Supernurse to the rescue!

By Carrie Sue Halsey | 10/15/2015

A clinical nurse specialist defends the CNS role. 


Photo of a superwoman

It is generally acknowledged that nurses are amazing. They save lives and improve patient health. The public and the medical community may not be aware, however, of a group of special nurses who practice in relative obscurity. They can be found in education, research, and administration—or quietly at the bedside—in universities, clinics, and hospitals. You may work with one or for one. You may even receive primary care from one of these supernurses. Who are these Clark Kents of nursing? Although their functional titles vary, their nursing designation—CNS—is what really sets them apart.
 
Unmasking these undercover superheroes
A clinical nurse specialist is an advanced practice nurse (APRN). Four types of APRNs are licensed in the United States—certified nurse midwives, nurse practitioners, nurse anesthetists, and clinical nurse specialists—and there are 72,000 of the latter.
 
Carrie Sue HalseyAll APRNs have special powers and characteristics. They have the power—in most states—to prescribe medicine and treatments for patients in a variety of settings. They possess expert knowledge and skill gained from years of nursing experience. In addition to master’s and/or doctoral degrees in nursing, APRNs have advanced education and hundreds of hours of specialized clinical training. Clinical nurse specialists attend the same core classes that are required of all APRNs, after which they branch off into training for their specialty. To be eligible for licensure in most states, clinical nurse specialists must obtain national certification.
 
Certified nurse midwives (CNMs), nurse practitioners (NPs), and certified nurse anesthetists (CRNAs) have become visible and trusted health care professionals in the public arena. However, the public is not as familiar with—or cannot define—the role of the CNS. In addition to advanced clinical expertise in a chosen specialty, clinical nurse specialists must have leadership, collaboration, and consultation skills; possess professional attributes; exemplify ethical conduct; and practice professional nursing citizenship.
 
Every superhero has a backstory
The clinical nurse specialist role originates in Florence Nightingale’s vision of integrating illness care with disease care. Her emphasis on treating and preventing illness, as well as utilizing scientific principles to research nursing practice, are elements of current CNS practice. Hildegard E. Peplau, EdD, RN, FAAN, further shaped Nightingale’s vision, defining the CNS as the first advanced practice nurse role. The explosion of nursing science that occurred after 1960 was translated into practice by clinical nurse specialists, cementing their recognition within the nursing community as supernurses.
 
Similar to a nurse practitioner, a clinical nurse specialist focuses on a specific patient population and utilizes differential diagnosis to treat symptoms and disease. A CNS’s scope goes beyond expert assessment and treatment of individual patients and includes developing and implementing evidence-based practice, shaping nursing practice, and improving health care systems. The CNS is a nurse advocate who promotes autonomous nursing practice for all nurses. Practicing in three spheres of influence—nurses, patients, and systems—the clinical nurse specialist’s professional responsibility extends to influencing organizations, systems, and nursing practice.
 
The work and role of the CNS are integral to advancement of nursing and patient care, and the literature is clear that the role benefits health care on multiple levels. Patients are safer and healthier, and care costs decrease. Considering the beneficial nature of the clinical nurse specialist, one would expect health care in general, hospitals specifically, and the public to embrace and promote the clinical nurse specialist role. Unfortunately, this is not reality in 2015. Even superheroes have problems.
 
Barriers to practice, aka Kryptonite
The CNS practices in any—or all—of the three spheres of influence. This broad scope is what makes the CNS role unique and difficult to define. One CNS may be employed to improve systems and integrate nursing science into practice. Another CNS may work in a pain clinic, treating patients. Yet another clinical nurse specialist may be employed as a clinical or university educator. In other words, defining the CNS role for the public is difficult, and there is no national effort currently underway to accomplish this task.
 
Only about 25 percent of clinical nurse specialists in the United States maintain prescriptive authority, a power that identifies them in the public mind as physician extenders or midlevel practitioners. Authority to prescribe treatment for a patient is something that patients and insurance companies understand. Moreover, it is challenging to quantify the benefit of a CNS consult when hospitals speak only in billing hours and charges.
 
Legislative barriers to autonomous practice are greater for clinical nurse specialists compared to other APRNs. For example, in California a clinical nurse specialist cannot practice independently and is not given prescriptive authority. Without equitable autonomy under the law, it is impossible for a CNS to practice to the full scope of his or her training, which undermines the Institute of Medicine’s recommendation for the future of nursing.
 
Title protection is an ongoing legal issue in many states and countries. The clinical nurse specialist designation is not universally protected, making it possible for people to call themselves a CNS without regard to education, certification, or training. Without title protection, the role of the CNS is slowly being eroded.
 
The diverse nature of the CNS role can also become an obstacle to continued practice. Although the clinical nurse specialist may work in many different roles within the three spheres of influence, many of these roles do not come with the official title of clinical nurse specialist. This can suppress re-licensure, as many boards require APRN practice hours for renewal eligibility.
 
Nor are these barriers limited to nursing practice in the United States. The CNS role has developed worldwide over the last three decades; nevertheless, the obstacles I have identified are encountered worldwide by members of the CNS community.
 
Three ways to stand for equality
Clinical nurse specialists have a vitally important role in nursing and health care. Removing barriers to practice would allow clinical nurse specialists to contribute more fully and broadly to the improvement of patient care. Unlike comic book superheroes, they cannot fight these battles alone.
  1. Political advocacy is essential to changing laws that limit CNS autonomy. From the local level to the national, advocacy for change is needed. AARP is among organizations asking their members to advocate for legislative changes.
  2. Hospitals must extend health-care team collaboration to include all APRNs, including the CNS. The clinical nurse specialist does not replace a physician, but rather adds the illness care model to the medical model, as envisioned by Nightingale, and patients benefit from being treated by a well-rounded health care team.
  3. Institutions should ban look-alike, sound-alike position descriptors such as “nurse specialist” or “clinical specialist.” These and similar terms confuse the public and weaken the CNS role. Also, the abbreviated titles often accompany an abbreviated CNS scope of practice, indicating an institutional attempt to avoid employing an APRN. Consider, for example, the absurdity of a hospital needing to employ a CRNA but seeking to get around the requirement by hiring a registered nurse and changing the title to “anesthesia nurse expert.” A registered nurse cannot perform the same functions as a CRNA. The education, training, licensure, and scopes of practice are different. The same applies to clinical nurse specialists.
Join the superhero alliance
I am a clinical nurse specialist. I do not count myself among the superheroes of nursing, but I know quite a few of them. They inspire me to live up to the CNS legacy and add to it whenever possible. I look forward to the day when I can tell any person I am a CNS, and they will know exactly what that means. I will continue to advocate for CNS autonomy and recognition. Maybe that is how I will earn my cape.
 
Click here to learn more about the role of the clinical nurse specialist. 
 
Carrie Sue Halsey, MSN, CNS-AD, RNC-OB, ACNS-BC, is a clinical nurse specialist and natural birth and breastfeeding advocate who resides in Houston, Texas, USA. She teaches childbirth classes for expectant parents and assists mothers with breastfeeding goals. Her experiences as a mother-nurse—of pregnancy, labor, and birth—have made her passionate about perinatal empowerment. To learn more, visit http://perinatalempowerment.com.
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