AACN Advanced Critical Care Volume 26, Number 1, pp. 58-63 © 2015 AACN
Clinical Nurse Specialist Regulation The Maryland Experience Paul Thurman, RN, MS, ACNPC, CCNS, CCRN
ABSTRACT High-quality care will continue to be a driver in the evolution of today’s health care environment. Ensuring effective, cost-conscious, quality care is the core of clinical nurse specialist (CNS) practice. The CNS practice varies by state, depending on each state’s Nurse Practice Act. Some states have separate scopes of practice for CNSs, including pre-
scriptive authority, whereas some states do not recognize CNS practice as different from the practice of the registered nurse. The journey to state recognition and title protection for the CNS role in the state of Maryland is described. Keywords: clinical nurse specialist, consensus model, scope of practice, title protection
T
he role of the clinical nurse specialist (CNS) was developed as an expanded nursing role and the first advanced practice role that required a master’s degree. The National Association of Clinical Nurse Specialists (NACNS) defines CNSs as advanced practice nurses who are licensed registered nurses with graduate nursing degrees, at the master’s and/or doctoral levels, in a specialty.1 This group of professionals represents the second largest number of advanced practice registered nurses (APRNs) in the United States and functions in diverse settings, including hospitals, rehabilitation facilities, outpatient offices and private clinics, and nursing homes.1 The stability of the CNS role has varied since its inception. As the financial picture of health care shifted in the 1980s and 1990s, the CNS role was no longer perceived as an integral contributor to direct patient care, resulting in loss of CNS positions, whereas the market grew for other APRN roles.2 Currently, health care in the United States is undergoing more change as the system is reformed through changes in reimbursement structures. In the pay-for-performance model, organizations whose patients have complications associated with low quality of care will receive reduced reimbursement. Since passage of the Patient Protection and Affordable Care Act3 and
publication of the Institute of Medicine’s The Future of Nursing,4 APRNs have achieved significant recognition and gains in the health care marketplace. In 2013, CNNMoney/PayScale5 rated the top 100 careers with big growth, great pay, and satisfying work. The CNS role was rated the second best job out of 100 careers.5 As health care reform shifts the focus from fee-for-service to pay-for-performance, the demand for CNSs will continue to grow. Clinical nurse specialists possess distinct and advanced-level competencies (Table 1) that enable them to meet contemporary societal needs for improving health care quality and safety, maximizing health outcomes and reducing health care costs.2 These skills are critically important to address the health of a rapidly aging population, fragmentation of care across diverse health care settings, the problems of unequal access to care, and managing comorbidity and chronic disease. For CNSs to optimally contribute to improving the quality of care for patient populations, they
Paul Thurman is Clinical Nurse Specialist, University of Maryland Medical Center, 613 Jasper St, Baltimore, MD 21201 ([email protected]). The author declares no conflicts of interest. DOI: 10.1097/NCI.0000000000000067
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could have a dramatic effect for currently practicing APRNs who can be grandfathered at the state level with legislative changes to meet Consensus Model requirements. Those who are grandfathered will be able to continue to practice in that state, but if they move to a different state that has enacted the guidelines, they would be ineligible to practice until they met those requirements. The guidelines provide specific directions about grandfathering.6 To fully implement the Consensus Model, each state must enact legislation to align their Nurse Practice Act with Consensus Model requirements. States are at varying levels of implementation of the proposed Consensus Model guidelines. As of May 2014, 11 states have fully implemented the guidelines7 (see Table 2). Twenty-five states grant CNSs independent practice,8 with 17 states granting independent prescriptive authority.9 The Maryland Nurse Practice Act provides for the scope of practice for the registered nurse, certified registered nurse anesthetist, CNP, certified nurse midwife, and nurse psychotherapist. Clinical nurse specialists practice under the scope of practice for the registered nurse. In Maryland, the legislature enacts statutes. Administrative agencies adopt, amend, and repeal regulations under the authority granted to them by statutes. Unless the legislature has created an exemption, agencies must follow the procedures in the Administrative Procedure Act when adopting, amending, or repealing regulations. Maryland law grants the Maryland Board of Nursing (MBON) the authority to adopt regulations as may be
Table 1: Examples of Clinical Nurse Specialist Competencies That Are Key in the Current Health Care Environmenta Lead change in health organizations Develop evidence-based programs to prevent avoidable complications Coach individuals with chronic diseases to prevent costly hospital readmissions Manage the care of diverse, complex, and/or vulnerable populations Improve transitional care between hospital, community caregivers, and home Facilitate teams in acute care and other facilities to improve care quality and safety Educate, train, and grow a highly skilled and critically thinking nursing workforce a
Data from Bell.2
