Pamela A. Minarik

Statutory and regulatory issues for clinical nurse specialist (CNS) practice: ensuring the public's access to CNS services.

The practice environment of healthcare in the United States is fluid, dynamic, and sometimes chaotic. Statutory, regulatory, and credentialing requirements are critical elements of this changeable environment affecting clinical nurse specialists (CNSs) and other advanced practice nurses (APNs). CNSs are estimated to comprise approximately 54,000 APNs, based on the 2000 National Sample Survey of Registered Nurses. Although statutes and regulations related to APNs are reviewed regularly, there has not been a critical analysis of statutes and regulations specifically governing CNS practice in the United States. This lack is largely due to the absence of a national association devoted to CNSs before 1995. However, recently there has been a resurgence of interest and need for CNS services. Therefore, it is particularly important that any statutory and/or regulatory barriers to CNS practice be removed. In 1998, the National Association of Clinical Nurse Specialists Legislative and Regulatory Committee embarked on a critical analysis of state statutes and regulations governing CNS practice. All 50 state boards of nursing and the District of Columbia board of nursing were requested to send copies of their statutes and regulations governing CNS practice. Responses were received from 48 states. This article summarizes the state of regulation of CNS practice and identifies significant barriers to CNS practice that should be systematically addressed. The patchwork quilt of CNS regulation that varies from state to state results in over-restrictive and underinclusive provisions that preclude ease of reciprocity and deprive the public full access to CNS services. Recommendations for addressing the barriers are made.

Sleep Disturbance in Midlife Women

Emphasizing midlife women, this review describes sleep and compares self-report sleep data with objective findings from laboratory studies of women. Sleep disturbance is a more prevalent complaint for women than men. Not due to chronologic age per se, it is associated with menopausal symptoms and most importantly with comorbidities and stress. Sleep problems in midlife women should not be attributed only to the menopausal symptom experience and should trigger a clinical evaluation. Assessment guidelines are included.

Responding to 'difficult' patients

The best way to handle that difficult patient is to confront their behaviors directly. If they are complaining about your performance, ask them to be direct and tell you exactly what you did wrong and how they feel you could have been better. Maybe they are right and you are not aware of how you are, but maybe they don’t understand your job and responsibilities and with a little education they can learn something.

Ethics in Japanese health care: a perspective for clinical nurse specialists.

Bioethical issues relevant to nurses in Japan are described in this article. Significant Japanese values and behavior patterns, the impact of religion on ethical concerns, patient and family roles in illness, and relationships with the physician are described. Within this context, Japanese nursing involvement in ethics and selected ethical issues are explored with examples.

Issue: Competence assessment and competency assurance of healthcare professionals.

CLIN ICAL NURSE SPEC IALI ST specialty nursing certifying organizations, The Pew Health Professions Commission, the Citizen Advocacy Center (CAC) (www.cacenter.org), the Council on Licensure, Enforcement and Regulation (CLEAR) (www.clearhq.org), and the Federation of Associations of Regulatory Boards (www.farb.org). The latter 3 organizations are resources for professional regulatory board members; as such, they do not represent a particular healthcare professional group. The CAC is a resource for the public members of regulatory boards and other governing bodies who serve as representatives of the public interest. The CAC advocates for change in the measurement of healthcare professionals’ competence, and, in 2004, published a road map of actions to achieve continuing competence assurance. The road map will be discussed later. The work of The Pew Health Professions Commission Taskforce on Health Care Workforce Regulation prompted the current debate about healthcare professionals’ regulation and continuing competence. Regarding all healthcare professions, the 1998 report identified major concerns about consumer protection, quality of care, and the competence of professionals to provide quality care. The taskforce observed that it is possible for a practitioner’s competence to diminish years after initial licensure, and, further, that continuing education hours, the most common requirement for continuing competence, do not guarantee competence. The report recommended that state boards should set not only competence standards for entry into practice but also require healthcare practitioners to demonstrate competence throughout their careers. Writing about the issue of continued competence, Lyon and Boland reported that nursing associations agreed with the basic premise that continued competence of healthcare practitioners is critical to a quality healthcare system but urged that documentation of competency be deferred to professional associations. Lyon and Boland defined the domains of competence as knowledge competence, technical competence, cultural competence, and communication competence. From the Yale University School of Nursing, New Haven, Conn.

The plight of the psychiatric clinical nurse specialist: the dismantling of the advanced practice nursing archetype.

If there were an endangered species list for nursing practice, the psychiatric-mental health clinical nurse specialist (PMHCNS) would surely now be at the very top. Changes in the delivery of mental healthcare over the past 2 decades have clouded the value of the traditional PMHCNS role and pushed this specialist to the brink of extinction. The latest assault was the announcement by the American Nurses Credentialing Center (ANCC) in November 2011 that it was retiring the Adult and Child/ Adolescent Psychiatric Clinical Nurse Specialist examinations as well as the Adult Psychiatric and Mental Health Nurse Practitioner examination by 2014. Currently certified PMHCNSs can renew their credentials using clinical practice hours and professional development activities. American Nurses Credentialing Center is making these changes to the certification examinations as part of the implementation of the new Consensus Model for APRN (advanced practice registered nurse) Regulation: Licensure, Accreditation, Certification & Education, also known as the LACE or the APRN Consensus Model (www.nurse credentialing.org). After that date, any nurse wanting to pursue practice in advanced psychiatric nursing will have only 1 optionVthe Family Psychiatric Nurse Practitioner (across the life span) certification. With this announcement, we fear that the remaining PMHCNS programs will transition to nurse practitioner (NP) programs, leaving those of us who proudly hold the CNS credential to join the ranks of the endangered species. This would be particularly troublesome for child and adolescent psychiatric CNSs whose patient population lacks an adequate number of providers. Many CNSs are now asking how this could happen to the first and historically one of the most influential nursing specialty groups, is it inevitable, and what can we do about it?

