September 2021
In 2010, the Institute of Medicine released the landmark report The Future of Nursing: Leading Change, Advancing Health (IOM, 2010). A key recommendation of this report was that nurses be allowed to practice to the full extent of their education and training. Consistent with these recommendations is the critical need to remove legislative and regulatory barriers that interfere with Advanced Practice Registered Nurses’ (APRNs) ability to effectively deliver the care patients need. Additionally, the Consensus Model for APRN Regulation (2010) recommends full independent prescriptive authority as a key component of APRN scope of practice. The NACNS supports efforts by the States to move forward with legislation that provides independent practice for nurses recognized as CNSs.
Clinical Nurse Specialists (CNSs) are APRNs who practice at an advanced level of nursing. This practice is enhanced through well-grounded knowledge and understanding of advanced pharmacologic principles. NACNS (2019) supports autonomous prescribing of “medications, therapeutics, diagnostic studies, equipment, and procedures to manage the health issues of patients.” (p. 26) Prior to 2010, 31 states provided some level of prescriptive authority for the CNS (Ray & Mittelstadt, 2016). According to the most recently reported update 24 states currently allow independent prescribing for the CNS and an additional 15 allow prescribing with a collaborative practice agreement with a physician (NCSBN, 2021). Further, the National Council of State Boards of Nursing NCSBN (2012) supports granting CNSs authority for planning patient therapeutic regimens that can include non-pharmacological interventions such as durable medical equipment and devices, nutrition, blood and blood products, physical and occupational therapy, home health care, and hospice services.
The CNS provides advanced direct and indirect care to complex and vulnerable populations in a variety of health care settings. To provide comprehensive and safe patient care to specialty populations, the CNS must assess, use differential diagnoses, and create plans of care that are tailored to the individual. The plans of care include activities of prescribing as well as consultative, rehabilitation, and supportive services. NACNS endorses prescribing and ordering privileges be granted by State Boards of Nursing and/or health care systems for CNS practice.
The prescribing and ordering privilege can be exercised by the CNS who has met entry into APRN practice criteria that includes at a minimum, the completion of three separate comprehensive graduate-level courses in advanced health/physical assessment, advanced physiology/pathophysiology, and advanced pharmacology (NACNS, 2019). Additionally, NACNS supports efforts by the States to create mechanisms for prescribing among CNSs who completed graduate education prior to the requirement of these three courses. The 3-separate comprehensive, graduate-level courses include:
- Advanced physiology/pathophysiology – includes general principles that apply across the lifespan;
- Advanced health assessment – includes assessment of all human systems, advanced assessment techniques, concepts, and approaches;
- Advanced pharmacology – includes pharmacodynamics, pharmacokinetics, and pharmacotherapeutics of all broad categories of agents.
References:
APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee. (2010). Consensus model for APRN regulation: Licensure, accreditation, certification & education. https://ncsbn.org/aprn-consensus.htm.
Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. The National Academies Press.
National Association of Clinical Nurse Specialists. (2019). Statement on Clinical Nurse Specialist Practice and Education (3rd ed.). Author.
National Council of State Boards of Nursing (2020, October 16). NCSBN Model Act 2014. https://www.ncsbn.org/14_Model_Act_0914.pdf
National Council of State Boards of Nursing (2017). NCSBN Model Rules. https://www.ncsbn.org/17_Model_Rules_0917.pdf
National Council of State Boards of Nursing (2021, January 20). APRN Consensus Implementation Status. https://www.ncsbn.org/5397.htm
Ray, M. M., & Mittelstadt, P. (2016). Prescriptive authority and independent practice progress for the clinical nurse specialist-changes since 2010. Clinical Nurse Specialist CNS, 30(5), 302–303. https://doi.org/10.1097/NUR.0000000000000242.