Moving Forward with Role Recognition for Clinical Nurse Specialists

The State of Advanced Practice Registered Nursing in Alabama

Independent practice and full practice authority

The Landscape of Advanced Practice Nursing

Rapid changes in the health care marketplace are driving health care systems to modify operations by which the advanced practice registered nurse (APRN) and physician assistant (PA) clinicians serve patients. By identifying more effective and efficient utilization workflows, organizations can meet these demands resulting in high-functioning clinical teams. With the growing number of APRNs and PAs within a large academic medical center, there was a recognized need to establish effective and efficient utilization practices for these health care providers. Directors of the Advanced Practice Provider Best Practice Center developed an internal nurse practitioner (NP)/certified nurse midwife (CNM)/clinical nurse specialist (CNS)/PA assessment service in which evaluations were conducted to optimize APRN and PA practice at the clinical/department level. This assessment excluded certified registered nurse anesthetists. Thirty-two clinical areas were evaluated between September 2016 and May 2019. This included an NP/CNM/CNS/PA survey and over 200 individual NP/CNM/CNS and PA provider interviews. Assessments addressed utilization, billing practices, professional development, and communication among team members. Qualitative and quantitative reports were compiled. Many common themes were identified. These were broken down into three major categories: productivity, clinical operations, and professional development/support. Several recommendations were presented to department leaders regarding NP/CNM/CNS/PA practice. Those departments who implemented several of the recommendations showed positive outcomes. This was evidenced by increased financial gain (increased relative value units, increase in revenue generated), increased patient access (increased clinic densities), and overall NP/CNM/CNS/PA satisfaction.

Advanced practice registered nurses (APRNs) provide care that includes tasks traditionally done by physicians. APRNs combine the holistic nursing care model with additional practitioner training. Research shows that APRN care is at least as effective as physician care, contrary to the claims of some physicians and their organizations. Hollywood depictions tend to suggest that APRNs are merely skilled assistants to physicians. Other portrayals show disdain; consider a joking suggestion on Disney’s Lab Rats in 2013 that one character was a nurse practitioner because he had flunked out of medical school. Other shows have suggested that ambitious nurses aim for medical school. Some news stories have given a sense of APRN practice, but APRNs are usually ignored as health experts. Other press accounts have wrongly suggested that APRNs can treat only minor problems. The news and advertising media often reinforce the idea that practitioner care is provided only by “doctors.”

An Update on the Consensus Model for APRN Regulation: More Than a Decade of Progress

The practice environment of healthcare in the United States is fluid, dynamic, and sometimes chaotic. Statutory, regulatory, and credentialing requirements are critical elements of this changeable environment affecting clinical nurse specialists (CNSs) and other advanced practice nurses (APNs). CNSs are estimated to comprise approximately 54,000 APNs, based on the 2000 National Sample Survey of Registered Nurses. Although statutes and regulations related to APNs are reviewed regularly, there has not been a critical analysis of statutes and regulations specifically governing CNS practice in the United States. This lack is largely due to the absence of a national association devoted to CNSs before 1995. However, recently there has been a resurgence of interest and need for CNS services. Therefore, it is particularly important that any statutory and/or regulatory barriers to CNS practice be removed. In 1998, the National Association of Clinical Nurse Specialists Legislative and Regulatory Committee embarked on a critical analysis of state statutes and regulations governing CNS practice. All 50 state boards of nursing and the District of Columbia board of nursing were requested to send copies of their statutes and regulations governing CNS practice. Responses were received from 48 states. This article summarizes the state of regulation of CNS practice and identifies significant barriers to CNS practice that should be systematically addressed. The patchwork quilt of CNS regulation that varies from state to state results in over-restrictive and underinclusive provisions that preclude ease of reciprocity and deprive the public full access to CNS services. Recommendations for addressing the barriers are made.

