Clinical Nurse Specialist Education and Practice Challenges
Clinical nurse specialists (CNSs) are well-positioned to participate in the transformation of healthcare as outlined by the Institute of Medicine and called upon by the Patient Protection and Affordable Care Act of 2010. CNSs exercise their expertise through population-based care across three spheres of influence (patient/family, nurses/other professionals, systems). However, challenges during the educational process as well as implementation in practice can be barriers to optimization of the role, denying the public full benefit from the potential of CNSs. This article highlights some of the issues and provides solutions for mitigating these difficulties.
Clinical nurse specialists (CNSs) are advanced practice nurses that bring specialized knowledge to the practice setting. As they work across three spheres of influence, CNSs facilitate quality outcomes for individual patients and patient populations, support and mentor nurses, and spearhead innovative changes that advance the healthcare system in meeting the needs of patients, families, populations, and communities. CNSs employ seven core competencies in their practice: direct care, consultation, systems leadership, collaboration, coaching, research, and ethical decision-making (NACNS, 2010). The complexity of the role itself creates challenges in the educational preparation of CNSs. Finding room in the curriculum to address all seven competencies, application to the three spheres of influence, and addressing complex diseases and other health issues can be problematic. Furthermore, lack of standardization in educational preparation, regulation, and even advanced practice recognition across states has challenged CNS educators and development and sustainability of CNS education programs. Additional concerns include adequacy of faculty, clinical preceptors, clinical practicum settings, physical resources, and funding sources for students. A number of recent initiatives lend potential for solutions to some of these issues; however, they may also create a new set of problems. This article will address the Consensus Model for APRN Regulation, IOM Report, and Guidelines for CNS Education.
The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (LACE Model), is a product of the APRN Consensus Work Group and the National Council of State Boards of Nursing (2008), and was finalized and released in 2008, with a goal of full implementation by 2015. The LACE Model defines advanced practice nursing (APRN) and delineates four roles: clinical nurse specialist (CNS), certified nurse practitioner (CNP), certified registered nurse anesthetist (CRNA), and certified nurse midwife (CNM). Each of the roles is educated in at least one patient population focus: family/individual across lifespan, adult-gerontology, neonatal, pediatrics, women's health/gender-related, and psychiatric-mental health across the lifespan (APRN Consensus Work Group/National Council of State Boards of Nursing APRN Advisory Committee, 2008).
Advanced education builds on the pre-licensure preparation for RNs and occurs at the role and population level, which then prepares the individual for initial certification. The LACE Model specifies educational program requirements and the program is accredited accordingly. APRNs may achieve specialization; however, licensure cannot be exclusively within a specialty focus. The CNS is educated and certified to practice across the range of wellness to acute care. Specialty education, recognition, and regulation will be the responsibility of the professional specialty organizations (APRN Consensus Work Group/National Council of State Boards of Nursing APRN Advisory Committee, 2008).
Another tenet of the LACE Model is the population designated as adult-gerontology. This includes the young adult to the older adult, as well as the frail elderly. These three changes (population focus, specialty focus post-certification, wellness-acute care scope) are most dramatic for CNSs, who, obviously by the title, have always practiced with a specialty focus sometimes defined as what is now a population. For example, a critical care CNS for adults would include little practice in "wellness," and may not have preparation in elderly care. Both CNS education programs and certification exams have had to undergo profound revision as a result in order to add gerontology content and disband specialty content. The American Association of Critical Care Nurses, for example, has changed the name of the adult CCNS exam to ACCNS-AG and added items that cover wellness to acute care and items that address care of the elderly (American Association of Critical Care Nurses, 2013). For institutions that have offered only specialized CNS programs such as palliative care or gerontology, these changes can go so far as to terminate the program.
