leads others to influence practice and political processes within and across systems. Performance Expectations: Leads micro- and macrosystem-level change Masters and employs skilled communication Uses leadership, team building, negotiation, and conflict resolution skills to promote a healthy work environment 20

28 Develops a culture where hostile work environments are not tolerated Provides leadership in implementation of innovation Facilitates the creation of a common vision for care within the health care team and system Role models professional leadership and accountability for nursing s role within the health care team and community Participates in professional organizations to address issues of concern in meeting patients needs and improving nursing practice and system effectiveness Advocates for legislation and policies that promote health and improve care delivery standard 10 Systems Thinking The acute care CNS develops and participates in organizational systems and processes to promote optimal outcomes. Performance Expectations: Applies knowledge of organizational theories and systems to provide safe, patient-centered, high-quality, cost-effective care Performs system-level assessments to identify variables that influence nursing practice and outcomes Determines nursing practice and system interventions that promote patient, family, and community safety Designs and develops care paths and initiatives across the continuum of acute care services Anticipates unintended consequences of the introduction of new technology Participates in the design of clinical decision support systems Advocates for equity in health and health care for patient populations of diverse cultural, ethnic, and spiritual backgrounds across the life span Evaluates the ongoing integration of evidence and practice standards into systems of health care delivery Identifies, participates in, and assists with the development of institutional and organizational system responses to natural and man-made disasters Integrates knowledge of governmental and regulatory opportunities and constraints to impact patient transitions across the continuum of care 21

29 22 aprns and health care Current Issues and Trends Advanced practice registered nurses have successfully adapted their roles to meet the ever-changing needs of society. APRN roles have advanced and expanded due to health care reform, the Affordable Care Act, the national emphasis on providing safe and quality care, and pay-for-performance initiatives. The Institute of Medicine s report titled A Summary of the October 2009 Forum on the Future of Nursing: Acute Care 1 called for all nurses, including APRNs, to be allowed to work to the fullest extent of their scopes of practice without restrictions or barriers. Among those barriers to practice are the issues of title protection, prescriptive authority, recognition of the role impact, and certification requirements. The emergence and acceptability of advanced practice roles is a result of several factors: the growing number of older adult patients as baby boomers reach retirement age, the increased complexity and severity of illness in patients who are hospitalized, a further reduction in medical residents clinical work hours, the call for greater access to health care for all citizens, and a varying degree of nursing shortages across the nation. Regulation of APRNs occurs at the state level, but both educational and certification prerequisites exist. Educators and members of professional organizations who identify essential curricular goals, content, and competencies expected of APRN graduates guide the graduate-level educational preparation of APRNs. In 2004, the American Association of Colleges of Nursing urged doctoral-level preparation for APRNs. 2 Although many schools of nursing moved their APRN education to the doctoral level, with most offering a DNP degree, only one APRN group, nurse anesthetists, mandated doctoral education for entry into practice, beginning in Requirements for consistent educational preparation across all APRN roles have provided greater uniformity. The content for all APRNs must include graduate-level courses in advanced pathophysiology, advanced physical assessment, and advanced pharmacology, referred to as the APRN core. 4 In addition, content related to the population served, role development, and clinical experiences in the specific role are required. Upon completion of an accredited educational program, graduates must be able to sit for one of the national certification exams in the area of intended practice before applying for state licensure. consensus model for aprn regulation Many issues have been identified with the current regulatory process, particularly the ability of APRNs to move across states and remain eligible to be licensed and to practice. In response to this barrier to practice, the need to develop more consistent standards for APRN recognition across states was undertaken by the APRN Consensus Work Group and the NCSBN, resulting in the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. 4 The Consensus Model laid the foundation for nurses, regulatory bodies, legislators, and graduate programs to better understand and formally recognize the 4 APRN roles. The Consensus Model will also make possible the implementation of an interstate compact for APRNs similar to the Nurse Licensure Compact, which allows nurses to practice in their home state as well as other participating states with 1 license. The Consensus Model recommendations, endorsed by numerous nursing organizations and stakeholder groups, acknowledge 4 APRN roles (1) CNS, (2) NP, (3) nurse anesthetist, and (4) nurse midwife. The model recognizes that APRN practice must be regulated in one of these 4 roles and in at least 1 of 6 population foci: (1) family/patient across the life span (2) adult-gerontology, (3) pediatrics, (4) neonatal, (5) women s health/gender-related, or (6) psychiatric/mental health. The recommendations of the Consensus Model influence the licensure, accreditation, certification, and educational preparation of all future APRNs.