With the evolution of the clinical nurse specialist (CNS) and nurse practitioner (NP) roles and with the changes in the healthcare delivery system, recent debate in advanced practice nursing has centered on blending or merging the roles to meet future healthcare needs. To determine the views of CNSs, the University of Texas at Houston Health Science Center School of Nursing conducted a survey of 80 nurses (all active graduate program preceptors) functioning in the CNS role in the Houston area. Respondents were asked whether they felt the role should be deleted or merged, their ideas for the future of the role, and how education could better prepare the CNS student. Forty-two questionnaires were returned (53% return). Twenty-nine (71%) respondents did not want the role deleted, seven (17%) favored deletion of the CNS role, five (12%) favored blending the CNS and NP roles, and one (0.02%) suggested the title of acute care nurse practitioner. Although the survey's results did not show overwhelming support for either deletion or merging of the CNS role, valuable information was gathered from the responses. The CNS community identified recommendations that will help shape our focus for practice and guide us in educational design in curriculum revision.

Background: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm records advance care planning for patients with advanced illness or frailty as actionable medical records. The National POLST Paradigm Task Force recommends that physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs) be permitted to execute POLST forms.Objective: To investigate the percentage of Oregon POLST forms signed by APRNs, and examine the obstacles faced by states attempting to allow APRNs to sign POLST forms.Design: Cross-sectional.Setting/subjects: 226,101 Oregon POLST Registry forms from 2010 to 2015.Measurements: POLST forms in the Oregon Registry were matched with signer type (MD, DO, APRN, PA).Results: 226,101 POLST forms have been added to the Oregon POLST Registry from 2010 to 2015: 85.3% of forms were signed by a physician, 10.9% of forms were signed by an APRN, and 3.8% of forms were signed by a PA. From 2010 to 2015, the overall percentage of POLST forms signed by an APRN has increased from 9.0% in 2010 to 11.9% in 2015. Physicians are authorized signers in all 19 states with endorsed POLST Paradigm programs; 16 of these states also authorize APRN signature, and 3 states (LA, NY, and GA) allow only physicians to sign.Conclusions: More than 10% of Oregon POLST forms are signed by APRNs. Given the need for timely POLST form completion, ideally by a member of the interdisciplinary team who knows the patient's preferences best, these data support authorizing APRNs to complete POLST forms.

The objective of this decision support synthesis was to identify and review published and grey literature and to conduct stakeholder interviews to (1) describe the distinguishing characteristics of clinical nurse specialist (CNS) and nurse practitioner (NP) role definitions and competencies relevant to Canadian contexts, (2) identify the key barriers and facilitators for the effective development and utilization of CNS and NP roles and (3) inform the development of evidence-based recommendations for the individual, organizational and system supports required to better integrate CNS and NP roles into the Canadian healthcare system and advance the delivery of nursing and patient care services in Canada. Four types of advanced practice nurses (APNs) were the focus: CNSs, primary healthcare nurse practitioners (PHCNPs), acute care nurse practitioners (ACNPs) and a blended CNS/NP role. We worked with a multidisciplinary, multijurisdictional advisory board that helped identify documents and key informant interviewees, develop interview questions and formulate implications from our findings. We included 468 published and unpublished English- and French-language papers in a scoping review of the literature. We conducted interviews in English and French with 62 Canadian and international key informants (APNs, healthcare administrators, policy makers, nursing regulators, educators, physicians and other team members). We conducted four focus groups with a total of 19 APNs, educators, administrators and policy makers. A multidisciplinary roundtable convened by the Canadian Health Services Research Foundation formulated evidence-informed policy and practice recommendations based on the synthesis findings. This paper forms the foundation for this special issue, which contains 10 papers summarizing different dimensions of our synthesis. Here, we summarize the synthesis methods and the recommendations formulated at the roundtable.

The purpose of this article is to describe the development of a professional practice model (PPM) for advanced practice registered nurses (APRNs). A literature review was conducted on PPMs. Simultaneous review of authoritative resources, including The National Organization of Nurse Practitioner Faculties (NONPF) and the Licensure, Accreditation, Certification and Education (LACE) Consensus Model, was performed. An expert panel was established to validate the transformational advanced professional practice (TAPP) model. APRNs are relied upon by organizations to provide leadership in the delivery of high-quality, cost-effective health care while improving access and eliminating preventable morbidities. Existing models fail to fully capture the professional scope of practice for APRNs. The TAPP model serves as a framework to guide professional development and mentorship of APRNs in seven domains of professional practice (DOPP). To meet the Institute of Medicine's recommendations for the future of nursing, APRNs should practice to the fullest extent of their education and training. Providing clarification regarding the DOPP of the APRN role is needed to standardized professional practice. The TAPP model is an inspiring blueprint that allows APRNs to model the way by delivering comprehensive health care in seven DOPP.