must be recognized in all states to practice as independent APRNs. This article describes one state’s journey to achieve recognition and title protection for CNSs as APRNs. APRN Model and Regulation The 2008 Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education has become the model for the regulation of the 4 APRN roles: certified nurse practitioner (CNP), certified registered nurse anesthetist, certified nurse midwife, and CNS.6 It defines APRN practice, describes the APRN regulatory model, identifies the titles to be used, defines specialty, describes the emergence of new roles and population foci, and presents strategies for implementation. Advanced practice registered nurses are educated in 1 of the 4 roles and in at least 1 of 6 population foci: family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women’s health/ gender-related, or psychiatric/mental health. Education is broad based, including 3 separate graduate-level courses in advanced physiology/ pathophysiology, physical/health assessment, and pharmacology, also known as the 3 Ps, with appropriate clinical experiences. Education, certification, and licensure of an individual must be congruent in terms of role and population foci. Advanced practice registered nurses may specialize, but they cannot be licensed solely within a specialty area. Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by professional organizations.6 These guidelines
Table 2: States That Have Fully Implemented the Consensus Modela Connecticut Hawaii Idaho Minnesota Montana Nevada New Mexico North Dakota Rhode Island Utah Vermont a
Data from National Council of State Boards of Nursing.7
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necessary to carry out the provisions of the law. The MBON is mandated to regulate the practice of registered nurses, licensed practical nurses, nurse anesthetists, nurse midwives, nurse practitioners, nursing assistants, medication technicians, and electrologists. Maryland currently has implemented between 50% and 75% of the Consensus Model.7
Maryland Experience
On a February afternoon in 2010, 3 CNSs initiated efforts to form a local chapter of the NACNS for Maryland. It was to be a forum for common ground where challenges that CNSs faced in their current roles could be discussed and solutions shared. Invitations were sent to national NACNS members in Delaware, Maryland, and Virginia. In addition, CNSs invited colleagues in personal informal networks. The first meeting of what became the Chesapeake Bay Affiliate of the NACNS (CBANACNS) was held in the Spring of 2010. The obligatory bylaws were crafted and officers were elected. Because of universal concern that CNSs were not recognized as APRNs in Maryland, an agreement was reached that one of the first actions of this group would be examination of current state legislative issues affecting all APRNs and seeking support of the MBON for drafting new regulations for CNS licensure, accreditation, certification, and education. The Consensus Model requirements were reviewed and discussed in depth. Most CNSs were not familiar with this document or the impact it could have on their practice. The topic generated a great deal of interest. Confusion arose about the need for national certification (in the CNS role and a particular population) in addition to existing specialty certification. Several CNSs lacked specialty certification because no examination was available for their area of practice. Most had completed their graduate education many years before the recent curriculum changes that prepare current students for new certification examination eligibility. The director of Advanced Practice for the MBON was invited to the next CBANACNS meeting to discuss CNS practice in Maryland. She noted that in the 1980s, CNSs in the state had petitioned the MBON for APRN recognition alongside the nurse psychotherapists (an advance practice mental health nurse). The nurse psychotherapist regulations were developed and implemented, but the CNS regulations were never developed because of lack of follow-up by the CNSs. She described the process that would be needed for CNS regulation and indicated that the MBON would entertain such a petition.
CNS Regulation
Today, regulation of CNS practice varies from state to state, and the existing body of CNS professionals is diverse in educational and practice backgrounds. Clinical nurse specialists who recently graduated from academic programs that are in compliance with the Consensus Model will possess the academic credentials necessary to apply for certification and to gain licensure. Those most challenged by these new regulations are our most senior and experienced CNSs. If their original education does not meet the new educational requirements of the Consensus Model and they did not take a certification examination before the change in eligibility requirements, they may not be eligible to be licensed as APRNs. Their knowledge and skills must be protected, and in many cases, states will need to find ways to grandfather them into licensure. Title protection is supported by the Consensus Model to ensure that the CNS title will be restricted to use by nurses who possess all requisite education and national certification and can be licensed as CNSs. Without title protection, individuals who may not possess the appropriate education and certification could call themselves CNSs.10 Standardizing CNS regulations in nurse practice acts across the United States will protect the CNS title and ensure that only qualified individuals call themselves CNSs. Implementation of the Consensus Model regulations may make it unlawful for some CNSs to retain their title if they cannot meet academic and certification requirements for licensure and cannot be grandfathered into licensure. Clinical nurse specialists in states that do not currently license CNS practice must come together to collaborate with their state Boards of Nursing to develop or expand legislation and regulations that recognize and license CNSs as APRNs. Clinical nurse specialists in states that currently license CNSs should critically evaluate their Nurse Practice Act to determine whether it is consistent with Consensus Model regulations.