Collaboration between service and education: perils or pleasures for the clinical nurse specialist?

A critical challenge to nursing today is the development of effective models of service and education collaboration. Collaborative roles that include formal responsibilities for both education and service offer many opportunities and challenges for the clinical nurse specialist; they also require a juggling act. This paper describes the authors collaborative role in a university medical center with an emphasis on the perils and pleasures of the role. Also included is a brief history of the development of collaborative roles, the strengths and benefits of collaborative roles, and a presentation of selected collaborative models using a framework from the literature.

Advanced practice nurses: a new skirmish in the continuing battle over scope of practice.

I n 1999, this column described the hotly contested efforts of advanced practice nurses (APNs) to define in federal regulations relationships between APNs and physicians that recognized the full scope of practice and quality of care of APNs. With the new skirmish described here, the battle continues. In June 2006, the deceptively titled Healthcare Truth and Transparency Act (HR 5688) was introduced by Congressman Sullivan, with co-sponsorship by Congressmen Green (Texas), and was referred to the Committee on Energy and Commerce. Eleven cosponsors, all Republicans, signed onto the legislation, including Representative Charles Bass (NH), Representative Michael Bilirakis (FL), Representative Michael C. Burgess (Texas), Representative Barbara Cubin (Wyoming), Representative John R. Randy Kuhl (New York), Representative Jim McDermott (Washington), Representative Joseph R. Pitts (PA), Representative Ted Poe (Texas), Representative John J. H. Joes Schwartz (Michigan), Representative Pete Sessions (Texas), Representative John E. Sweeney (NY), and Representative Gene Green (Texas), who withdrew his co-sponsorship on June 28, 2006. This bill pits organized physician groups against APNs and other nonphysician providers. The bill, designed to limit selected scopes of practice, creates a federal cause of action against nonphysician healthcare professionals who ‘‘make any deceptive or misleading statement, or engage in any deceptive or misleading act, that deceives or misleads the public or a prospective or current patient that such person is a medical doctor, doctor of osteopathic medicine, doctor of dental surgery, or doctor of dental medicine or has the same or equivalent education, skills, or training.’’ Penalties for misleading consumers about their licensure, scope of practice or expertise, or misrepresentation include treatment of the act as a violation of section 5 of the Federal Trade Commission Act (15 U.S.C. 45). The bill would compel the Federal Trade Commission to conduct studies of what are perceived unfair and deceptive acts and practices:

Cognitive assessment of the cardiovascular patient in the acute care setting.

In acute care setting, patients with cardiovascular disease are at risk for changes in cognition caused by both disease and treatments. Cognitive impairment can result in a number of problems, such as communication difficulties, compromised safety, self-care deficits, and behavioral problems. This article reviews the role of the nurse in cognitive assessment, the incidence of cognitive complications in the cardiovascular patient population, the disorders of delirium and dementia, suggestions for and components of a cognitive assessment, and standardized tools for cognitive assessment.

Re: editorial entitled "clinical nurse specialist as attending nurse".

We could not agree more strongly with Jan Fulton’s suggestion that the clinical nurse specialist (CNS) as ‘‘attending nurse’’ is an idea whose time has come. In our agreement, we do not imply a need for change of title or regulation but rather a recognition of stature earned. The need in hospitals and health facilities for patient care quality and safety and the development of both expertise and collaborative teamwork of nurses and other healthcare providers are clear and recognized. The CNS is well prepared as an attending nurse. However, we would not have gone to the physician literature to find the kernel of the idea. Diane Cooper, attributing the idea to her colleague Mildred Czar, wrote in 1983 that the CNS with more than 5 years of experience ‘‘should be the essence of the refined expert,’’ or the attending nurse. According to Cooper, CNSs should achieve the refinement, excellence, stature, and desire for learning exemplified by top attending physicians. Later, in our book Clinical Nurse Specialist: Implementation and Impact, Cooper described a statue in Philadelphia named Consultation, which depicts a group of 5 physicians in different roles and which captures the peer esteem earned by each. The attending physician in the statue stands as a resource for others; they value his direction because it is based in deep clinical experience, and he listens and hears differently compared to the others in the group. Then Cooper envisioned a future time (now?) when a similar statue will exist but the depicted professionals will be nurses and the focal point of the statue will be the CNSVthe attending nurse exuding confidence and the skill of years of direct clinical activity with patients. The literature now yields models for attending nurses. The attending nurse model in adolescent psychiatry was developed by Niemela et al and further described by Moreau et al. Watson and Foster described the attending nurse caring model as a way to address the nursing shortage, the crisis of patient safety, and care dilemmas of our current healthcare system. We suspect that there are many more examples of effective attending nurse models. Yes! The time is now. However, we have promulgated the idea in the past, and now it is time to publish exemplars of CNSs as attending nurses.