Despite the difficulties the LACE Model may generate, one of the primary benefits is that it provides for standardization in educational and certification requirements with APRN recognition in all states. Of all the APRN roles, this is especially valuable to CNSs because in many states, graduate education is not a requirement and CNSs do not enjoy advanced practice recognition. The LACE Model will help move along process changes in these states, which will be good for CNS education and practice.
Another influential document is "The IOM Report". The Institute of Medicine in partnership with the Robert Wood Johnson Foundation first released a report brief in 2010 entitled The Future of Nursing: Leading Change, Advancing Health, followed by a full publication in 2011 describing the barriers to nursing practice that impede the ability to fulfill the objectives of the 2010 Patient Protection and Affordable Care Act and the changes within nursing that must happen to meet the nation's health care needs (IOM, 2011). Four key messages surfaced with eight corresponding recommendations. One of the messages relevant to CNS education was nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression (IOM, 2011). This goes hand in hand with the standardization of educational programs as set forth by the APRN Consensus Model, which at this time requires a minimum of a master's degree. However, the American Association of Colleges of Nursing (AACN) released a document in 2004, proposing the doctorate of nursing practice (DNP) as entry level preparation for CNSs and other APRNs, effective 2015 (AACN, 2004). Because the Consensus Model for APRN curricula requires a course in advanced pathophysiology, advanced physical assessment, and advanced pharmacotherapeutics ("the Three Ps") and the majority of DNP programs thus far are post-master's, CNSs can "seamlessly" move from a master's level of preparation into a DNP program, as sanctioned by the IOM report.
For nurses to achieve higher levels of education, be it master's or DNP, more nursing faculty is required. With a looming faculty shortage likely to worsen as seasoned faculty retire, having adequate numbers of faculty is a problem for all of nursing education, not just CNS programs. In 2012, the AACN reported results of a Special Survey on Vacant Faculty Positions; of the 662 nursing schools responding (78.9%), there were 1,181 vacancies, most of which required or preferred a doctorate degree (7.6% vacancy rate). The top two reasons identified were 1) limited pool of doctoral prepared nurses (32.9% of respondents) and 2) poorly competitive salaries (27.6%) (AACN, 2012). Recommendation 5 of the IOM Report advocates for doubling the number of nurses with doctorate degrees by 2020 (IOM, 2011, p. 281). The report goes on to say that private funding agencies and federal monies should be used to expand programs and offer accelerated curricula to reach this goal. Because salaries in the service sector (hospitals) are typically higher than those paid in academia, offering competitive benefit packages to recruit and retain faculty will help to build a cadre of qualified faculty. This allows for educating nurses to become CNSs as well as attracting CNSs into faculty positions.
Recommendation 3 of the IOM Report promotes nurse residency programs for nurses after completing prelicensure and advanced degree programs when transitioning into a new clinical practice area (IOM, 2011, p 280). Some take issue with the term residency for preparing advanced practice RNs, believing the term fellowship is more appropriate, which somewhat parallels the medical education process: completion of medical school (nursing school) – residency (graduate school with at least 500 post-baccalaureate clinical hours) – fellowship. Putting semantics aside, academic programs are designed to prepare CNSs to perform at a novice advanced practice level; an opportunity to proceed through a residency/fellowship program for development as an expert clinician meets with one of the fundamental competencies of CNS practice which is Direct Care (National CNS Competency Task Force, 2010). The major intent of the IOM for this recommendation is to improve nurse retention rates and improve patient outcomes; retention rates is relative to baccalaureate prepared/newly licensed nurses, however, improving patient outcomes under CNS leadership is consistent with fundamental CNS practice. An example of an APRN fellowship is NET SMART, the Neurovascular Education and Training in Stroke Management and Acute Reperfusion Therapy program, which is a post-graduate APRN fellowship designed to teach recognition and management of acute stroke (Alexandrov, et al., 2009). The program is comprehensive, consisting of 14 modules using an on-line platform with 24/7 availability covering epidemiology, pathophysiology, neuro-imaging, management including reperfusion and concomitant therapy, complications, and emergency systems, stroke centers and stroke units. In addition to didatic content, fellows are required to contract with a local physician, preferably a neurologist for clinical training and education. Competency validation occurs at the conclusion of each module before advancing to the next; following completion of the 14 modules, fellows fulfill 80 hours of on-site supervised clinical time with the program faculty and stroke team (Alexandrov, et al., 2009). Besides complying with the IOM recommendations, this program satisfies the APRN Consensus Model by providing post-graduate specialty education. In addition to increased knowledge of stroke gained by participants, early patient related outcomes of the NET SMART program included a 7% increase in thrombolytic administration and stroke unit certification (Alexandrov, et al., 2009), fulfilling a key principle of IOM recommendation 3, creating opportunities for improving patient outcomes.
