For more than 40 years, clinical nurse specialists have worked in hospitals, agencies and other health care facilities to strengthen nursing and improve health care. Their contributions haven’t always been recognized, but a recent rule amendment by the Georgia Board of Nursing has brought them into the limelight.
Clinical nurse specialists were among the first master’s-prepared nurses. They work in health care facilities and in the community as nursing experts, educators, researchers, innovators and big-picture thinkers. With such a wide scope of practice, their roles haven’t always been understood.
Jobs haven’t always been plentiful, but that is changing.
“Since the IOM [Institute of Medicine] Future of Nursing [report] specifically named the clinical nurse specialist as a role instrumental in health care reform, I’ve seen more job openings in metro Atlanta,” said Anne Hysong, MSN, RN, CCNS, a clinical nurse specialist in critical care at Gwinnett Medical Center. “Today, a CNS can have a pick of jobs and as more schools start CNS clinical rotations, the role awareness should grow among nursing students.”
As of Jan. 1, clinical nurse specialists who meet the state’s requirements will be recognized as advanced practice registered nurses (APRNs) by the Georgia Board of Nursing.
“The new rule and law will legally define what it means to be a clinical nurse specialist, which will protect the title. Only those individuals who meet the board requirements and credentials will be able to use it,” said Jim Cleghorn executive director of the Georgia Board of Nursing.
Cleghorn says the new authorization accomplishes three things. “It will clean up [confusion in] the profession. Clinical nurse specialists will be able to apply for prescriptive authority, and they could receive increased reimbursement.”
Most nurses believe it will make the role and the nursing profession stronger.
“The recent authorization is a very good thing for Georgia,” said Virginia (Dare) Domico, RN, DSN, associate dean for graduate programs at the Georgia Baptist College of Nursing of Mercer University.
“In recent years, more nurses have chosen the nurse practitioner role in order to be able to practice more independently and outside of the hospital,” Domico said. “Now, the health care arena is recognizing that hospitals need nursing leaders to oversee the quality care of patients and the education of nurses.”
Despite low enrollment, Mercer has kept its CNS program because the school sees a need for the role.
“It’s a way for nurses who want to work in the acute care environment to increase their knowledge and advance their careers,” Domico said.
Domico believes that the recent authorization in Georgia and the Institute of Medicine’s landmark 2010 report will spark new interest in the role.
The recognition of clinical nurse specialists has been a long time coming and is not without controversy, said Marianne Baird, RN, MN, PCCN, a CNS in acute care at St. Joseph’s Hospital of Atlanta and co-president of the Atlanta Area CNS Group.
The Atlanta group has been fighting for APRN recognition since the 1990s. Members have sat on the APRN committee of the Board of Nursing and have promoted Georgia’s adoption of the APRN consensus model. Written by the National Council of the State Boards of Nursing in 2008, the model sets national recommendations for licensure, accreditation, education and certification of advanced practice nurses. It has been accepted by most states.
Georgia requires APRNs to hold a master’s degree or higher and certification in their area of specialty. All APRNs must have passed advanced pharmacology, adult pathophysiology and advanced physical health assessment. Because the CNS curriculum wasn’t regulated until 2002, older practitioners may not have taken those courses or be able to sit for national certification exams.
The state decided not to grandfather in practicing clinical nurse specialists; all applicants must meet the current requirements. That means OB/GYN clinical nurse specialists can’t be authorized as APRNs because they have no certification exam. The Atlanta Area CNS Group is trying to get legislators to write an exception to the rule.
“The move to protect the title is absolutely the right thing to do, but the lack of grandfathering will be challenging for some,” Baird said.
While the new legislation keeps people from abusing the CNS title, it also makes it difficult for some nurses with credentials to prove that they qualify.
Baird feels fortunate to have been in on the early CNS movement. She worked at Rush University Medical Center in Chicago with nursing pioneer Luther Christman in the 1970s. Christman believed nursing leaders could be empowered through education and was instrumental in developing the nurse practitioner/teacher role, a foundation of the CNS movement.
Baird, who earned her CNS degree from Emory University in 1982, has worked at St. Joseph’s Hospital in Atlanta for 32 years. She works in many areas of the hospital, focusing on staff development and patient care.
Among her many leadership roles, Baird has helped guide St. Joseph’s through the process of being a Magnet Hospital for Nursing Excellence. St. Joseph’s has held Magnet status since 1995.
For Baird, the role of clinical nurse specialist was a perfect fit in creating an environment for patient-centered care, evidence-based practice and nursing self-governance.
“I’m so grateful for my training as a CNS. It prepared me to do so many things, including how to communicate with everyone,” she said.
Baird is satisfied with her role, but realizes that her title may change with Georgia’s new rules. She recently earned an A in an advanced pharmacology course, but she is waiting for Emory University to provide proof that she has met the other course requirements. The school no longer has a CNS program, so it takes time to check old records, she said.
Baird is also waiting word from the American Nurses Credentialing Center on whether she can take the CNS certification exam. She hasn’t heard of anyone losing a job due to the rule amendment, but she knows nurses who are working to get credentialed for jobs they have been doing for years. Other states are going through similar growing pains as they define the CNS role, she said.
The Atlanta Area CNS group is working to get the word out to practitioners and hospitals about the new rule. Nurses can learn more at www.AtlantaCNS.org.
‘I WEAR A LOT OF HATS’
Gwinnett Medical Center CNS performs several key roles
About two years ago, Gwinnett Medical Center in Duluth put into a practice an innovative procedure called therapeutic hypothermia. Research has shown that cooling a patient’s body down to between 91 and 93 degrees Fahrenheit after cardiac arrest can preserve precious brain cells and improve patient outcomes.
A team of doctors, nurses, emergency medical technologists, pharmacists, respiratory therapists and others at GMC perform the practice several times a month. The procedure has produced a 37 percent successful neurologic rate in patients; the national average is 20 percent.
Gwinnett Medical calls the innovative procedure one of its “best-kept secrets.” So is Anne Hysong, the person who pulled together the 15-member team, educated them about the procedures and guidelines recommended by the American Heart Association, and helped test the new technology. Hysong, MSN, RN, CCNS, is a clinical nurse specialist in critical care.
There are 72,000 clinical nurse specialists in the United States, but outside of the staffs at progressive hospitals, not many people understand their role. Hysong would like to change that.
“Pulling people together from different disciplines is a reflection of my role as a clinical nurse specialist,” said Hysong, co-president of the Atlanta Area CNS Group, an affiliate of the National Association of Clinical Nurse Specialists (NACNS). “I became a clinical nurse specialist five years ago because I wanted to stay with nursing and advance nursing practices. I wanted to provide other nurses with the education and tools they need to do the best job.”
While nurse practitioners — another group of master’s degree-prepared nurses — spend most of their time in direct patient care, clinical nurse specialists have three different roles.
“A third of my time is spent in the treatment of patients to improve outcomes at the bedside; a third is spent developing nurses and creating best-practice policies. The rest is spent affecting change at the system/organizational level. I wear a lot of hats,” Hysong said.
On any given day, she might go on rounds with physicians, consult on complicated cases, facilitate family conferences, mentor or train nurses, or help develop new policies to improve the quality and safety of patient care.
“My days are all different and that keeps me on my toes. I love the complexity and variety of my job,” Hysong said.
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