White Paper On Certification Of Clinical Nurse Specialists

September 2005

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Introduction

The National Association of Clinical Nurse Specialists (NACNS) supports the masters or doctoral degree in nursing focused on Clinical Nurse Specialist (CNS) core knowledge and competencies as the only required credential for entry to practice as a CNS. NACNS supports validation of core knowledge, specialty knowledge, and attainment of CNS competencies. Verification of both core and specialty knowledge and competencies is the responsibility of professional organizations (ANA, 2003; ANA, 2004). Professional organizations validate specialty knowledge and competencies at both the generalist and advanced levels. Specialty nursing certification is an objective measure of knowledge that validates qualifications to provide specialized nursing care (ABNS, 2005).

Clinical Nurse Specialists (CNS) were the first group to be recognized as advanced practice nurses who have a unique body of knowledge and competencies based on education at the graduate level (Mick and Ackerman, 2002). This body of knowledge and subsequent competencies distinguish CNSs from the other three advanced practice groups: Nurse Practitioners, Nurse Anesthetists, and Nurse Midwives.

One of the hallmarks of CNS practice is advanced specialization within nursing. Further, the advanced specialization is a narrowing and deepening of focus of the autonomous practice of nursing as defined and protected by RN licensure in each state. A critical attribute of all CNSs, regardless of specialty, is that they possess advanced knowledge of both the basic science and the nursing science underpinning the specialty. The CNS applies that knowledge to the assessment and diagnosis of illness, defined as the subjective experience of discomfort (ANA, 2004, p. 48). Additionally, the following are examples of how CNS applies that knowledge in advanced practice competencies. For a full description please see the Statement on Clinical Nurse Specilaist Practice and Education (2004).

deliver, design, and test nursing interventions to prevent, lessen, or alleviate illness experiences

• Assure patient safety.
• Improve the quality of nursing care.
• Perform systems analyses.
• Conduct cost-benefit analyses.
• Advance evidence-based nursing practice.

Traditionally, professional assessment of CNS core and/or specialty knowledge and skills has been conducted through the use of national examinations with evidence of sound psychometric properties. However, alternative mechanisms exist to create additional strategies for professional validation with equivalent psychometric soundness.

NACNS believes that verification of CNS knowledge and competencies requires three (3) multilevel indicators:

1)  Education: The CNS must graduate from nationally accredited masters or doctoral program that provides entry-level knowledge and competencies in a specialty area of CNS practice. All CNS education programs must provide a broad based foundation of advanced knowledge, as well as specialty knowledge.
2)  Validation of core CNS knowledge and competencies: Core CNS knowledge and competencies are validated with a psychometrically sound and legally defensible assessment method. This may be accomplished through examination or other psychometrically sound and legally defensible assessment methods.
3)  Validation of CNS specialty practice knowledge and competencies: Validation of the additional knowledge and competencies in the specialty practice is needed. This may be accomplished through specialty examination or other psychometrically sound and legally defensible assessment methods, such as a portfolio process administered by a testing service, like ANCC, and reported to State Boards of Nursing, like current exam scores are reported (ANA/Black, 2004).

The NACNS Core Competency Validation Process

There is no single, nationally accepted process for competency validation of advanced practice in nursing. Nursing organizations developing competencies have used somewhat similar processes with certain consistent elements. The consistent elements of competency validation include:

• Expert Development: Convening experts to write the competencies based on the best available information known about the role or specialty.
• First Tier Validation: Soliciting validation of the developed competencies from individuals who practice and/or teach in the role or specialty.
• Second Tier Validation: Soliciting validation of the developed competencies from other stakeholders from the larger nursing community.
• Expert Review and Editing: The experts review comments from the first and second tier validation process. Changes are made as appropriate.
• Competency Release: The competencies are published. Endorsement may be sought from other organizations.