Another recommendation of the IOM report is to "expand opportunities for nurses to lead and diffuse collaborative improvement efforts" (IOM, 2011, p 279). Systems Leadership is a core competency for CNSs and as such is integral to CNS education. Thompson and Nelson-Martin (2011) describe a process for teaching leadership in a CNS program at the University of Colorado through development and implementation of a change project that incorporates another core competency, (using) research. Over a series of three courses, students identify a problem/issue, search and appraise the literature, and using a theoretical approach, design educational materials, measurement instruments, screening tools, and the like. At the conclusion of the CNS program, students deliver a poster presentation highlighting results achieved under their leadership of the project (Thompson & Nelson-Martin 2011). Not all CNS programs entail implementation of a project, however; the degree requirement may be merely to propose an idea. Merely proposing a project can be a disservice to the CNS student following graduation because during their clinical preceptorship, students may spend more time "following" than "leading." Bringing a project full circle, on the other hand, provides opportunities for CNS students to see the impact of their projects while preparing them to be competent in systems leadership.
In 2004, Guidelines for Clinical Nurse Specialist Education was released (NACNS, 2004a). Recommendations pertinent to the organization/administration, curriculum, clinical resources, and program evaluation were included in the publication. Seven items compose the organization/administration portion of the document addressing accreditation, program definition, and faculty qualifications. The curriculum requirements put forth in the guidelines are the most prescriptive, mandating inclusion of CNS-specific didactic content and a minimum of 500 clinical hours. The guidelines advise that clinical resources for CNS education include 1:6 or 8 faculty: student ratio and 1:1 or 2 preceptor: student ratio, preceptor qualifications, and clinical experiences that ensure students achieve the competencies as outlined in the NACNS Statement on Practice and Education (NACNS, 2004b). This aspect of the guidelines can carry the greatest challenge. Few practicing CNSs may be available to students and/or may practice in institutions that are limited in clinical services, with little opportunity for CNS students to encounter a multiplicity in specialty services or even challenging patients. Due to variety in understanding and utilization of the role across practice settings, CNSs who are available may function as hospital educators vs. systems leaders applying solid clinical expertise and improving outcomes with application of research findings. This role confusion is further exacerbated by the …assets that strengthen CNS education and development of core competencies include simulation classrooms, information technology support, and library resources… proliferation of nurse practitioners whose role too may be poorly understood and hospital administrators require them to do "CNS work". With the growth of online master's programs, attaining preceptors for CNS students can become very competitive as "local" and "distant" students seek out a limited number of individuals.
Other assets that strengthen CNS education and development of core competencies include simulation classrooms, information technology support, and library resources, to name a few. Variability among universities in these resources can hamper CNS students' growth and integration of core competencies.
Preparing a solid workforce of CNSs carries many challenges. Diverse role competencies, faculty shortages, changing educational requirements, and scarce resources are some of the issues. Thoughtful solutions have been put forth to meet some of these challenges; continued work by CNS educators, policy makers, legislators, and regulators will be necessary to provide for preparation of CNSs in order to meet the growing healthcare needs of Americans.