30 cns recognition as aprn The CNS is expected to have education and specialty certification requirements equivalent to his or her APRN colleagues. In some states, the title can be held by those who do not have CNS education and certification. This practice must change for the role to be recognized as an equal partner in patient care delivery. Recognition in all states of CNSs as APRNs with the authority and privileges of advanced practice, including prescriptive authority, will ensure their place beside the other recognized APRN roles. Privileges to prescribe medications and therapies are a natural extension of clinical CNS practice. Prescriptive authority, recognized as an attribute of the NP role that aligns the CNS with medical practice, is wholly within the scope of CNS education and experience. The integration of advanced assessment, pharmacology, and pathophysiology in the graduate curriculum makes the use of prescriptive authority a value-added skill for the CNS. The ability to expedite the delivery of care by prescribing medication, therapies, and durable medical equipment has an advantage in the provision of care. This privilege confers added value when the patient transitions from the ICU to progressive care and then to extended care, or the patient s home. The ability to offer a comprehensive plan for diagnostic, nutrition, home health, or supportive therapies enhances the patient s experience and cost-effectiveness. All of these competencies are consistent with the education, licensure, and certification of the CNS and support the Institute of Medicine s recommendation for practice at the fullest extent of licensure. 1 The CNS develops a close working relationship with bedside providers, assisting them with critical thinking, problem analysis, and active intervention. As these relationships develop, additional attributes, such as interprofessional collaboration and communication, can be role modeled to achieve quality, safe patient outcomes. Interaction at the bedside allows inclusion of the patient and family as part of patient-centered care. This method of addressing quality and patient safety has the added benefit of increasing patient and family satisfaction. The ability to provide care coordination across the transitions of care, especially to identify the population issues driving readmission, is valuable in the current and future health care system. Implementation of evidence-based practices and education of staff in evaluation of research and literature supports every facility s goal of cost containment and the best care for patients. the cns and certification Currently, certification is not required for CNS recognition and practice in all states. However, implementation of the Consensus Model calls for certification consistent with education in both the role and the population to be the universal standard. In the interim, confusion exists between educational programs, learner s expectations, and the requirements of certifying bodies. CNSs may not have had the required number of clinical hours or been educated in the core subjects of advanced physiology/pathophysiology, pharmacology, and advanced health assessment to meet upcoming certification requirements. Looking ahead to the time when CNSs must be certified in order to practice in the role, it is important for currently practicing CNSs to pursue all avenues to ensure they can meet the criteria to become certified. references 1 Institute of Medicine. A Summary of the October 2009 Forum on the Future of Nursing: Acute Care. Washington, DC: National Academies Press; American Association of Colleges of Nursing. AACN Position Statement on the Practice Doctorate in Nursing; Accessed March 4, American Association of Nurse Anesthetists. Nurse Anesthesia Education. Park Ridge, IL: American Association of Nurse Anesthetists; APRN Consensus Work Group, National Council of State Boards of Nursing APRN Advisory Committee. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. Washington, DC: American Nurses Association; PublicPolicy/APRNRegulation.pdf. Accessed March 4,

