CNS

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Clinical Nurse Specialist
CNS

A CNS is a register nurse, "who through study and supervised practice at the graduate level (master's or doctorate), has become an expert in a defined area." (ANA, 1980, p.23)

According to the American Nurses' Association (ANA), there are 58,185 CNSs. They are registered nurses with master's or doctorate degrees in advance nursing. The CNS is an expert in a specialized area of clinical practice such as:

Mental Health
Gerontology
Cardiac Care
Cancer Center
Community Health
Neonatal Health

CNS work in hospitals, clinics, nursing homes, their own offices, and other community based settings, such as industry, home care and HMO's.

Qualified to handle a wide range of physical and mental health problems, CNSs provide primary care and psychotherapy.

They conduct health assessments, make diagnoses, deliver treatment and develop quality control methods.

Besides delivering direct patient care , CNSs work in consultation, research, education and administration.

Some work independently or in private practices and can be reimbursed by Medicare, Medicaid, Champus and private insurers. (ANA, 1997, online)

Links
Historical Context
Medical Reimbursement
Prescriptive Authority
Research: CNS Impact on Health care
Current Issues
Future Trends
References
Other Useful Links

Historical Context
"Nurse educators developed the concept of a clinical nurse specialist in an attempt to decrease the fragmentation of patient care that occurred post-World War II and respond to the knowledge explosion of new technology and increasing complexity of the healthcare system." (Fenton & Brykczynski, 1993, p.313)

Initially, the need for a clinical expert at the bedside was the catalyst and original intent of the development of the CNS role.
Traditionally, CNSs practiced in the acute care setting, providing direct patient care.
Since then the role has evolved into an ever widening scope of practice into many nursing specialty areas. (Hester & White, 1996, p.190)
The CNS role is multifaceted,

"The specialist is an

expert in clinical practice

an educator

a consultant

a researcher

an administrator." (ANA, 1986, p.2)

The role of the CNS was not developed for a specific market, but to enhance the overall quality of patient care through direct and indirect caregiving and organizational systems. (Sechrist & Berlin, 1998, p. 309)
Fenton and Brykczynski (1993, p.315) found that "...the CNS is much more involved in promoting the overall functions of the organization by support staff, patients and families coping with the bureaucracy."
Accordingto Sechrist and Berlin (1998, p.306) "Actualization of the CNS role, however, has been problematic. The role has been described, dissected, reframed, and retitled as CNSs and employing organizations struggle to clarify role responsibilities and expectations."
The CNS does not function in one particular way. Influences on patient care is often indirect and difficult to quantify.
The diversity and change in utilization of the role contributes to difficulty of delineating a clear actualization of the CNS role.
In addition, Sparacino (1995, p.240) states why quantifying the CNS impact is difficult, "There is no comparison group for CNSs, in contrast with nurse practitioner's, who are readily compared with physicians in regard to the qualitative and quantitative impact on primarily heathcare." (U.S. Office of Technological Assessment, 1986)
Barriers to practice were identified in a survey of approximately 5868 CNSs in December 1992 conducted by the Division of Nursing. The top three barriers identified by CNSs were:

Lack of knowledge of role function-52.5%

Lack of understanding of the role by other health care professionals-46.3%

Lack of 3rd party reimbursement (Sechrist & Berlin, 1998, p.307)

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Medical Reimbursement

State law governs practice, federal policy can affect the scope of practice. (Price & Minarik, 1999, p.90)
Medical reimbursement for nurse practitioners (NPs and CNSs was passed as part of the 1997 Balance Budget Act.
Rules are available on-line through the Government Printing Office (GPO) Web site, go to the section containing pages 58872-58875.
For the purpose of Medicare Part B payment, a CNS must:

1. Be a registered nurse who is currently licensed to practice in the states where he or she practices and be authorized to perform the services of a clinical nurse specialist.

