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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.

Monday, September 3, 2012

The LACE organization is going through a re-birth of sorts. When the APRN Consensus Model was "birthed" in July of 2008 there was still much work to be done. The group that created the model was very vested in ensuring it would be implemented as it was intended to be implemented. The model took four years of difficult dicussion to create. It was important to all stakeholders that it be implemented and tended so that it could grow in a positive way.
The key principles were to share information in a non-partisan way (refering to the "parties" of the member organizations) with no particular bias toward or away from any of the groups. The intent was to create the forum where parties involved in licensure, accreditation, certification and education could work toward full implementation and with as few unintended consequences as possible. Dialogue between the various silos of nursing was sorely lacking and needed to have a forum where it could be nurtured and grow.
The key stakeholders knew that it would be a difficult process that would be fraught with unanticipated pitfalls along the way. It was important to identify that no one entity "owned" the LACE process so the groups agreed, through a collaborative that was facilitated by Dr. Michael Bligh, to create the online community that is LACE.
LACE has been in existence now for two years...yes it took us two years (2008-2010) to get the specifics nailed down and bring the LACE community together. There have been meetings on at least a quarterly basis online and on conference calls as well as some hybrid meetings that were partially face to face and partially online/conference called. The past two years there has been much to discuss when the group gets together...updates on how various states are implementing the model, how the accreditors have focused and changed the expectations for accreditation of educational programs, how the certifiers are notifying their constituent audiences of the pending retirement of examinations and the process for creation of new exams or updating the current ones to meet the model needs, and the changes that are taking place in education with the updating or creation of role specific competencies and their integration into the curriculum.
The site license for the LACE website is up for renewal and it is providing an opportunity for many of the stakeholders to reflect on whether or not the format of a web site has actually met the needs of the group. It will be interesting to see what happens.
My perspective is that the site has done some things well and some things not as well as they could. There is a perception of partisanship since the site is "owned" by one party but I am not sure how that could change and still run effectively. Initially there was a board set up made up of a number of individuals who would have responsibility for the maintenance of the site and the content on it....I was one of those folks. I have done little over the last two years as the site really has run itself. I would hazard that the others who were on that 'board' would say the same.
Will it stay the same? Will it change? Time will tell. It has been and continues to be an interesting journey. 

Sunday, July 8, 2012

OK...summer vaction is done for me...I hope you all had a healthy and safe 4th of July and an excellent month of 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 " 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 about you? Do you agree or disagree with my analysis...let me know!     

Monday, May 28, 2012

The Licensure, Accreditation, Certification and Education (LACE) group are meeting in both virtual and face to face environments on a monthly basis. There was a meeting on April 24 immediately before the APRN Roundtable discussion in Chicago. This was attended both in person by a number of folks and also there was a large contingent on the phone (in fact there were equal numbers in both venues!).
What were the key topics of discussion on the calls? Here is a summary of the agenda on both the days:
Age parameters...should the LACE group define what the age parameters should be for the pediatric population in particular? The discussion has really centered around cases such as this: a Pediatric Nurse Practitioner caring for a cystic fibrosis patient will still need to provide consultation for them regardless of them being "outside" of the perceived range for a pediatric population (i.e. the 21 year old who has survived due to improved patient care processes as compared to previous years).  
CNS role regarding Wellness to Acute Care...the American Association of Critical Care Nurses Certification Corporation added in a request that CNSs be both educated and tested across the continuum of wellness to acute care as one of the last issues we discussed at the APRN Consenus document discussions. The organizations that represent CNSs, inlcuding NACNS agreed to the statement and now the LACE group is attempting to define what that means exactly. The educator groups are asking what it means and need guidance on how to interpret and then implement.
Primary Care vs Acute Care NP roles....the stakeholder groups are working on a draft statement regarding the similarities and differences.
NACNS Statement on the APRN Consensus Model Implementation ...The document that I have been discussing in the past couple of postings has also been getting discussed at the LACE group. Many of the issues I raised in my discussion of the document were also raised by the parties involved. For example the certifiying bodies were mirroring my comments from May 13th. Other discussions are being held as well and I will keep you updated as conclusions are reached.
National Council of State Boards of Nursing...has created a new document on the requirements for accrediting agencies and criteria for APRN certification programs. I will go into more detail on this document in subsequent postings but take a look for yourself. The document is available on the NCSBN website. What do you think of the requirements that have been listed?
The work goes on and it is being done collaboratively with input from all of the APRN groups. That is a positive step from my perspective. It holds all the groups accountable to the intent of the Consensus Model and ensures that there is little rogue behavior that can occur...good...let's hold each other true to the document and the work that was done.