Drafting the Regulations
A task force of members from the CBANACNS reviewed CNS regulations from State Boards 60
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of Nursing across the United States and drafted a set of regulations that they believed were consistent with the requirements of the Consensus Model and included grandfathering language agreed on by the membership. The task force felt strongly that nurses with graduate nursing education who had been actively practicing in the CNS role should be able to retain their ability to practice as CNSs. The intent was to protect rather than marginalize the role further by disenfranchising CNSs who had not or could not obtain national certification. The draft petition was circulated to members of CBANACNS as well as CNS member colleagues. A revised version of the regulations was presented as a petition to the MBON on January 25, 2011. The Board approved the petition and agreed to draft a formal set of CNS regulations for the Maryland Nurse Practice Act. Members of CBANACNS met with MBON staff to formalize the regulations during the next few months (Table 3). On September 8, 2011, CNSs from across the state attended a public meeting of the
MBON to review the newly proposed regulations. Significant discussion was held about the grandfathering clause. Specific grandfathering language was established that was agreeable to all stakeholders; an applicant would have 2 years to achieve a national certification where available, a requirement for state certification. Ultimately, the chapter of the State Nurse Practice Act for nurse psychotherapists was rewritten and subsumed under the broader category of CNS regulations. The CNS scope of practice for Maryland is grounded in the NACNS Core Competencies as well as other competencies defined by CNS certifying organizations (American Nurses Credentialing Center, American Association of Critical-Care Nurses Certification Corporation, etc). Practice must be in accordance with the state statute; any consideration for prescriptive authority would require legislation to change the statute. Once the regulations were drafted, they were published in the State Register on July 13, 2012, and were open for comment until August 13, 2012. No changes were
Table 3: Clinical Nurse Specialists Involved in Drafting the Petition for Clinical Nurse Specialist Recognition and Title Protection in Maryland Sharon J. Olsen, RN, PhD, AOCN, Assistant Professor, Johns Hopkins University School of Nursing Kathryn T. Von Rueden, RN, MS, ACNS-BC, FCCM, Assistant Professor, University of Maryland School of Nursing Paul Thurman, RN, MS, ACNPC, CCNS CCRN, CNRN, R. Adams Cowley Shock Trauma Center, University of Maryland Medical System Michelle Salmon, RN, MSN, ACNP, CNS-BC, Sinai Hospital of Baltimore Melinda Sawyer, RN, MSN, CNS-BC, Patient Safety Officer, Department of Medicine, The Johns Hopkins Hospital Pam O’Keefe, RN, MS, C-EFM, Clinical Nurse Specialist Perinatal, Johns Hopkins Bayview Medical Center MiKaela Olsen, RN, MS, OCN, Oncology and Hematology Clinical Nurse Specialist, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Samantha Young, RN, MS, CCRN, CCNS, ACNPC, Weinberg Intensive Care Unit, The Johns Hopkins Hospital Brenda K. Shelton, RN, MS, CCRN, AOCN, Clinical Nurse Specialist, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Barbara Van de Castle, MSN, OCN, BC, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Susan Immelt, RN, PhD, Assistant Professor, Johns Hopkins University School of Nursing Jocelyn Andersen, RN, MSN, Johns Hopkins University School of Nursing Jodi Shaefer, RN, PhD, Assistant Professor, Johns Hopkins University School of Nursing Laura Kress, RN, MAS, Assistant Director of Nursing Practice, The Johns Hopkins Hospital Mary P. McCaffrey, MSN, RNC-OB, CNS-BC, University of Maryland Medical Center Elizabeth “Ibby” Tanner, RN, PhD, FNGNA, Associate Professor, Johns Hopkins University School of Nursing and School of Medicine, Division of Geriatric Medicine and Gerontology Core Faculty, Center on Aging and Health 61 Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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advised and the CNS regulations became law—Code of Maryland Regulations Title 1011 (The Department of Health and Mental Hygiene. Subtitle 27 Board of Nursing. Chapter 27 Practice of Clinical Nurse Specialist). The requirements for APRN licensure by the regulation are a current license to practice registered nursing in Maryland, certification as a CNS from the American Nurses Credentialing Center or any other certifying body recognized by the MBON, completion of the application, and payment of required fees. Maryland law assigns approval of regulatory changes in practice to the MBON. This process facilitated the relatively rapid development and approval of the new CNS regulations. Today, all CNSs in Maryland must be licensed as APRNs by the MBON. However, at this time, no CNS has been licensed in the 2 years since the adoption of the regulations. Operationalization of the new CNS regulations has been plagued by technical challenges associated with the application process and development of an internal database designed to track CNS practice. Additional problems included turnover in MBON staff and officers, including the director of Advanced Practice. At an August 2014 public meeting, the MBON assured members of the CBANACNS that progress had been made. An individual has been hired to review applications and begin the state certification process. Figure 1 illustrates the timeline. Organizaon
February 2010 Incepon of Local CNS Organizaon April 2010 CBANACNS Formed June 2010 Goals Set Including Title Protecon
Practicing to the Fullest Extent of Our Education
