Brenda L. Lyon

Getting back on track: nursing's autonomous scope of practice. 1990.

S of you will say “We’ve never been off track, the practice of nursing is right on track!” However, I believe that the necessity of using the modifier “autonomous” to speak of nursing practice at this point in our evaluation tells an important story. It reflects that as a discipline we have for too long been sidetracked in our focus. None of nursing’s foremost leaders in the past felt the need to use such words when defining the focus of nursing or its unique practice focus. Yet today it is necessary to clarify, in some manner, that when speaking of nursing practice we are not referring to the practice of medicine. Over 130 years have passed since Nightingale gave us direction by essentially defining nursing in the context of treating the person, not the disease. She said that she used the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet and the proper selection and administration of diet—all at the least expense of vital power to the patient. Furthermore she purported that the purpose of nursing “is to put the patient in the best condition for nature and act upon him.” Despite the direction given by Nightingale, “we do not yet know exactly what nursing is.” Is it that the essence of nursing has not been defined, or is it that the real nature of nursing is too often adulterated for a variety of seemingly justifiable, although spurious, reasons? I believe it is the latter. The adulteration of nursing and the resulting lack of consensus within the discipline on what we are about is our most serious and pressing, yet least attended to, problem. Lacking consensus, we lack unified direction in resolving our problems in both the educational and practice arenas. We get off track because we are not sure of who we are, and to compensate we try to be everything to everybody and pretend that all nurses have the same competencies in practice. Not having a clear and distinct identity, we often look like and feel like nobodies or, at best, substitutes for other health team members. By losing sight of who we are and what nursing is, we create an unnecessary sense of inadequacy and experience a paucity of pride in the discipline. Because we want more respect than we get and we want more status than we have, we often fight the wrong battles. We fight for prescription writing privileges and also for third-party reimbursement for

Developing Clinical Nurse Specialist Practice Competencies

Background: In 1998, the National Association of Clinical Nurse Specialist (NACNS) developed the first ever core competencies for clinical nurse specialist (CNS) practice. Purpose: This article describes the method used to develop, validate, and revise CNS core practice competencies. Methods: The stepwise method of identifying core CNS competencies included content analysis of CNS position/job descriptions, extensive literature review, development by role experts, first-tier corroboration, second-tier corroboration encompassing stakeholder review, final review/editing, approval by the board of directors, and dissemination. Discussion: The process used by professional organizations to develop competencies and standards varies; however, it should be transparent and consist of adequate review and validation for accuracy and applicability by members of the representative group for whom the standards and competencies apply. Conclusions: The stepwise method used by the National Association of Clinical Nurse Specialist generated valid CNS core competencies and may be instructive to professional organizations interested in developing competencies and standards.

A vision of the future for clinical nurse specialists: prepared by the National Association of Clinical Nurse Specialists, July 2007.

This document represents a compilation of thought from the past, present, and future leaders of the National Association of Clinical Nurse Specialists (NACNS) and clinical nurse specialists in both Canada and the United States. It is our presentation of the vision of what the future holds for clinical nurse specialists (CNSs) as seen from the present. It has been a labor of love that has taken 17 months to create, validate, and edit into the document you see today. The work involved volunteers from a variety of backgrounds and represented CNS students, educators, and clinicians from a diverse set of specialties. These individuals may be invisible in the author list, but their contributions are invaluable. A call to the membership attending the annual conference held in Salt Lake City in March 2006 initiated the creation of this document. More than 100 volunteers stepped up to assist in the creation of a vision of the preferred future for CNSs. Past, present, and future leaders of NACNS were then commissioned to write sections of the paper, including content on education, practice, certification, and regulation of CNSs as visioned into the future. Once edited into a single document, the full paper was sent to a task force of NACNS members who volunteered to serve as reviewers. We are grateful for their comments, feedback, and edits. Those edits were incorporated, and the document was further scrutinized by a broad variety of stakeholders through a call on the CNS listserve for additional comments, feedback, and edits. This additional feedback was incorporated into the document, which was reviewed and approved by the NACNS Board of Directors in June 2007. Heartfelt thanks to the unnamed volunteers who spent time in thoughtful edit of the concepts presented here and how they fit with their current CNS practice. It is with honor that this author team is able to present to you the work of our members.

Integrating theory and research into practice.

An experiential learning assignment was imPlemented in an undergraduate nursing course. The purpose of the assignment was to integrate theory and research into a nursing practice activity. The authors describe the development, implementation, and evaluation of the assignment. Evaluation data indicated that the assignment was an appropriate way to prepare beginning nursing students for building knowledge about nursing as a scholarly discipline.

Reflecting on "getting back on track: nursing's autonomous scope of practice".