Abstract and Introduction
Abstract
Clinical nurse specialists (CNSs) are well-positioned to participate in the transformation of healthcare as outlined by the Institute of Medicine and called upon by the Patient Protection and Affordable Care Act of 2010. CNSs exercise their expertise through population-based care across three spheres of influence (patient/family, nurses/other professionals, systems). However, challenges during the educational process as well as implementation in practice can be barriers to optimization of the role, denying the public full benefit from the potential of CNSs. This article highlights some of the issues and provides solutions for mitigating these difficulties.
Introduction
Clinical nurse specialists (CNSs) are advanced practice nurses that bring specialized knowledge to the practice setting. As they work across three spheres of influence, CNSs facilitate quality outcomes for individual patients and patient populations, support and mentor nurses, and spearhead innovative changes that advance the healthcare system in meeting the needs of patients, families, populations, and communities. CNSs employ seven core competencies in their practice: direct care, consultation, systems leadership, collaboration, coaching, research, and ethical decision-making (NACNS, 2010). The complexity of the role itself creates challenges in the educational preparation of CNSs. Finding room in the curriculum to address all seven competencies, application to the three spheres of influence, and addressing complex diseases and other health issues can be problematic. Furthermore, lack of standardization in educational preparation, regulation, and even advanced practice recognition across states has challenged CNS educators and development and sustainability of CNS education programs. Additional concerns include adequacy of faculty, clinical preceptors, clinical practicum settings, physical resources, and funding sources for students. A number of recent initiatives lend potential for solutions to some of these issues; however, they may also create a new set of problems. This article will address the Consensus Model for APRN Regulation, IOM Report, and Guidelines for CNS Education.
Consensus Model for APRN Regulation
The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (LACE Model), is a product of the APRN Consensus Work Group and the National Council of State Boards of Nursing (2008), and was finalized and released in 2008, with a goal of full implementation by 2015. The LACE Model defines advanced practice nursing (APRN) and delineates four roles: clinical nurse specialist (CNS), certified nurse practitioner (CNP), certified registered nurse anesthetist (CRNA), and certified nurse midwife (CNM). Each of the roles is educated in at least one patient population focus: family/individual across lifespan, adult-gerontology, neonatal, pediatrics, women's health/gender-related, and psychiatric-mental health across the lifespan (APRN Consensus Work Group/National Council of State Boards of Nursing APRN Advisory Committee, 2008).
Advanced education builds on the pre-licensure preparation for RNs and occurs at the role and population level, which then prepares the individual for initial certification. The LACE Model specifies educational program requirements and the program is accredited accordingly. APRNs may achieve specialization; however, licensure cannot be exclusively within a specialty focus. The CNS is educated and certified to practice across the range of wellness to acute care. Specialty education, recognition, and regulation will be the responsibility of the professional specialty organizations (APRN Consensus Work Group/National Council of State Boards of Nursing APRN Advisory Committee, 2008).
Another tenet of the LACE Model is the population designated as adult-gerontology. This includes the young adult to the older adult, as well as the frail elderly. These three changes (population focus, specialty focus post-certification, wellness-acute care scope) are most dramatic for CNSs, who, obviously by the title, have always practiced with a specialty focus sometimes defined as what is now a population. For example, a critical care CNS for adults would include little practice in "wellness," and may not have preparation in elderly care. Both CNS education programs and certification exams have had to undergo profound revision as a result in order to add gerontology content and disband specialty content. The American Association of Critical Care Nurses, for example, has changed the name of the adult CCNS exam to ACCNS-AG and added items that cover wellness to acute care and items that address care of the elderly (American Association of Critical Care Nurses, 2013). For institutions that have offered only specialized CNS programs such as palliative care or gerontology, these changes can go so far as to terminate the program.
Despite the difficulties the LACE Model may generate, one of the primary benefits is that it provides for standardization in educational and certification requirements with APRN recognition in all states. Of all the APRN roles, this is especially valuable to CNSs because in many states, graduate education is not a requirement and CNSs do not enjoy advanced practice recognition. The LACE Model will help move along process changes in these states, which will be good for CNS education and practice.