Changes in the delivery of health care make it necessary that nurses practice to the full extent of their education.12 Maryland law assigns approval of regulatory changes in practice to the MBON. This process facilitated the relatively rapid development and approval of the new CNS regulations. However, changes in prescriptive authority require legislative approval in Maryland. This process is much more complex and will require a return to the negotiation table to expand this area of APRN practice advocated by the Consensus Model. Other states have included prescriptive authority in the CNS’s scope of practice. Little direction has been provided to guide states in preparing their CNSs for prescriptive authority, as many may have graduated prior to the 3 Ps requirement. In 2005, Oregon added independent prescriptive authority to the scope of practice for CNSs.12 The new privilege gave CNSs the same authority granted to nurse practitioners, including autonomous prescribing and dispensing of Schedule II-V medications. At that time most CNS programs did not prepare graduates for prescriptive authority. The language of the statute granted the board authority to interpret how to establish requirements for CNSs that would ensure their competency to prescribe. Oregon incorporated competencybased assessment with a refresher course and/or
Peon
Regulaon
October 2010 MBON Director of APNs Perspecve December 2010 Peon Task Force January 2011 MBON Presentaon of Peon
June 2011 MBON and CBANACNS Dra Regulaon September 2011 Dra Regulaons Presented to Open Forum July 2012 Dra Regulaons Published for Public Comment August 2012
Regulaons Became Law August 2014 Implementaon Incomplete
Figure 1: Maryland timeline of the clinical nurse specialist regulation change process. CNS indicates clinical nurse specialist; CBANACNS, Chesapeake Bay Affiliate of the National Association of Clinical Nurse Specialists; MBON, Maryland Board of Nursing. 62 Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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a period of supervised practice. This method is similar to a nurse who is reentering practice after a prolonged absence. This model can assist states as they transition their practice acts to include legal autonomous prescribing for CNSs. Clinical nurse specialists must shape the framework for their practice by building CNS prescriptive authority as an autonomous APRN role within established nursing specialty expertise by collaborating with regulators, educators, and national certifying bodies.
Acknowledgments I thank Sharon J. Olsen, RN, PhD, AOCN, for the spark that ignited the flame burning in the hearts of CNSs across Maryland. I also thank those listed in Table 3 for their contributions in drafting the initial petition to the MBON and the founding members of the Chesapeake Bay Affiliate of NACNS, including its first president Reba McVay, RN, MSN; treasurer Mary P. McCaffrey, MSN, RNC-OB; and secretary Candace L. Rouse, MSN, RNC, CNS-BC. REFERENCES
Discussion Before the regulations supported in the Consensus Model can be fully implemented, each state must enact legislation bringing their Nurse Practice Act into alignment with the proposals in the document. Nursing organizations, educators, accreditation and certification bodies, and individual APRNs will need to collaborate to accomplish Consensus Model implementation across the country. Individual CNSs must familiarize themselves with the Consensus Model and lobby for their right to practice to the full extent of their education or be left to practice as others see fit. The demand for CNSs will continue to increase, as organizations look to reduce costs and improve quality of care. Clinical nurse specialists are very effective at working within and across systems to align scientific evidence, resources, provider groups, and organizational policies and practices for improved clinical outcomes. In some areas of the country, the current shortage of CNSs can make this job very difficult to fill. Geographic areas with strong CNS academic programs have a steady stream of graduates, and finding applicants is not an issue.13 Maryland CNSs have now guaranteed a future where the CNS has a defined scope of practice and will meet national standards for practice. The journey to enable CNSs across this nation to practice to the fullest extent of their preparation is far from over, but it has begun.
1. National Association of Clinical Nurse Specialists. Organizing framework and CNS core competencies. www.nacns.org/docs/CNSCoreCompetencies.pdf. Published 2010. Accessed November 4, 2014. 2. Bell L. Issues in advanced practice. Is the clinical nurse specialist role still viable? AACN Adv Crit Care. 2006; 17(4):373. 3. The Patient Protection and Affordable Care Act (PPACA). Pub L No. 111-148, 124 Stat 119 (2010). 4. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2010. 5. Best Jobs in America. www.Money.CNN.com/pf/bestjobs. Published 2013. Accessed November 4, 2014. 6. APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. www.aacn .nche.edu/education-resources/APRNreport.pdf. Published 2008. Accessed November 4, 2014. 7. National Council of State Boards of Nursing. Scoring grid for implementation status of the Consensus Model. www.ncsbn.org/5397.htm. Published 2013. Accessed November 4, 2014. 8. National Council of State Boards of Nursing. CNS independent practice map. www.ncsbn.org/5406.htm. Accessed November 4, 2014. 9. National Council of State Boards of Nursing. CNS independent prescribing map. www.ncsbn.org/5410.htm. Accessed November 4, 2014. 10. Hudspeth R. Understanding clinical nurse specialist regulation by the boards of nursing. Clin Nurse Spec. 2009;23(5):270–277. 11. State of Maryland. 10.27.27 Practice of Clinical Nurse Specialists. Code of Maryland Regulations. www.dsd .state.md.us/comar/comar.aspx. Published 2012. Accessed November 4, 2014. 12. Klein TA. Implementing autonomous clinical nurse specialist prescriptive authority: a competency-based transition model. Clin Nurse Spec. 2012;26(5):254–262. 13. Harwood K. The clinical nurse specialist role: perspectives of an administrator. Clin Nurse Spec. 2013;27(6): 281–282.