I is hard to imagine that more than 15 years have passed since I wrote this chapter for Norma Chaska’s book The Nursing Profession: Turning Points. Amazingly, but yet not so, most of the points I made in this chapter are still of paramount importance today— perhaps even more so. The focus of the original work published in 1990 was on nursing’s autonomous and unique scope of practice, which today, increasingly is the focus of discussion in educational and regulatory arenas. What has changed in the last 15 years and how has it colored the conversation? First, the National Association of Clinical Nurse Specialists (NACNS) did not exist until 1995. The downsizing of clinical nurse specialist (CNS) staff in many hospitals has been reversed. Although many more schools of nursing are adding new CNS programs or bringing back previously existing CNS programs, the demand for CNSs is outstripping the supply. In particular, the exploding interest on the part of hospitals to attain Magnet status has awakened the desire to hire CNSs who can facilitate the advancement of evidence-based nursing practice to cost-effectively improve patient outcomes. Thanks to NACNS, there is an advocate for the autonomous scope of nursing practice and the advanced practice of CNSs in nursing’s autonomous domain at national policy tables. Second, over the past 15 years, nurse practitioners (NPs) have made significant progress in obtaining the legislated authority to both diagnose and initiate prescriptive drug treatment for disease without physician supervision or collaboration. Although there are still many states where NPs must work in collaboration with physicians, the extension of autonomy to NPs in the diagnosis and treatment of disease in several states has facilitated the delivery of care to persons in need in medically underserved areas. As a result of a concerted effort in the 1970s by nurse leaders, states passed/amended nurse practice acts delineating nursing’s autonomous scope of practice within the legal scope of registered nursing practice, that is, the diagnosis of health conditions that require nursing interventions, teaching, and counseling to promote health. Additionally, each practice act contained language encompassing the delegated authority scope of RN practice in implementing physician orders/delegated treatments. Existing practice acts do not include the diagnosis and treatment of disease with prescriptive drugs as evidenced by the requirement in many states for NPs to obtain a second license covering these activities.

Reader responds to APRN Consensus Model.

I read with particular interest Thompson’s article ‘‘The APRN Consensus Model: Curricular Implications for Clinical Nurse Specialist Education.’’ The course, competency, and content grid for students in integrated curriculums was a helpful tool. However, I would like to correct some misinformation and also offer a differing view from Thompson’s on the importance of moving now to change curricula to meet the recommendations of the Advanced Practice Registered Nurse (APRN) Consensus Model. Thompson stated: ‘‘Educational programs are expected to be transitioning in 2012 tomeet the proposed full implementation of the model, which promotes the doctor of nursing practice (DNP) degree as entry into advanced nursing practiced, in 2015.’’ It is imperative that both clinical nurse specialist (CNS) faculty and CNSs in practice recognize that neither the American Association of Colleges of Nursing (AACN) nor any of the organizations that endorsed the Consensus Model have authority to mandate either the DNP for entry into practice or a 2015 deadline. In addition, the AACN has recently backed away from the 2015 recommended implementation date. At present, most DNPs are postmaster’s programs. Gilliss and Hill recently explained: In 2004, the American Association of Colleges of Nursing (AACN) Board and, subsequently, the membership, voted to support the implementation of theDNPas a replacement for theMSNdegree forAPRN education by 2015. In fact, this implementation date was intended to be an aspirational goal. However, it was interpreted as a mandate, setting off a remarkably rapid proliferation of DNP programs, the majority of which are post-masters programs. The intention that master’s programs stop educating APRNs has not taken hold and many schools have not closed their masters programs because they opened a DNP program. Thompson urged faculty to change CNS curricula to fit the APRN Consensus Model recommendations. However, faculty should carefully consider 2 of the cornerstone components of the proposed ConsensusModel that, if enacted, would be harmful to CNSs. First, the APRN Consensus Model eliminates specialty content/foci from master of science in nursing (MSN) programs, reducing areas of expertise in practice to only 5 population foci (family/individual across the life span; adult-gerontology; neonatal; pediatrics, women’s health/ gender related; or psychiatric-mental health). The change would be harmful to the CNS practice and the specialty populations served because (1) specialty populations (eg, critical care, oncology, cardiology, neurology) have unique advanced nursing care needs due, at a minimum, to the differing complexities of physiological/pathophysiological dynamics and corresponding medical therapeutics (this is why medicine specializes to meet the medical care needs of patients) as well as differing psychosocial and self-care demands inherent in the nature of their conditions; and (2) the context for the experience of symptoms and functional problems differs across specialty populations. Although phenomena of concern to nursing often occur across specialty populations (eg, pain, skin breakdown, delirium,malnutrition, nausea, fatigue, falls) and can be taught in ‘‘core’’ advanced nursing courses, specialty contextual and evidence-based knowledge is required for accurate diagnostic and interventional reasoning in thenursingdomain. Eliminating specialty practice from the curriculum puts patients at risk for not receiving the best possible nursing care that will prevent harm and/or enhance symptom control and functional ability. Second, themodel requires the same3 separate advanced (not defined) comprehensive courses in physiology/pathophysiology, pharmacology, and physical assessment for all APRN roles. The typical 3 ‘‘P’’ courses will necessarily continue to have a focus in the medical domain. Adding or switching to these courses is harmful to CNSs because it results in a decline in the number of credit hours that can be devoted to (1) the altered physiological phenomena of concern to nursing and the scientific knowledge required for accurate diagnostic and interventional reasoning in the nursing domain, (2) holistic health assessment, and the (3) unique pharmacological needs of specialty populations. Thecourses recommended in theAPRNConsensusModel seem to be based on a presumption that all APRN roles are purposed toward the provision of primary healthcare and/or are purposed heavily in the medical domain, evidenced in Apple’s reflection on the importance of the model: This model has become more important, especially with the passage of healthcare reform legislation, because APRNs (nurse practitioners, clinical nurse specialists, nurse midwives and nurse anesthetists) have an increasingly important role to play in the delivery of primary care.