Nursing Programs Could Sharpen LTC Focus

Advanced practice registered nurses (APRN) embedded full-time within nursing homes (NH) improve key resident outcomes such as reducing hospitalizations, increasing advance directive use, and improving resident/family satisfaction. Despite positive evidence, this care model is not widely adopted, and there has been minimal research on how APRN practice impacts outcomes. Informed by Donabedian’s Structure-Process-Outcome framework, we conducted a cross-case analysis to understand how APRNs influenced patient (direct) and facility-level (indirect) outcomes through nursing home structures and processes. We used eight years of data generated from The Missouri Quality Initiative, a CMS-funded demonstration project aimed to reduce avoidable hospitalizations through embedded APRN care in 16 midwestern nursing homes. Cases consisted of two higher-performing homes and two lower-performing NHs. Each case was analyzed using deductive coding of four databases to create a cross-database table. First and second level thematic coding was applied to the cross-database tables to create the high and low performing cases for cross-case comparison. Stark differences arose between the higher and the lower performing cases around themes including proactive/reactive processes, individual vs. group-oriented processes, and administrative supports (present/absent/lip-service). APRNs applied proactive processes at the patient (direct) and facility (indirect) level when NH structure (i.e. adequate administrative support) was present. More successful homes, even with higher turnover, demonstrated proactive mentoring processes, initiated and supported by the APRN, instead of passive, reactive processes and deference to administration. APRNs are effective caregivers if structural supports allow for proactive processes maximizing APRN expertise, supporting the inclusion of APRNs within NH care delivery models.

In the present cost containment environment, hospitals often change their employment patterns. Nurses in advanced practice roles are particularly vulnerable to reassignment. In order to determine if the employment of Clinical Nurse Specialists (CNSs) in the Baltimore-Washington area had decreased and to determine what specialty areas employed the most CNSs, a survey of all area hospitals was conducted. The nursing departments of all 88 hospitals were contacted by phone with 40 of them (45%) agreeing to provide data. Seventeen institutions reported employing a total of 119 CNSs. Of these, only 12 required a Master's degree for nurses to hold that position. As expected, larger institutions employed more CNSs. This role appears to be stable, with only two institutions having eliminated CNS positions recently and five reporting plans to add such positions in the near future. Most CNSs reported either directly or indirectly to the Director of Nursing. Those in positions funded by another source reported to personnel in the funding department or agency. Almost all CNSs had clinical titles, and Psychiatric, Oncology, Medical and/or Surgical, Pediatrics or Critical Care were the most prevalent specialties mentioned. The CNS role is a viable role in the Baltimore-Washington area even in this time of cost containment. Most CNSs are identified with their area of clinical specialization.

Previous research has empirically demonstrated that personal resilience and organizational level interventions are important considerations when studying workplace adversity such as burnout and excessive workloads in the context of a pandemic. To explore interest in participating in a wellness initiative program designed specifically for advanced practice registered nurses (APRNs) and physician associates (PAs), with a voluntary option for participation in research. An anonymous, brief, online survey with Likert-response type items and one free-text question was delivered with passive informed consent via email to all APRNs and PAs (N = 312 participants) within one health care system. A positive correlation between likelihood of seeking well-being care and having sufficient time (0.36, p < .01) was found, which indicates that APRNs or PAs who felt they had sufficient time to get counseling were actually more likely to seek counseling services. Results from the path model show that the comfort-level of seeking counseling completely mediates the relationship between fear of negative perceptions of receiving counseling and the likelihood of participating in a wellness program. Well-being strategies are important for organizations to engage in to support their employees; however, confidentiality concerns and competing priorities for time may influence engagement. Interest among APRNs and PAs for participation in research exists if enough information is provided and anonymity can be assured. Organizations should focus on finding innovative ways to integrate wellness into APRN and PA practice that mitigates the belief around the burden of time commitment and seeks ways to provide psychological safety for its employees.