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Clinical Nurse Specialist Regulation The Maryland Experience Paul Thurman, RN, MS, ACNPC, CCNS, CCRN
ABSTRACT High-quality care will continue to be a driver in the evolution of today’s health care environment. Ensuring effective, cost-conscious, quality care is the core of clinical nurse specialist (CNS) practice. The CNS practice varies by state, depending on each state’s Nurse Practice Act. Some states have separate scopes of practice for CNSs, including pre-
scriptive authority, whereas some states do not recognize CNS practice as different from the practice of the registered nurse. The journey to state recognition and title protection for the CNS role in the state of Maryland is described. Keywords: clinical nurse specialist, consensus model, scope of practice, title protection
T
he role of the clinical nurse specialist (CNS) was developed as an expanded nursing role and the first advanced practice role that required a master’s degree. The National Association of Clinical Nurse Specialists (NACNS) defines CNSs as advanced practice nurses who are licensed registered nurses with graduate nursing degrees, at the master’s and/or doctoral levels, in a specialty.1 This group of professionals represents the second largest number of advanced practice registered nurses (APRNs) in the United States and functions in diverse settings, including hospitals, rehabilitation facilities, outpatient offices and private clinics, and nursing homes.1 The stability of the CNS role has varied since its inception. As the financial picture of health care shifted in the 1980s and 1990s, the CNS role was no longer perceived as an integral contributor to direct patient care, resulting in loss of CNS positions, whereas the market grew for other APRN roles.2 Currently, health care in the United States is undergoing more change as the system is reformed through changes in reimbursement structures. In the pay-for-performance model, organizations whose patients have complications associated with low quality of care will receive reduced reimbursement. Since passage of the Patient Protection and Affordable Care Act3 and
publication of the Institute of Medicine’s The Future of Nursing,4 APRNs have achieved significant recognition and gains in the health care marketplace. In 2013, CNNMoney/PayScale5 rated the top 100 careers with big growth, great pay, and satisfying work. The CNS role was rated the second best job out of 100 careers.5 As health care reform shifts the focus from fee-for-service to pay-for-performance, the demand for CNSs will continue to grow. Clinical nurse specialists possess distinct and advanced-level competencies (Table 1) that enable them to meet contemporary societal needs for improving health care quality and safety, maximizing health outcomes and reducing health care costs.2 These skills are critically important to address the health of a rapidly aging population, fragmentation of care across diverse health care settings, the problems of unequal access to care, and managing comorbidity and chronic disease. For CNSs to optimally contribute to improving the quality of care for patient populations, they
Paul Thurman is Clinical Nurse Specialist, University of Maryland Medical Center, 613 Jasper St, Baltimore, MD 21201 ([email protected]). The author declares no conflicts of interest. DOI: 10.1097/NCI.0000000000000067
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could have a dramatic effect for currently practicing APRNs who can be grandfathered at the state level with legislative changes to meet Consensus Model requirements. Those who are grandfathered will be able to continue to practice in that state, but if they move to a different state that has enacted the guidelines, they would be ineligible to practice until they met those requirements. The guidelines provide specific directions about grandfathering.6 To fully implement the Consensus Model, each state must enact legislation to align their Nurse Practice Act with Consensus Model requirements. States are at varying levels of implementation of the proposed Consensus Model guidelines. As of May 2014, 11 states have fully implemented the guidelines7 (see Table 2). Twenty-five states grant CNSs independent practice,8 with 17 states granting independent prescriptive authority.9 The Maryland Nurse Practice Act provides for the scope of practice for the registered nurse, certified registered nurse anesthetist, CNP, certified nurse midwife, and nurse psychotherapist. Clinical nurse specialists practice under the scope of practice for the registered nurse. In Maryland, the legislature enacts statutes. Administrative agencies adopt, amend, and repeal regulations under the authority granted to them by statutes. Unless the legislature has created an exemption, agencies must follow the procedures in the Administrative Procedure Act when adopting, amending, or repealing regulations. Maryland law grants the Maryland Board of Nursing (MBON) the authority to adopt regulations as may be
Table 1: Examples of Clinical Nurse Specialist Competencies That Are Key in the Current Health Care Environmenta Lead change in health organizations Develop evidence-based programs to prevent avoidable complications Coach individuals with chronic diseases to prevent costly hospital readmissions Manage the care of diverse, complex, and/or vulnerable populations Improve transitional care between hospital, community caregivers, and home Facilitate teams in acute care and other facilities to improve care quality and safety Educate, train, and grow a highly skilled and critically thinking nursing workforce a
Data from Bell.2
