The Unique Practice of the Clinical Nurse Specialist.

Abstract

Over the last several years I have been asked numerous times, “How can clinical nurse specialists (CNS) retain our unique nursing care focused contributions while integrating full practice authority?” After years of practicing as a palliative care CNS, the question proved to be a bit more daunting than I anticipated. Practice is the process of acting in response to a need requiring judgement and independent decision-making within a scope of autonomous authority. All nurses have an autonomous scope of practice with authority for decision-making granted by the registered nurse license. Within that scope, nurses deliver individualized care and comfort contextualized to individual circumstances such as a medical diagnosis, pharmacological and surgical treatment, personal preferences, and ethical principles to name a few. How then is CNS practice distinguished from the practice of nursing in general? Like staff nurses, CNSs are direct care providers. However, unlike the generalist nurse with registered nurse (RN) license, CNSs provide care as advanced practice registered nurses (APRN). APRNs are being granted full practice authority, a regulatory phrase currently used to mean an expanded scope of practice that includes diagnosis and treatment of disease and prescriptive authority. Thus, APRNs have an expanded scope of practice and corresponding expanded authority for decision-making. Like all APRNs, including nurse practitioners (NP), nurse midwives, and nurse anesthetists, CNSs have statutory authority to diagnose disease and pathological conditions, provide pharmacologic interventions, and order durable medical equipment. And like all APRNs, the exact scope of this authority is regulated at the state level and varies somewhat across all 50 states. As a staff nurse, I found clinical care challenging and rewarding. I chose the CNS role to be able to continue as a direct care provider AND to expand my knowledge and skills in improving nursing practice and leading changes in the clinical care delivery environment. I saw opportunities to create new programs for patients and study how these programs improved care delivery in organizations. The CNS role was a perfect fit since it integrates three domains of practice – direct clinical care, educating and mentoring nurses in best practices, and improving care across the system by creating care programs and removing barriers to best practices. Yet the central element of the CNS role is clinical expertise in a specialty area of practice, which keeps me aligned with direct clinical care. How does CNS practice differ from NP practice? The best care outcomes are achieved through interprofessional team-based care where physicians, RNs and APRNs, pharmacists, social workers, chaplains, and others collaborate to meet the total needs of a patient. Palliative care is one specialty where care is heavily dependent on teamwork and having full practice authority, including prescriptive authority, facilitates my CNS practice as an APRN team member. Thus, in palliative care practice, distinctions between CNS and NP as direct care providers may be obscured. Both APRNs provide similar care in the management of patients. For example, both CNS and NP may manage pain and other symptoms by prescribing pharmacologic agents and other nonpharmacological interventions. In the context of team-based care, physicians, pharmacists, and chaplains may also be involved in planning and delivering palliative care with some overlapping care but from the unique lens of their profession. Since CNS practice includes three domains, additional responsibilities arise. For example, recently several nurses shared during daily rounds that families with dying members were refusing basic care and essential symptom management medications. Confronted with refusal of care, the nurses were unsure of how to respond to these grief-stricken families. As the CNS team member, I mentored staff in best practices for communication and created a script for the nurses to use with families. Additionally, I collaborated with the physician and nursing management to devise a strategy to address this reoccurring communication challenge. In team-based care providers work together to achieve patient-centered outcomes. No one provider is “captain”, and no one works in isolation. It is particularly important that the CNS and NP collaborate for best practices in nursing care delivery. For example, should an NP colleague identify a reoccurring problem with the nursing staff delivering clinical care prescribed by a team member, I will take the lead on investigating, identifying the cause, reviewing best practice evidence, and working with the nurses, other stakeholders, and system administrators to devise a plan to resolve the problem for improved nursing practice. While all nurses, including APRNs are educated in using evidence to improve practice, it is the CNS that works most closely with staff nurses and managers to bring evidence-based change to nursing practice. And CNSs address sustainability of change by considering system-level implications, collaborating with organizational leaders and departments to assure success. Many a best practice change breaks down over time for failure to address corresponding system-level changes, such as modifying a pharmacy drug delivery procedure or procuring different supplies. Serving as a change agent is what makes the CNS role really appealing to many young nurses considering graduate school. However, much of a CNSs change related work takes place out of view of staff. The tendency for many elements of CNS practice to be invisible to others is one reason I created and facilitate a system-wide Moral Distress Consult Service. The service, which helps providers identify sources of moral distress and devise mitigation strategies, is available to staff nurses and APRNs, as well as all providers including physicians. CNS practice has been changing slowly as we are achieving full practice authority in many states resulting in a broader scope of autonomous authority. With full practice authority, our collective outcomes in direct care are taking on new dimensions. Our practice is unique among APRNs in that we integrate three domains of practice. In one domain, provider of direct care, CNSs should have access to an expanded scope of practice, including full practice authority with prescriptive privileges. As a result, at times our direct care practice may be the same as other APRN providers; however, it’s the sum of our practice outcomes across all three domains that make the CNS role unique. With the current post-pandemic workforce crisis, there has never been a more crucial time in healthcare for CNSs. Our mentoring, guidance, and clinical care support for specialty populations is needed in all settings, acute, long-term care, and ambulatory care. Our focus on quality and safety, evidence-based practice, and clinical care improvements are imperative. The CNS role and practice will continue to be shaped by external forces and individual employer demands. CNS practice outcomes, individually and collectively, constitute CNSs “unique contributions” and full practice authority only strengthens our options for assuring innovative, cost-effective, clinical care.