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APRN LACE dialogue for CNSs
Blog is about the changes and updates related to the implementation of the Advanced Practice Registered Nurse Consensus Model for Regulation and the Licensure, Accreditation, Certification and Education changes that will need to take place over the next few years.
Sunday, July 08, 2012
Definition: Preparation and practice of CNSs from Wellness to Acute care
OK...summer vaction is done for me...I hope you all had a healthy and safe 4th of July and an excellent month of June....now back to work. The month of June was interesting with another LACE call where discussion about the definition of the CNSs preparation and practice from wellness to acute care occurred. If you remember there was a clause in the APRN concensus paper discussing the need for CNSs to be prepared to provide care across the continuum. What has happened from the time the statement was made until now is apparently confusion...what does this mean when the rubber meets the road?
 
Discussions have occurred among a small group of folks who represent various stakeholders in CNS education, licensure and certification. Here is what they came up with as a definition:
 
"The purpose of this statement is to clarify the scope of CNS preparation to provide care across the health-illness continuum, inlcuding wellness to acute care. Clinical Nurse Specialists (CNSs) are educated with the CNS role competencies in one of six population foci and practice at an advanced level across three spheres of influence: the patient, nurse/nursing practice, and organization/system. CNS role and population competencies across the continuum from the provision of health maintenance and preventive care through the management of patients with physiologically unstable conditions are assessed through the national certification process. Education in a clinical specialty, if included, may occur concurrently with or following the population-based education.
 
Within the patient sphere of influence, the CNS through provision of direct care, is prepared to meet the specialized physiologic and psychological needs of patients throughout the continuum of wellness through acute care. Although the Nurse Practitioner (NP) and Certified Nurse Midwife (CNM) are uniquely prepared to serve as the primary care provider, the CNS provides components of primary care services. In addition to treating individual patients, the CNS is likely to be engaged in the direct management of a population of patients with a specific disease or condition or engaged in influencing outcomes of care of populations through team initiatives or within systems. The CNS is responsible and accountable for:
  • health promotion
  • prevention of illness and risk behaviors among individuals, families, groups and communities, and
  • diagnosis and treatment of health/illness states and disease management

The CNS contributes services as an independent provider and/or as a member of the health care team in a range of settings including but not limited to primary care, accountable care organizations, hospitals, long term care and home care."

So...what do you think? I personally have some concerns. I will list them here for you but I would like to hear your thoughts as well. You have an opportunity to share your feedback and I will ensure that the NACNS leadership hears your concerns and that ulitmately the LACE group hears them....

My concerns are:

  1. certification examinations: the statement says that CNSs "ARE assessed..." (emphasis added). The problem is that there are not enough examinations at present so that will automatically exclude some folks currently practicing as CNSs....wording should be changed to "will be" at the very least and add the phrase "...as examinations are developed" to the end...
  2. "Education in a clinical specialty, IF INCLUDED..." (emphasis added)....if included? If not included then we are clinical nurses...this is a core concept to who we are as CNSs...why would it NOT be included? If educators are thinking that specialty is optional then that is a BIG PROBLEM from my perspective...
  3. CNSs provide care to a broad range of populations...nowhere in this statement is the concept of caring for families, communities, groups etc. Nor is there anything about the indirect care provided by CNSs and others...the focus is on direct care...but there is a need to be able to provide indirect care through reaching out and teaching family/significant others, other nurses, other APRNs, etc. We MUST include the concept of indirect care or a large portion of our work will be unaccounted for and we will begin to look more and more like an NP...please understand that I do not think there is anything wrong with the NP role...what I am saying is that the CNS role is unique in many ways and as we focus the language on being more and more like an NP we lose our unique contributions and may as well merge with the NP world as was suggested many years ago...we have something unique to contribute still...we need to maintain that unique flavor and keep our areas of expertise as a focus in APRN practice. Let's put those elements BACK into the definition...they are in the APRN Consensus Paper...why not here?
  4. the CNS provides "...components of primary care services..." Really? I don't think so...we need to leave primary care to the NPs and others who are truly providers of primary care. What a CNS does is provide the specialty care that is so essential in support of primary care. The CNS is the specialist that the NP can refer to for specific specialized knowlege about disease conditions...THAT is how we fit beautifully into the current accountable care model and focused care teams known as the medical home...the primary non-specialized but essential basic care belongs to the NP...we provide essential supportive care to the NP as they see issues beyond their scope in a specialty area.

Those are just a few of my thoughts....how about you? Do you agree or disagree with my analysis...let me know!     

About the Author

Kelly A Goudreau DSN, RN, ACNS-BC
Kelly A Goudreau DSN, RN, ACNS-BC is an Associate Editor for the Clinical Nurse Specialist Journal and has been a participant on behalf of NACNS in the development of the APRN Consensus Model and subsequent discussions about implementation of the LACE entity.

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