The IOM Report
Another influential document is "The IOM Report". The Institute of Medicine in partnership with the Robert Wood Johnson Foundation first released a report brief in 2010 entitled The Future of Nursing: Leading Change, Advancing Health, followed by a full publication in 2011 describing the barriers to nursing practice that impede the ability to fulfill the objectives of the 2010 Patient Protection and Affordable Care Act and the changes within nursing that must happen to meet the nation's health care needs (IOM, 2011). Four key messages surfaced with eight corresponding recommendations. One of the messages relevant to CNS education was nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression (IOM, 2011). This goes hand in hand with the standardization of educational programs as set forth by the APRN Consensus Model, which at this time requires a minimum of a master's degree. However, the American Association of Colleges of Nursing (AACN) released a document in 2004, proposing the doctorate of nursing practice (DNP) as entry level preparation for CNSs and other APRNs, effective 2015 (AACN, 2004). Because the Consensus Model for APRN curricula requires a course in advanced pathophysiology, advanced physical assessment, and advanced pharmacotherapeutics ("the Three Ps") and the majority of DNP programs thus far are post-master's, CNSs can "seamlessly" move from a master's level of preparation into a DNP program, as sanctioned by the IOM report.
For nurses to achieve higher levels of education, be it master's or DNP, more nursing faculty is required. With a looming faculty shortage likely to worsen as seasoned faculty retire, having adequate numbers of faculty is a problem for all of nursing education, not just CNS programs. In 2012, the AACN reported results of a Special Survey on Vacant Faculty Positions; of the 662 nursing schools responding (78.9%), there were 1,181 vacancies, most of which required or preferred a doctorate degree (7.6% vacancy rate). The top two reasons identified were 1) limited pool of doctoral prepared nurses (32.9% of respondents) and 2) poorly competitive salaries (27.6%) (AACN, 2012). Recommendation 5 of the IOM Report advocates for doubling the number of nurses with doctorate degrees by 2020 (IOM, 2011, p. 281). The report goes on to say that private funding agencies and federal monies should be used to expand programs and offer accelerated curricula to reach this goal. Because salaries in the service sector (hospitals) are typically higher than those paid in academia, offering competitive benefit packages to recruit and retain faculty will help to build a cadre of qualified faculty. This allows for educating nurses to become CNSs as well as attracting CNSs into faculty positions.
Recommendation 3 of the IOM Report promotes nurse residency programs for nurses after completing prelicensure and advanced degree programs when transitioning into a new clinical practice area (IOM, 2011, p 280). Some take issue with the term residency for preparing advanced practice RNs, believing the term fellowship is more appropriate, which somewhat parallels the medical education process: completion of medical school (nursing school) – residency (graduate school with at least 500 post-baccalaureate clinical hours) – fellowship. Putting semantics aside, academic programs are designed to prepare CNSs to perform at a novice advanced practice level; an opportunity to proceed through a residency/fellowship program for development as an expert clinician meets with one of the fundamental competencies of CNS practice which is Direct Care (National CNS Competency Task Force, 2010). The major intent of the IOM for this recommendation is to improve nurse retention rates and improve patient outcomes; retention rates is relative to baccalaureate prepared/newly licensed nurses, however, improving patient outcomes under CNS leadership is consistent with fundamental CNS practice. An example of an APRN fellowship is NET SMART, the Neurovascular Education and Training in Stroke Management and Acute Reperfusion Therapy program, which is a post-graduate APRN fellowship designed to teach recognition and management of acute stroke (Alexandrov, et al., 2009). The program is comprehensive, consisting of 14 modules using an on-line platform with 24/7 availability covering epidemiology, pathophysiology, neuro-imaging, management including reperfusion and concomitant therapy, complications, and emergency systems, stroke centers and stroke units. In addition to didatic content, fellows are required to contract with a local physician, preferably a neurologist for clinical training and education. Competency validation occurs at the conclusion of each module before advancing to the next; following completion of the 14 modules, fellows fulfill 80 hours of on-site supervised clinical time with the program faculty and stroke team (Alexandrov, et al., 2009). Besides complying with the IOM recommendations, this program satisfies the APRN Consensus Model by providing post-graduate specialty education. In addition to increased knowledge of stroke gained by participants, early patient related outcomes of the NET SMART program included a 7% increase in thrombolytic administration and stroke unit certification (Alexandrov, et al., 2009), fulfilling a key principle of IOM recommendation 3, creating opportunities for improving patient outcomes.