must be recognized in all states to practice as independent APRNs. This article describes one state’s journey to achieve recognition and title protection for CNSs as APRNs. APRN Model and Regulation The 2008 Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education has become the model for the regulation of the 4 APRN roles: certified nurse practitioner (CNP), certified registered nurse anesthetist, certified nurse midwife, and CNS.6 It defines APRN practice, describes the APRN regulatory model, identifies the titles to be used, defines specialty, describes the emergence of new roles and population foci, and presents strategies for implementation. Advanced practice registered nurses are educated in 1 of the 4 roles and in at least 1 of 6 population foci: family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women’s health/ gender-related, or psychiatric/mental health. Education is broad based, including 3 separate graduate-level courses in advanced physiology/ pathophysiology, physical/health assessment, and pharmacology, also known as the 3 Ps, with appropriate clinical experiences. Education, certification, and licensure of an individual must be congruent in terms of role and population foci. Advanced practice registered nurses may specialize, but they cannot be licensed solely within a specialty area. Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by professional organizations.6 These guidelines
Table 2: States That Have Fully Implemented the Consensus Modela Connecticut Hawaii Idaho Minnesota Montana Nevada New Mexico North Dakota Rhode Island Utah Vermont a
Data from National Council of State Boards of Nursing.7
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necessary to carry out the provisions of the law. The MBON is mandated to regulate the practice of registered nurses, licensed practical nurses, nurse anesthetists, nurse midwives, nurse practitioners, nursing assistants, medication technicians, and electrologists. Maryland currently has implemented between 50% and 75% of the Consensus Model.7
Maryland Experience
On a February afternoon in 2010, 3 CNSs initiated efforts to form a local chapter of the NACNS for Maryland. It was to be a forum for common ground where challenges that CNSs faced in their current roles could be discussed and solutions shared. Invitations were sent to national NACNS members in Delaware, Maryland, and Virginia. In addition, CNSs invited colleagues in personal informal networks. The first meeting of what became the Chesapeake Bay Affiliate of the NACNS (CBANACNS) was held in the Spring of 2010. The obligatory bylaws were crafted and officers were elected. Because of universal concern that CNSs were not recognized as APRNs in Maryland, an agreement was reached that one of the first actions of this group would be examination of current state legislative issues affecting all APRNs and seeking support of the MBON for drafting new regulations for CNS licensure, accreditation, certification, and education. The Consensus Model requirements were reviewed and discussed in depth. Most CNSs were not familiar with this document or the impact it could have on their practice. The topic generated a great deal of interest. Confusion arose about the need for national certification (in the CNS role and a particular population) in addition to existing specialty certification. Several CNSs lacked specialty certification because no examination was available for their area of practice. Most had completed their graduate education many years before the recent curriculum changes that prepare current students for new certification examination eligibility. The director of Advanced Practice for the MBON was invited to the next CBANACNS meeting to discuss CNS practice in Maryland. She noted that in the 1980s, CNSs in the state had petitioned the MBON for APRN recognition alongside the nurse psychotherapists (an advance practice mental health nurse). The nurse psychotherapist regulations were developed and implemented, but the CNS regulations were never developed because of lack of follow-up by the CNSs. She described the process that would be needed for CNS regulation and indicated that the MBON would entertain such a petition.
CNS Regulation
Today, regulation of CNS practice varies from state to state, and the existing body of CNS professionals is diverse in educational and practice backgrounds. Clinical nurse specialists who recently graduated from academic programs that are in compliance with the Consensus Model will possess the academic credentials necessary to apply for certification and to gain licensure. Those most challenged by these new regulations are our most senior and experienced CNSs. If their original education does not meet the new educational requirements of the Consensus Model and they did not take a certification examination before the change in eligibility requirements, they may not be eligible to be licensed as APRNs. Their knowledge and skills must be protected, and in many cases, states will need to find ways to grandfather them into licensure. Title protection is supported by the Consensus Model to ensure that the CNS title will be restricted to use by nurses who possess all requisite education and national certification and can be licensed as CNSs. Without title protection, individuals who may not possess the appropriate education and certification could call themselves CNSs.10 Standardizing CNS regulations in nurse practice acts across the United States will protect the CNS title and ensure that only qualified individuals call themselves CNSs. Implementation of the Consensus Model regulations may make it unlawful for some CNSs to retain their title if they cannot meet academic and certification requirements for licensure and cannot be grandfathered into licensure. Clinical nurse specialists in states that do not currently license CNS practice must come together to collaborate with their state Boards of Nursing to develop or expand legislation and regulations that recognize and license CNSs as APRNs. Clinical nurse specialists in states that currently license CNSs should critically evaluate their Nurse Practice Act to determine whether it is consistent with Consensus Model regulations.