31 Glossary AACN Synergy Model for Patient Care Conceptual model of certified acute and critical care nursing practice that specifies that the needs and/or characteristics of patients and families drive the characteristics or competencies of the nurse from novice through advanced practice. Acute and critical care nursing Nursing specialty that specifically deals with human responses to actual and potential life-threatening problems. Acute critical illness Condition of a patient who is at high risk for actual life-threatening health problems. The more critically ill the patient, the more likely he or she is to be highly vulnerable, unstable, and complex. Assessment Systematic, dynamic process by which the CNS through interaction with the patient/family, nursing personnel, and interdisciplinary team, collects and analyzes data. Data may include physical, psychological, social, environmental, regulatory requirements, external demands, cultural, cognitive, functional, organizational, developmental, and economic factors. Caregiver Family, custodian, or legal guardian. Chronic critical illness Condition of an adult patient who survives the life-threatening phase of critical illness but continues to require extensive critical care support services. 1 (A separate definition for pediatrics was not found.) Competency Integration of the knowledge, attitudes, and skills necessary to function in a specific role and work setting. 2 Consensus Model for APRN Regulation Model developed to align the licensure, education, accreditation, and certification requirements for the 4 APRN roles: certified nurse anesthetist, certified NP, CNS, and certified nurse midwife. Continuity of care Interprofessional process that includes patients and families or significant others in the development of a coordinated plan and facilitates the patient s transition between settings, based on patient s changing needs and the available resources. Continuum of care Conceptual model that describes a person s movement from wellness through the desired quality of life to a dignified death. A person s place on the continuum is determined individually. Credentialing Systematic process of screening and evaluating qualifications and other credentials, including licensure, required education, relevant training and experience, and current competence and health status. Diagnosis Clinical judgment about the patient s response to actual and potential health conditions or needs; may be medical or nursing diagnosis; provides the basis for determining an interprofessional plan of care to achieve expected outcomes. Evaluation Process of determining the patient s progress toward the attainment of expected outcomes. Evidence-based practice Paradigm and lifelong problem-solving approach to clinical decision making that involves the conscientious use of the best available evidence (including a systematic search for and critical appraisal of the most relevant evidence to answer a clinical question) with one s own clinical expertise, and patient values and preferences to improve outcomes for individuals, groups, communities, and systems. 3 24

32 Family Family of origin or significant others, and/or surrogate decision makers as identified by the patient. Guidelines Broad practice recommendations based on scientific theory, research, and/or expert opinion. Healing environment Organizational philosophy and commitment to structuring resources to support and focus on integrating science and spirituality; provides conditions that stimulate and support the inherent healing capacities of patients and families. 4 Healthy work environment Work setting that supports the standards of skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership. Implementation Process of carrying out the interdisciplinary plan of care, which may include implementing, delegating, and/or coordinating interventions; the patient and/or family or health care providers may be designated to implement interventions within the plan. Judgment Formation of a conclusion that encompasses critical thinking, problem solving, ethical reasoning, and decision making. Knowledge Encompasses thinking, an understanding of science and humanities, professional standards of practice, and insights gained from practical experiences, personal capabilities, and leadership performance. Licensed independent practitioner (LIP) An individual permitted by law and by the organization to provide care, treatment, and services without direction or supervision. An LIP operates within the scope of his or her license, consistent with individually granted privileges. 5 Nurse Person who is licensed by a state agency to practice as a registered nurse. Nurse characteristics Reflection of the integration of knowledge, skills, experience, and attitudes to meet the needs of patients and families as defined by the AACN Synergy Model for Patient Care. The continuum of nurse characteristics is derived from patient needs. These characteristics include clinical judgment, advocacy and moral agency, caring practices, collaboration, systems thinking, facilitation of learning, response to diversity, and clinical inquiry. Nursing Health care profession that protects, promotes, and optimizes patient health and abilities, prevents illness and injury, alleviates suffering through the diagnosis and treatment of human response, and provides advocacy in the care of patients, families, communities, and populations. 6 Nursing process Dynamic, systematic method of caring for patients from a nursing perspective. The steps include assessment, diagnosis, planning, implementation, and evaluation and are circular rather than linear. The circular nature of the process assumes that nurses include the patient, the family, and the health care team in the formulation of the plan. Outcomes Measurable and expected goals that describe anticipated or expected results based on CNS interventions. Patient Individual, family and/or caregiver, or group or community who are recipients of nursing care. Patient characteristics As defined by the AACN Synergy Model for Patient Care, patient characteristics span the continuum of health and illness and include resilience, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability. Peer review The process by which professionals with similar knowledge, skills, and abilities judge the processes and/or outcomes of care. 25