2. Have a master's degree in a defined clinical area of nursing from an accredited educational institution.

3. Be certified as a clinical nurse specialist by the American Nurses Credentialing Center. (GPO, 1997, p. 58875)

The third requirement will need to be addressed because many CNSs do not have appropriate certifying examination available. (Price & Minarick, 1999, p.91)
The change means that NPs and CNSs can be independent Medicare providers, billing Medicare for services regardless of the geographical area in which they practice.
"Traditionally, nurses in advance clinical practice has been restricted to providing healthcare to consumers who lack access to physician care, i.e., rural or inner-city populations." (Ray, G.L. & Hardin, S., 1995, p.45)
According to Keepnews (1998, p.63), an important feature of the new law is that it defines "clinical nurse specialist" for the first time in Medicare law. Previous laws never defined who would be considered a CNS and most states do not have provisions for CNSs. Many states have added laws defining CNS practice, or at least providing "title protection"- (i.e. establishing who can call herself or himself a CNS).
Keepnews (1998, p.63) also states, "This national recognition is unprecedented. It offers CNSs not only the opportunity-the chance to serve medicare beneficiaries- but a basis for continuing to establish the CNS's role as provider of primary and specialty care services."

Return to Links Prescriptive Authority

The ANA 1996 Prescriptive Authority Chart. (Prescriptive privileges are regulated by each state)
Privileges parameters vary across states due to lack of legislative consistency.
This is one of the biggest obstacles to autonomy in advanced nursing practice.( Mirr, 1995, p. 43)

Return to Links Research: CNS Impact on Health Care

"Nursing research involves a systematic search for knowledge about issues important to nurses." (Polit, D.F. & Hungler, B.P., 1997, p.5)
Nursing Research:

Provides a solid foundation from which to practice

Improves patient care

Defines the parameters of nursing

Identifies nursing interventions that make a difference in health care of the individual and are cost effective

Professional accountability to patients to use high quality research evidence in their clinical decisions. (Polit, D.F. & Hungler, B.P., 1997, p.5-6)

Therefore, it is necessary for the CNS to define and quantify their impact on health care, most importantly in economic terms.
"Documentation of the economic benefits of the CNS to the institution and consumer will help justify the position of the CNS within the evolving healthcare system." (Bakker & Vinceni, 1995, p.50)
Research studies confirm cost effectiveness and quality of care provided by the CNS
The following studies selected, were done in the last five years and focused on CNS's intervention(s) and the impact on the outcome of care.
Topp, Tucker, & Webber (1998) study clearly indicates that patients with congestive heart failure (CHF) who were case managed by a Clinical Case Manager (CCM)/CNS experienced, on average, 1.69 shorter day of length of stay (LOS) and $2,700 less in hospital charges than patients with CHF who were not case managed by a CCM/CNS.
Fendrick, Major, and Brown (1994) demonstrated interventions by a CNS with nursing mothers in a nurse-managed, hospital based, breast feeding program. 35% of the mothers continued to breast feed at 6 months, which is higher than the national average estimated at 18.9%.
Mathew, Gutsch, Hackney, and Munsat (1994) demonstrated interventions by a geropsychiatric CNS enhanced the care of geropsychiatry patients and can be cost-effective.
Naylor, Brooten, & Jones et. al. (1994) study supported the need for comprehensive discharge planning designed for the elderly and implemented by CNSs to improve their outcomes after hospital discharge and to achieve cost savings. this intervention had the greatest effect in delaying or preventing rehospitalization of patients in the medical intervention group during the first 6 weeks after discharge.

Return to Links Current Issues

On going debate continues about whether the CNS and NP roles should be merged. Articles pertaining to this issue are available on-line:

Meeting Societal Needs for CNS Competencies: Why the CNS and NP Roles Should Not Be Blended in Masters Degree Programs

At the Crossroads: We Must Blend the CNS and NP Roles

Advanced Practice Psychiatric Nursing: The Need for a Blended Role

Territorial barriers exist between roles and groups within the nursing profession.
Nurses' lack of agreement dilutes the opportunity to develop and use a congruent power base to effect change." (O'Malley , J., Cummings, S., & King, C.S., 1996, p.67)

Return to Links Future Trends

"CNSs will continue to be a driving force to improve quality care through their clinical expertise. They are the front line for identifying interventions to reduce cost and increase quality. As healthcare continues to evolve an dexpand, so does the CNS's role." (Hester & White, 1996, p.193)

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References
American Nurses' Association. (1997) . Advanced practice nursing: A new age in health care. Available http://www.nursingworld.org/readroom/fsadvprc.htm

American Nurses' Associaton. (1986) . The role of the clinical nurse specialist. Kansas City: The Association.