Drafting the Regulations
A task force of members from the CBANACNS reviewed CNS regulations from State Boards 60
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of Nursing across the United States and drafted a set of regulations that they believed were consistent with the requirements of the Consensus Model and included grandfathering language agreed on by the membership. The task force felt strongly that nurses with graduate nursing education who had been actively practicing in the CNS role should be able to retain their ability to practice as CNSs. The intent was to protect rather than marginalize the role further by disenfranchising CNSs who had not or could not obtain national certification. The draft petition was circulated to members of CBANACNS as well as CNS member colleagues. A revised version of the regulations was presented as a petition to the MBON on January 25, 2011. The Board approved the petition and agreed to draft a formal set of CNS regulations for the Maryland Nurse Practice Act. Members of CBANACNS met with MBON staff to formalize the regulations during the next few months (Table 3). On September 8, 2011, CNSs from across the state attended a public meeting of the
MBON to review the newly proposed regulations. Significant discussion was held about the grandfathering clause. Specific grandfathering language was established that was agreeable to all stakeholders; an applicant would have 2 years to achieve a national certification where available, a requirement for state certification. Ultimately, the chapter of the State Nurse Practice Act for nurse psychotherapists was rewritten and subsumed under the broader category of CNS regulations. The CNS scope of practice for Maryland is grounded in the NACNS Core Competencies as well as other competencies defined by CNS certifying organizations (American Nurses Credentialing Center, American Association of Critical-Care Nurses Certification Corporation, etc). Practice must be in accordance with the state statute; any consideration for prescriptive authority would require legislation to change the statute. Once the regulations were drafted, they were published in the State Register on July 13, 2012, and were open for comment until August 13, 2012. No changes were
Table 3: Clinical Nurse Specialists Involved in Drafting the Petition for Clinical Nurse Specialist Recognition and Title Protection in Maryland Sharon J. Olsen, RN, PhD, AOCN, Assistant Professor, Johns Hopkins University School of Nursing Kathryn T. Von Rueden, RN, MS, ACNS-BC, FCCM, Assistant Professor, University of Maryland School of Nursing Paul Thurman, RN, MS, ACNPC, CCNS CCRN, CNRN, R. Adams Cowley Shock Trauma Center, University of Maryland Medical System Michelle Salmon, RN, MSN, ACNP, CNS-BC, Sinai Hospital of Baltimore Melinda Sawyer, RN, MSN, CNS-BC, Patient Safety Officer, Department of Medicine, The Johns Hopkins Hospital Pam O’Keefe, RN, MS, C-EFM, Clinical Nurse Specialist Perinatal, Johns Hopkins Bayview Medical Center MiKaela Olsen, RN, MS, OCN, Oncology and Hematology Clinical Nurse Specialist, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Samantha Young, RN, MS, CCRN, CCNS, ACNPC, Weinberg Intensive Care Unit, The Johns Hopkins Hospital Brenda K. Shelton, RN, MS, CCRN, AOCN, Clinical Nurse Specialist, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Barbara Van de Castle, MSN, OCN, BC, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Susan Immelt, RN, PhD, Assistant Professor, Johns Hopkins University School of Nursing Jocelyn Andersen, RN, MSN, Johns Hopkins University School of Nursing Jodi Shaefer, RN, PhD, Assistant Professor, Johns Hopkins University School of Nursing Laura Kress, RN, MAS, Assistant Director of Nursing Practice, The Johns Hopkins Hospital Mary P. McCaffrey, MSN, RNC-OB, CNS-BC, University of Maryland Medical Center Elizabeth “Ibby” Tanner, RN, PhD, FNGNA, Associate Professor, Johns Hopkins University School of Nursing and School of Medicine, Division of Geriatric Medicine and Gerontology Core Faculty, Center on Aging and Health 61 Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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advised and the CNS regulations became law—Code of Maryland Regulations Title 1011 (The Department of Health and Mental Hygiene. Subtitle 27 Board of Nursing. Chapter 27 Practice of Clinical Nurse Specialist). The requirements for APRN licensure by the regulation are a current license to practice registered nursing in Maryland, certification as a CNS from the American Nurses Credentialing Center or any other certifying body recognized by the MBON, completion of the application, and payment of required fees. Maryland law assigns approval of regulatory changes in practice to the MBON. This process facilitated the relatively rapid development and approval of the new CNS regulations. Today, all CNSs in Maryland must be licensed as APRNs by the MBON. However, at this time, no CNS has been licensed in the 2 years since the adoption of the regulations. Operationalization of the new CNS regulations has been plagued by technical challenges associated with the application process and development of an internal database designed to track CNS practice. Additional problems included turnover in MBON staff and officers, including the director of Advanced Practice. At an August 2014 public meeting, the MBON assured members of the CBANACNS that progress had been made. An individual has been hired to review applications and begin the state certification process. Figure 1 illustrates the timeline. Organizaon
February 2010 Incepon of Local CNS Organizaon April 2010 CBANACNS Formed June 2010 Goals Set Including Title Protecon
Practicing to the Fullest Extent of Our Education
Changes in the delivery of health care make it necessary that nurses practice to the full extent of their education.12 Maryland law assigns approval of regulatory changes in practice to the MBON. This process facilitated the relatively rapid development and approval of the new CNS regulations. However, changes in prescriptive authority require legislative approval in Maryland. This process is much more complex and will require a return to the negotiation table to expand this area of APRN practice advocated by the Consensus Model. Other states have included prescriptive authority in the CNS’s scope of practice. Little direction has been provided to guide states in preparing their CNSs for prescriptive authority, as many may have graduated prior to the 3 Ps requirement. In 2005, Oregon added independent prescriptive authority to the scope of practice for CNSs.12 The new privilege gave CNSs the same authority granted to nurse practitioners, including autonomous prescribing and dispensing of Schedule II-V medications. At that time most CNS programs did not prepare graduates for prescriptive authority. The language of the statute granted the board authority to interpret how to establish requirements for CNSs that would ensure their competency to prescribe. Oregon incorporated competencybased assessment with a refresher course and/or
Peon
Regulaon
October 2010 MBON Director of APNs Perspecve December 2010 Peon Task Force January 2011 MBON Presentaon of Peon
June 2011 MBON and CBANACNS Dra Regulaon September 2011 Dra Regulaons Presented to Open Forum July 2012 Dra Regulaons Published for Public Comment August 2012
Regulaons Became Law August 2014 Implementaon Incomplete
Figure 1: Maryland timeline of the clinical nurse specialist regulation change process. CNS indicates clinical nurse specialist; CBANACNS, Chesapeake Bay Affiliate of the National Association of Clinical Nurse Specialists; MBON, Maryland Board of Nursing. 62 Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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a period of supervised practice. This method is similar to a nurse who is reentering practice after a prolonged absence. This model can assist states as they transition their practice acts to include legal autonomous prescribing for CNSs. Clinical nurse specialists must shape the framework for their practice by building CNS prescriptive authority as an autonomous APRN role within established nursing specialty expertise by collaborating with regulators, educators, and national certifying bodies.