33 Plan of care Interprofessional outline of care based on expected outcomes for the particular patient. The patient, family, and health care providers participate in carrying out the plan for the implementation or delivery of care. Population foci The 6 categories of patient populations as defined by the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education: (1) family/individual across the life span, (2) adult/gerontology, (3) neonatal, (4) pediatric, (5) women s health/gender-related, (6) psychiatric/mental health. 7 Privileging Process by which a practitioner who is licensed for independent practice is permitted by law and the facility to practice independently and to provide specific medical or other patient care services within the scope of the license. Peer references, professional experience, health status, education, training, and licensure contribute to this determination of the clinical competence of the practitioner. Clinical privileges must be specific to both the facility and the provider. Quality of care Cooperative and collaborative process that combines the goals of professional standards of care within the defined expectations of the patient and family. Reflective learning Recurrent thoughtful and personal self-assessment, analysis, and synthesis of strengths and opportunities for improvement. Skill Ability that includes psychomotor, communication, interpersonal, and diagnostic components. Sphere of influence Domain of CNS practice that encompasses the pertinent stakeholders or consumers of CNS services. Spheres of influence for the CNS are patient/family, nursing/nursing practice and organization/systems. 8 Standard Authoritative statement articulated and supported by the profession that describes a level of care or performance by which the quality of practice, service, or education can be measured or judged. Standards of practice Authoritative statements that describe a level of care or performance common to the profession of nursing and by which the quality of practice can be judged. These standards describe a competent level of clinical practice demonstrated through assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Standards of professional performance Authoritative statements that describe a competent level of behavior in the professional role, including activities related to professional practice, education, collaboration, ethics, systems thinking, resource utilization, leadership, collegiality, quality of practice, and clinical inquiry. references 1 Daly BJ, Rudy EB, Thompson KS, Happ MB. Development of a special care unit for chronically critically ill patients. Heart Lung; (1): Alspach, JG. Designing Competency Assessment Programs: A Handbook for Nursing and Health-Related Professions. Pensacola, FL: National Nursing Staff Development Organization; Melnyk BM, Fineout-Overholt E. Evidence-based Practice in Nursing & Healthcare: A Guide to Best Practice. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; Molter NC. Environmental design and strategies to promote healing. In Creating Healing Environments. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; The Joint Commission Hospital Accreditation Standards. Oakbrook Terrace, IL: The Joint Commission; American Nurses Association. Nursing s Social Policy Statement: The Essence of the Profession. Silver Spring, MD: Nursesbooks.org; 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, NACNS Research and Practice Committee. Statement on Clinical Nurse Specialist Practice and Education, 2nd ed. Harrisburg, PA: National Association of Clinical Nurse Specialists;

34 Appendix A CONSENSUS MODEL FOR APRN REGULATION APRN Specialties Focus of Practice beyond role and population focus Linked to healthcare needs. Examples include but are not limited to: oncology, older adults, orthopedics, nephrology, palliative care Licensure Occurs at Levels of Role & Population Foci Family/Individual Adult- Women s Health/ Across Lifespan Gerontology Gender Related Neonatal Pediatrics Nurse Anesthetist Nurse Midwife POPULATION FOCI APRN ROLES Clinical Nurse Specialist ++ Nurse Practitioner + Psych/Mental Health +The certified nurse practitioner (CNP) is prepared with the acute care CNP competencies and/or the primary care CNP competencies. At this point in time the acute care and primary care CNP delineation applies only to the pediatric and adult-gerontology CNP population foci. Scope of practice of the primary care or acute care CNP is not setting specific but is based on patient care needs. Program may prepare individuals across both the primary care and acute care CNP competencies. If programs prepare graduates across both sets of roles, the graduate must be prepared with the consensus-based competencies for both roles and must successfully obtain certification in both the acute and the primary care CNP roles. CNP certification in the acute care or primary care roles must match the educational preparation for CNPs in these roles. ++The clinical nurse specialist (CNS) is educated and assessed through national certification processes across the continuum from wellness through acute care AACN CERTIFICATION CORPORATION 27

35 Appendix B Role Comparison: Acute Care NP and the Acute and Critical Care CNS In 2002, as part of Comprehensive Study of Acute and Critical Care Practice From Entry Level through Advanced Practice Roles, the knowledge, skills, and abilities required of the ACNP and the CCNS were studied using the same instrument. We learned that the basic competencies of the 2 roles were the same, but the actualization of the major components of the roles differed in the percentage of time devoted to each domain. The in-depth analysis of patient care problems encountered by each type of practitioner revealed that they were caring for the same patient population. The following tables taken from that study provide validation of the similar but different practice of these 2 APRN roles. Although the spheres of influence is intrinsic to the CNS role, we also asked ACNPs to indicate the percentage of their practice that was devoted to each of the traditional spheres of influence. However, we divided the patient sphere into 2 categories to allow us to determine the extent of population-based practice for each role. This table provides a clear difference in the focus of the CNS versus the NP role. In 2002, CNS respondents indicated that they spent the majority of their time with critically ill patients, and ACNPs primarily cared for acutely ill patients. However, the standard deviations are quite high for these rankings. 28