Sunday, May 13, 2012

Let's discuss the requirement for certification. As we get closer to the implementation of the model there are areas that lack clarity in the model. The model was never intended to be fully formed when born...unlike Greek was intended to be a roadmap that would have the points of interest and photos of exciting times added along the way.
One of the exciting times is related to certification examinations. According to the model, certification will be needed in the future in order to meet licensing requirements as an Advanced Practice Registered Nurse (APRN). The certification examinations that currently exist for ALL APRN groups will need to change. They will need to meet the expectations of the model for assessing minimum competence for entry to practice as an APRN and will need to assess the Three P's, the role, and the population. There are currently NO EXAMS that are structured in this manner...but the certifying bodies (AACN - Critical Care, and ANCC where CNSs are concerned) are working hard to get there by the deadline of 2015.
What are the issues though? Well....for CNSs the certification requirement will be brand new. In the past the CNS used certification as a mark of excellence....not minimum competence assessment for entry to practice. That shift needs to occur first. Then, the CNS has really been focused on specialty rather than the structure outlined by the model (3 P's, role, population) so that is the second shift that needs to occur. It is my sincere hope that schools of nursing are working toward the outcomes as outlined. If they are not we will be in deep trouble as a component of the functional roles of APRNs. The final issue is that since the first two issues have not been addressed before, the CNS world is lacking in a comprehensive array of examinations. We have the Adult (soon to be Adult-Gero) population examination, and we have had in the past the gender specific examination although it is now defunct. Additionally we have had elements of the "Across the lifespan" exam in the form of the public health examinations in the past...although this will need to shift significantly also to meet the current model. Finally we have the psychiatric/mental health examination although that too will be undergoing changes as the role definition (per the International Society for Psychiatric Nurses [ISPN] and American Society for Psychiatric Nurses [ASPN]) moves solely to Nurse Practitioner preparation.
Confused yet? It gets better!
The tests that are created and/or modified must have enough individuals taking them to allow for psychometric analysis that demonstrates that the test is psychometrically sound and legally defensible. In other words...they have to be able to prove that they are measuring what they say they are measuring and they cannot do that if only a few people take the test each year. There has to be enough power in the analysis to allow for variations in the population and that can withstand a legal challenge if presented.
So...will we have enough CNSs in each population to be able to ensure the tests are legally defensible and psychometrically sound? Only if we see an increase in the number of students and we can maintain that number over the subsequent years....can you help? Will you help? Tell those young nurses you are working with what you do...let them see your role to its fullest extent and have them decide if your role is what they want to do when they move on in their career trajectory. Help to generate the future and perpetuate the role. You know as well as I do that the health care system needs us now more than your part to ensure the survival of the role.
So what is happening with certification in general? Will we have enough examinations to meet the population bubbles on the model by 2015? What do you think?

Sunday, April 22, 2012

Another one of the issues raised in the NACNS Statement on the APRN Consensus Model Implementation (available on the NACNS web site) was related to the accreditors of schools of nursing not giving enough time for the schools to make the adjustments. The criteria for schools of nursing are changing based on the new requirements being implemented by CCNE and the NLN-AC that are in alignment with the model.
The needs as articulated in the APRN Consensus Model for schools of nursing are the incorporation of the three P's (pathophysiology, pharmacology, and physical/health assessment), and a shift from a focus on strictly role and specialty care to that which includes a population focus. The additional requirement of population is over and above role and specialty. Point of clarification....specialty is not included in the regulatory model but must be included in the CNS educational expectations.
The struggle that schools of nursing are apparently having is how to get both a population and specialty into the curriculum. Part of the difficulty is that there is no clear interpretation of what role, population and specialty mean to the various schools. The concept of "academic freedom" in the academic world means that each school/faulty group has the right to interpret it differently. That does not lend itself well to the concept of standardization as articulated in the what do we have? Chaos.  
One statement in the NACNS document that illustrates the narrow scope that many people have is on page 6 where the document discussed the need for "...balanc[ing] the requirements for education on population, role and specialty education which is unique to the CNS within the mandated 500 clinical hours"(emphasis added). The hours for clinical are not mandated...they are a MINIMUM required by a number of national documents including the APRN Consensus Model document. Also, in the world of evidence based practice there is no evidence that 500 hours is the magic is a number that was literally picked out of the air in the requirements for graduate education published by the AACN in 1996 and has become the standard expectation but there is NO EVIDENCE that this is the "right" number of hours.
So narrow thinking begets narrow thinking....
The accreditors are making changes to the accrediting requirements and are moving in the direction of the model in a timely manner. As a site visitor for CCNE I have seen some of those changes and the proposed timelines for the implementation. Can we afford to be inflexible though and hold all schools accountable to the proposed date of implementation? I don't know....there are two sides to that sword...if the accreditors do not draw the line in the sand and take a stand the schools may not make the changes until that line is drawn. If the accreditors do take a stand we all risk losing CNS programs for a lack of accreditation due to lack of responsiveness to the requirements. We can ill afford the loss of any CNS program in this volatile time.
What is the solution? We need to have some creative and innovative nurse educators out there who can look at the requirements of the APRN Consensus Model and move with them in the curriculum. Just like a large ship that is on the move, it takes a long time for curriculum change to occur in many institutions. Depending on the size of the organization, the size of the faculty, the level of entrenchment of the faculty, and the willingness of the group to change what they are doing can take a year, two years or longer to make the changes. 
Evidence based practice issue aside...we need to move toward the requirements in the model. We need to do it now so that there can be a well prepared and ready group of graduates when the model is expected to be fully in place (2015). Let's get our pending graduates ready for the future...and not set them up for failure before they even begin because they are not prepared in the requirements of the model. It is up to us to shepherd the future...let's do it well.
So is it the issue of the accreditors? Or is it the issue of the educators? You decide...but either way we need to move.....