Acknowledgments I thank Sharon J. Olsen, RN, PhD, AOCN, for the spark that ignited the flame burning in the hearts of CNSs across Maryland. I also thank those listed in Table 3 for their contributions in drafting the initial petition to the MBON and the founding members of the Chesapeake Bay Affiliate of NACNS, including its first president Reba McVay, RN, MSN; treasurer Mary P. McCaffrey, MSN, RNC-OB; and secretary Candace L. Rouse, MSN, RNC, CNS-BC. REFERENCES
Discussion Before the regulations supported in the Consensus Model can be fully implemented, each state must enact legislation bringing their Nurse Practice Act into alignment with the proposals in the document. Nursing organizations, educators, accreditation and certification bodies, and individual APRNs will need to collaborate to accomplish Consensus Model implementation across the country. Individual CNSs must familiarize themselves with the Consensus Model and lobby for their right to practice to the full extent of their education or be left to practice as others see fit. The demand for CNSs will continue to increase, as organizations look to reduce costs and improve quality of care. Clinical nurse specialists are very effective at working within and across systems to align scientific evidence, resources, provider groups, and organizational policies and practices for improved clinical outcomes. In some areas of the country, the current shortage of CNSs can make this job very difficult to fill. Geographic areas with strong CNS academic programs have a steady stream of graduates, and finding applicants is not an issue.13 Maryland CNSs have now guaranteed a future where the CNS has a defined scope of practice and will meet national standards for practice. The journey to enable CNSs across this nation to practice to the fullest extent of their preparation is far from over, but it has begun.
1. National Association of Clinical Nurse Specialists. Organizing framework and CNS core competencies. www.nacns.org/docs/CNSCoreCompetencies.pdf. Published 2010. Accessed November 4, 2014. 2. Bell L. Issues in advanced practice. Is the clinical nurse specialist role still viable? AACN Adv Crit Care. 2006; 17(4):373. 3. The Patient Protection and Affordable Care Act (PPACA). Pub L No. 111-148, 124 Stat 119 (2010). 4. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2010. 5. Best Jobs in America. www.Money.CNN.com/pf/bestjobs. Published 2013. Accessed November 4, 2014. 6. APRN Consensus Work Group & the National Council of State Boards of Nursing APRN Advisory Committee. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. www.aacn .nche.edu/education-resources/APRNreport.pdf. Published 2008. Accessed November 4, 2014. 7. National Council of State Boards of Nursing. Scoring grid for implementation status of the Consensus Model. www.ncsbn.org/5397.htm. Published 2013. Accessed November 4, 2014. 8. National Council of State Boards of Nursing. CNS independent practice map. www.ncsbn.org/5406.htm. Accessed November 4, 2014. 9. National Council of State Boards of Nursing. CNS independent prescribing map. www.ncsbn.org/5410.htm. Accessed November 4, 2014. 10. Hudspeth R. Understanding clinical nurse specialist regulation by the boards of nursing. Clin Nurse Spec. 2009;23(5):270–277. 11. State of Maryland. 10.27.27 Practice of Clinical Nurse Specialists. Code of Maryland Regulations. www.dsd .state.md.us/comar/comar.aspx. Published 2012. Accessed November 4, 2014. 12. Klein TA. Implementing autonomous clinical nurse specialist prescriptive authority: a competency-based transition model. Clin Nurse Spec. 2012;26(5):254–262. 13. Harwood K. The clinical nurse specialist role: perspectives of an administrator. Clin Nurse Spec. 2013;27(6): 281–282.
63 Copyright © 2015 American Association of Critical-Care Nurses. Unauthorized reproduction of this article is prohibited.
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