36 In the 2011 NP and CNS job analysis studies, each group was surveyed on separate instruments, which reflected national core and population competencies for the role. However, we were still able to make comparisons between the 2 roles in some major categories. By 2011, the acuity percentages had changed significantly with the percentage of patients who are critically ill beginning to even out between the 2 roles with a reduction in the percentage of critically ill patients for the CNS and an increase in critically ill patients for ACNPs. However, the detailed analysis of patient problems between the 2 groups continues to show that they are taking care of the same patient population. PERCENTAGE OF PATIENTS CARED FOR BY ACUITY 1 38 NURSE PRACTITIONER CLINICAL NURSE SPECIALIST Acute Acute Ambulatory Critical 1 Ambulatory Critical Long Term Long Term 7 Progressive Progressive Other Other In evaluating the time spent in each of the synergy domains by role, we can see a clear distinction between the 2 roles. The primary focus of the ACNP is on providing direct care to patients. ACNPs spend twice as much time within the Clinical Judgment domain as do CNSs; CNSs spend twice as much time within the combined domains of Clinical Inquiry/Facilitator of Learning as ACNPs. 29

37 In the 2011 job analysis study, we can see the impact that the Association of American Medical Colleges ruling on reduction in practice hours for house staff has had on the amount of time that ACNPs are spending in direct patient care (Clinical Judgment), while the percentage for the CNS has remained fairly steady. The CNS teaching time has increased in both consultation (Collaboration) and teaching (Facilitation of Learning). Time spent in research (Clinical Inquiry) has dropped for both groups Administration Consultation Direct Patient Care Research Teaching Nurse Practitioner Clinical Nurse Specialist 30

38 Appendix C Additional Foundational Resources Adult-Gerontology Clinical Nurse Specialist Competencies [PDF download] This 2010 publication delineates entry-level competencies for all graduates of master s, DNP, and post-graduate programs preparing adult-gerontology CNSs for certification and licensure. The competencies are intended to be used in conjunction with and build upon the graduate and APRN core competencies outlined in the American Association of Colleges of Nursing s (2006) The Essentials of Doctoral Education for Advanced Practice Nursing or (1996) The Essentials of Master s Education for Advanced Practice Nursing. In addition, these competencies build upon the Clinical Nurse Specialist Core Competencies (2008) for all CNSs. These competencies focus on the unique practice knowledge, skills, and attitudes of the adult-gerontology CNS. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education Clinical Nurse Specialist Core Competencies Criteria for the Evaluation of Clinical Nurse Specialist Master s, Practice Doctorate, and Post-Graduate Certificate Educational Programs Hartford Institute for Geriatric Nursing Core Competencies Guidance in evaluating competency in the care of older adult patients is critical to raising the bar for geriatrics. The Hartford Institute for Geriatric Nursing has developed a core set of hospital nursing competencies expected of nurses who care for older adults. Medicare Information on Billing for Advanced Practice Nurses MLN/MLNProducts/Downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN pdf 31

39 Appendix D AACN STANDARDS FOR ESTABLISHING AND SUSTAINING HEALTHY WORK ENVIRONMENTS A Journey to Excellence EXECUTIVE SUMMARY In 2001, the American Association of Critical-Care Nurses (AACN) made a commitment to actively promote the creation of healthy work environments that support and foster excellence in patient care wherever acute and critical care nurses practice. This commitment is based on the Association s dedication to optimal patient care and the recognition that the deepening nurse shortage cannot be reversed without healthy work environments that support excellence in nursing practice. There is mounting evidence that unhealthy work environments contribute to medical errors, ineffective delivery of care, and conflict and stress among health professionals. Negative, demoralizing and unsafe conditions in workplaces cannot be allowed to continue. The creation of healthy work environments is imperative to ensure patient safety, enhance staff recruitment and retention, and maintain an organization s financial viability. AACN is strategically committed to bringing its influence and resources to bear on creating work and care environments that are safe, healing, humane and respectful of the rights, responsibilities, needs and contributions of all people including patients, their families and nurses. Six standards for establishing and sustaining healthy work environments have been identified. Putting forth these six essential standards for establishing and sustaining healthy work environments is an important step in meeting our commitment. The standards uniquely identify systemic behaviors that are often discounted, despite growing evidence that they contribute to creating unsafe conditions and obstruct the ability of individuals and organizations to achieve excellence. The American Association of Critical-Care Nurses recognizes the inextricable links among quality of the work environment, excellent nursing practice and patient care outcomes. The standards represent evidence-based and relationship-centered principles of professional performance. Each standard is considered essential since studies show that effective and sustainable outcomes do not emerge when any standard is considered optional. This publication is available for download at the American Association of Critical-Care Nurses Web Site < Copyright 2005, American Association of Critical-Care Nurses. All rights reserved. 32