Another recommendation of the IOM report is to "expand opportunities for nurses to lead and diffuse collaborative improvement efforts" (IOM, 2011, p 279). Systems Leadership is a core competency for CNSs and as such is integral to CNS education. Thompson and Nelson-Martin (2011) describe a process for teaching leadership in a CNS program at the University of Colorado through development and implementation of a change project that incorporates another core competency, (using) research. Over a series of three courses, students identify a problem/issue, search and appraise the literature, and using a theoretical approach, design educational materials, measurement instruments, screening tools, and the like. At the conclusion of the CNS program, students deliver a poster presentation highlighting results achieved under their leadership of the project (Thompson & Nelson-Martin 2011). Not all CNS programs entail implementation of a project, however; the degree requirement may be merely to propose an idea. Merely proposing a project can be a disservice to the CNS student following graduation because during their clinical preceptorship, students may spend more time "following" than "leading." Bringing a project full circle, on the other hand, provides opportunities for CNS students to see the impact of their projects while preparing them to be competent in systems leadership.
Guidelines for Clinical Nurse Specialist Education
In 2004, Guidelines for Clinical Nurse Specialist Education was released (NACNS, 2004a). Recommendations pertinent to the organization/administration, curriculum, clinical resources, and program evaluation were included in the publication. Seven items compose the organization/administration portion of the document addressing accreditation, program definition, and faculty qualifications. The curriculum requirements put forth in the guidelines are the most prescriptive, mandating inclusion of CNS-specific didactic content and a minimum of 500 clinical hours. The guidelines advise that clinical resources for CNS education include 1:6 or 8 faculty: student ratio and 1:1 or 2 preceptor: student ratio, preceptor qualifications, and clinical experiences that ensure students achieve the competencies as outlined in the NACNS Statement on Practice and Education (NACNS, 2004b). This aspect of the guidelines can carry the greatest challenge. Few practicing CNSs may be available to students and/or may practice in institutions that are limited in clinical services, with little opportunity for CNS students to encounter a multiplicity in specialty services or even challenging patients. Due to variety in understanding and utilization of the role across practice settings, CNSs who are available may function as hospital educators vs. systems leaders applying solid clinical expertise and improving outcomes with application of research findings. This role confusion is further exacerbated by the …assets that strengthen CNS education and development of core competencies include simulation classrooms, information technology support, and library resources… proliferation of nurse practitioners whose role too may be poorly understood and hospital administrators require them to do "CNS work". With the growth of online master's programs, attaining preceptors for CNS students can become very competitive as "local" and "distant" students seek out a limited number of individuals.
Other assets that strengthen CNS education and development of core competencies include simulation classrooms, information technology support, and library resources, to name a few. Variability among universities in these resources can hamper CNS students' growth and integration of core competencies.
Preparing a solid workforce of CNSs carries many challenges. Diverse role competencies, faculty shortages, changing educational requirements, and scarce resources are some of the issues. Thoughtful solutions have been put forth to meet some of these challenges; continued work by CNS educators, policy makers, legislators, and regulators will be necessary to provide for preparation of CNSs in order to meet the growing healthcare needs of Americans.
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