American Nurses' Association. (1980) . Nursing: A social policy statement. Kansas City: The Association.

Bakker, D.J., & Vincensi, B.B. (1995). Economic impact of the CNS:Practioner role. Clinical Nurse Specialist ,9, 50-53.

Bradell, J.G., (1994). Cost-effective and quality of care provided by clinical nurse specialist. Journal of Psychosocial Nursing, 32, 21-23.

Fendrick, S.M., Major, A.L. Nursing mothers service: A community breast-feeding program. Pediatric Nursing, 20, 241-244.

Fenton, M.V., & Brykczynski, K.A. (1993). Qualitative distinctions and similarties in the practice of clinical nurse specialists and nurse practioners. Journal of Professional Nursing, 9, 313-326.

Keepnews, D. (1998). New opportunities an challenges for APRNs. American Journal of Nursing, 98, 62-64.

Hester, L.E., & White, M.J. (1996). Perceptions of practicing CNSs about their future role. Clinical Nurse Specialist,10, 190-1

Lynch, A.M. (August 1, 1996). At the crossroads: We must blend the CNS and the NP roles. Online Journal of Issues in Nursing. Available http://www.nursingworld.org/ojin/tpc1/tpc1_5.htm .

Lyon, B.L. (June 15,1996). Meeting societal needs for CNS competencies: Why the CNS and NP roles should not be blended in masters degree programs. Online journal of Issues in Nursing. Available http://www.nursingworld.org/ojin/tpc1/tpc1_3.htm

Mathew, L.J., Gutsch, H.M., Hackney, N.W. & Munsat, E.M. (1994). Promoting quality and cost-effective care to geropsychiatric patients. Isssues In Mental Health Nursing, 15, 169-185.

Mirr, M.P. (1995). Legal issues: Licensure and certification, prescriptive priviledges, and reimbursement. In M. Snyder & MP Mirr (Eds.). Advance practice nursing: A guide to professional development. (pp.43). New York, NY: Springer.

Moeller, D.M., & Haber, J. (August 1, 1996). Advanced practice psychiatric nursing:The need for a blended role. Online Journal of Nursing. Available http://www.nursingworld.org/ojin/tpc1/tpc1_7.htm

Naylor, M., Brooten, D., Jones, R., Lavizzo-Mourey, R., Mezey, M., & Pauly, M. (1994). Comprehensive discharge planning for the hospitalized elderly. Annals of Internal Medicine, 120, 999-1006.

O'Malley, J., Cummings, S. & King, C.S. (1996). The politics of advanced practice. Nursing Administration Quarterly, 20, 62-72.

Polit, D.F., & Hungler, B.P. (1997). Essentials of nursing research: Methods, appraisal, and utilization. (4th ed.) Philadelphia: Lippincott.

Price, L.C, & Minarik, P.A. (1999). Update on federal medicare rules affecting advanced practice nurses. Clinical Nurse Specialist, 13, 90-92.

Ray, G. L., & Hardin, S. (1995). Advanced practice nursing:Playing a vital role. Nursing Management, 26, 45-47.

Sechrist, K. R., & Berlin, L.E. (1998). Role of the clinical nurse specialist: An integrative review of the literature. AACN: Clinical Issues, 9, 306-324.

Sparacino, P.S.A. (1995). Demonstrating CNS impact on patient outcomes. Clinical Nurse Specialist,9, 240.

Survey fo certified nurse practioners and clinical nurse specialist: December, 1992. Rockville, MD: Division of Nursing Bureauof Health Professions Health Resources and Services Administration: 1994.

Topp, R., Tucker, D., & Weber, C. (1998). Effect of a clinical case manager/clinical nurse specialist on patients hospitalized with congestive heart failure. Nursing Case Management, 3, 140- 145.

U.S. Office of Technological Assessment. (1986). Nurse practioners, physicians assisstants, and certified midwives: A policy analysis. (Health Technology Case Study 37). Washington, DC; Author.