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Clinical Nurse Specialists Responsible for Entire Health Systems, But Issues Remain to Allow Full Scope of Practice

Only Survey of Clinical Nurse Specialists Provides Valuable Insights into Education Levels, Employment, Practice and More

Philadelphia, Pa. – Three in four clinical nurse specialists (CNSs) specialize in adult health or gerontology, most CNSs work in acute care hospitals that have or are seeking ANCC’s Magnet™ Recognition, more than half have nursing clinical-related responsibility for an entire health system, but only 1 in 5 CNSs are authorized to prescribe medications. These are among the key findings of the second nationwide survey of CNSs, conducted by the National Association of Clinical Nurse Specialists.

Clinical nurse specialists are one of the four types of advanced practice registered nurses (APRNs). Like other APRNs, CNSs have advanced education and training in physiology, pharmacology and physical assessment and spend a significant amount of time providing direct patient care. However, CNSs practice is focused on a specialty area, for example critical care, oncology, diabetes, pain management or cardiology. In addition to providing care for patients and their families, CNSs coach and develop other nurses, provide interprofessional education and update practice based on current evidence. The CNS Census confirmed that the CNSs who responded reflect this depth and breadth in their practice.

Daily activities for clinical nurse specialists vary. As a group, the survey found that CNSs spend most of their time providing direct patient care (22 percent), teaching nurses and staff (20 percent), consulting with nurses, staff and others (20 percent), leading evidence-based practice projects (14 percent) and assisting other nurses and staff with direct patient care (12 percent).

The CNS Census included questions about CNSs’ employment, prescriptive authority, education, practice, and demographics. It reveals that the vast majority of CNSs (88 percent) work full-time and four in five (80 percent) work in hospital settings. Of those, more than half (58 percent) have responsibility across the entire hospital system or system-wide.  Others have a span of influence that covers one or two units.

The survey results also reveal issues that need to be addressed to allow CNSs to practice at the full extent of their education and training: title protection and prescriptive authority. According to the survey findings, 21 percent of CNSs who responded to this survey are authorized to prescribe medications and only 16 percent are authorized to prescribe durable medical equipment. Prescriptive authority is a matter of state law. A 2015 analysis of states, completed by NACNS in collaboration with the National Council of State Boards of Nursing, indicates that CNSs have independent authority to prescribe in 19 states.  The CNS needs a collaborative agreement with a physician to legally prescribe in another 19 states.  The total number of states where a CNS may be eligible to prescribe is 38.

Another issue highlighted by the survey results is reimbursement. CNSs in independent ambulatory care practice, or who have hospital medical board privileges are able to bill insurance companies directly for their services, rather than through a third party, reducing insurance costs. According to the survey findings, only 6 percent of CNSs bill directly a third-party payor, like a private insurance company, Medicare or Medicaid, or an individual patient for the services they provide.

“CNSs are making incredible contributions that advance the practice of nursing, and this survey helps us understand how and where CNSs are practicing,” said NACNS President Vince Holly, MSN, RN, CCRN, CCNS, ACNS-BC. “It shows that the majority of CNSs are fulfilling their unique contribution to health care without prescribing medications and durable medical equipment. However, CNSs who choose to prescribe medications and/or durable medical equipment should be authorized to do so. More work needs to be done to allow CNSs to practice to the full extent of their education and training and break down barriers to CNSs working at their full scope of practice. Our country needs health care that is effective, patient-focused, high-quality and based on evidence—the clinical nurse specialist role is uniquely qualified to deliver this type of care.”

The overwhelming majority of clinical nurse specialists are white women. But, the CNS Census was completed by more men and minorities in 2016 than in 2014. The survey also revealed that 2 in 3 CNSs are nationally certified and, in addition to a master’s degree, more than 1 in 10 CNSs also holds a doctorate.

The online survey was completed by 3,118 nurses who had completed or were enrolled in a CNS education program. It was conducted from June 1 to December 31, 2016. This is the second CNS Census, the first was conducted in 2014 and the findings released in 2015. NACNS launched this comprehensive workplace survey to collect information that can be used to not only describe the population of CNSs but also to differentiate what CNSs do. The association conducts the survey every two years.

An infographic with additional findings is available here.

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