40 The standards align directly with the core competencies for health professionals recommended by the Institute of Medicine. They support the education of all health professionals to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics. With these standards, AACN contributes to the implementation of elements in a healthy work environment articulated in 2004 by the 70-member Nursing Organizations Alliance. The standards further support the education of nurse leaders to acquire the core competencies of self-knowledge, strategic vision, risk-taking and creativity, interpersonal and communication effectiveness, and inspiration identified by the Robert Wood Johnson Executive Nurse Fellows Program. The standards are neither detailed nor exhaustive. They do not address dimensions such as physical safety, clinical practice, clinical and academic education and credentialing, all of which are amply addressed by a multitude of statutory, regulatory and professional agencies and organizations. essential standard critical elements The standards are designed to be used as a foundation for thoughtful reflection and engaged dialogue about the current realities of each work environment. Critical elements required for successful implementation accompany each standard. Working collaboratively, individuals and groups within an organization should determine the priority and depth of application required to implement each standard. The standards for establishing and sustaining healthy work environments are: Absolutely required; not to be used up or sacrificed. Indispensable. Fundamental. Authoritative statement articulated and promulgated by the profession, by which the quality of practice, service or education can be judged. Structures, processes, programs and behaviors required for a standard to be achieved. Skilled Communication Nurses must be as proficient in communication skills as they are in clinical skills. True Collaboration Nurses must be relentless in pursuing and fostering true collaboration. Effective Decision Making Nurses must be valued and committed partners in making policy, directing and evaluating clinical care and leading organizational operations. Appropriate Staffing Staffing must ensure the effective match between patient needs and nurse competencies. Meaningful Recognition Nurses must be recognized and must recognize others for the value each brings to the work of the organization. Authentic Leadership Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage others in its achievement. 33

41 Call to Action Healthy work environments are essential to ensure patient safety, enhance staff recruitment and retention, and maintain an organization s financial viability. Inattention to relationship issues poses a serious obstacle to creating and sustaining those environments. Without them, the journey to excellence is impossible. The six standards put forward in this document offer the framework for healthcare organizations to elevate these competencies to the highest strategic and operational importance. The ensuing dialogue will guide the fundamental reprioritization and reallocation of resources necessary to create and sustain healthy work environments. For the American Association of Critical-Care Nurses, developing these standards is the first of two steps. The second step, already in progress, is to lead the way in developing practical and relevant resources to support individuals and organizations in standards implementation. AACN calls upon individual nurses, all health professionals, healthcare organizations and professional nursing associations to fulfill their obligation of creating healthy work environments where safety becomes the norm and excellence the goal. This call to action requires a fundamental shift in the work environments of this country and challenges: Nurses and all health professionals to: Embrace the personal obligation to participate in creating healthy work environments. Develop relationships in which individuals hold themselves and others accountable to professional behavioral standards. Follow through until effective solutions have been realized. Healthcare organizations to: Adopt and implement these standards as essential and nonnegotiable for all. Establish the organizational systems and structures required for successful education, implementation and evaluation of the standards. Demonstrate behaviors by example at every level of the organization. AACN and the community of nursing to: Bring to national attention the urgency and importance of healthy work environments. Promote these standards as essential to establishing and sustaining healthy work environments. Develop resources to support individuals, organizations and health systems in successfully adopting the standards, and recognizing and publicizing their successes. 101 Columbia Aliso Viejo, California AACN 34

42 This publication is available for download at the American Association of Critical-Care Nurses Web site: Copyright 2014, American Association of Critical-Care Nurses. All rights reserved.

43 Printed 05/ Columbia Aliso Viejo, California AACN