NACNS began development of competencies for the first edition of the Statement on CNS Practice and Education (Statement) (1998) with a national call for CNS job descriptions from members of NACNS and the American Association of Critical Care Nurses. Over 80 job descriptions from around the country were received. All geographic regions, except for Alaska and Hawaii, were represented. The job descriptions addressed a multitude of specialties, including Medical-Surgical, Critical Care, Oncology, Rehabilitation, Orthopedics, Diabetes, Pediatrics, Psychiatric/Mental Health, Pediatric Oncology, Neurology, Neurosurgery, Perioperative, Gerontology, and Women’s Health. Approximately 70 of the job descriptions contained substantive information regarding CNS competencies and/or tasks for which the CNS was responsible and were used in the initial competency development.

A panel of CNS experts developed a draft of the core competencies from the job descriptions and expert knowledge of the CNS role. These experts represented practice and education, as well as diversity in specialization and geographic areas. They began by conducting a content analysis of the 70 detailed CNS job descriptions. The content analysis revealed several common tasks and a few core competencies common across the job descriptions. Literature about CNS practice was reviewed and integrated into the competency development process. The product of this work was a list of identified core competencies needed by the CNS.

First tier validation was accomplished by soliciting review and comment from a select validation panel of over 100 CNS educators and practitioners who were NACNS members. Second tier validation was accomplished through extensive external review from stakeholders, employers, and organizations. Requested reviewers for the first edition included 51 national recognized nursing leaders and 9 national nursing organizations (Appendix A). These external reviewers included national nursing leaders and CNSs in organizations representing a variety of specialties and practice settings. Reviewers were selected for their special contributions to CNS practice and education. Numerous organizations and individuals provided comments about the competencies as well as other content in the Statement. Appendix B includes some of the comments from reviewers who gave permission to use them. Perhaps the most significant comment came from the founder of CNS practice, Dr. Hiledgard Peplau. She said:

“It is a superb statement, one which should favorably influence the field of graduate education and the practice of Clinical Nurse Specialists. It is a masterpiece of scholarly work – more so since it is a product of ‘group think’. This publication should be printed and disseminated widely especially to all of the specialty organizations.”

The panel of CNS experts who drafted the core competencies evaluated all recommendations received about the initial draft and revised the document. The revised document was then sent out to all NACNS members for review and critique on two occasions over a 10- month period. Ongoing refinement of the Statement was a major topic of discussion at two NACNS national conferences. The panel of CNS experts then created and distributed the final document. Over 8,000 copies of the first Statement were disseminated to practicing CNSs, graduate students, schools of nursing, employers, state boards of nursing, and other national groups. Feedback was ongoing and positive about the value of the core competencies.

Practice trends, feedback from consumers, and feedback from stakeholders necessitated refinement and updating of the Statement in 2004. Similar to the ANA process of updating nursing standards, the core competencies were revalidated and modified and then updated in the second edition of the Statement (2004) to assure that contemporary CNS practice was reflected.

“The second edition, like the first, has been extensively reviewed by practicing CNSs, CNS educators, nursing leaders, nursing organizations, and other stakeholders in nursing practice” (NACNS, 2004, p. 2).

A panel of CNS experts from the NACNS membership comprised the Statement Revision Task Force and reviewed all of the core competencies for their relevancy to CNS practice today. These experts were diverse in specialization, job settings, geographic location, and included representatives from both practice and education. In addition to the core competencies, all of the outcomes of CNS practice were critiqued for their relevancy. The NACNS Education Committee provided input and critiques on multiple drafts of sections of the second edition of the Statement, including the core competencies.

The core competencies were posted on the NACNS website for electronic web-based review during September 2003 and October 2003. NACNS announced the request for public comment through a variety of means. Internally, all members of NACNS were alerted to the need to review and comment. An announcement was posted prominently on the website to invite visitors’ comments. In addition the request for comment was circulated throughout the nursing community via the Nursing Organizations Alliance and the ANA Nursing Insider.

NACNS directly requested review and comment from major national organizations via their Executive Directors on two occasions (see Appendix C), from all CNS education programs via their Deans or Program Directors, and from all State Boards of Nursing via their Executive Officers during the public comment period. The request for comment was circulated internationally via the leaders of the 2004 ICN NP/APN conference.

Numerous organizations and individuals provided comments about the competencies as well as other content in the second edition of the Statement. NACNS did not request formal endorsement of the Statement.

The Statement Revision Task Force evaluated all recommendations and comments received and revisions were made to the document. They held several meetings to discuss the recommendations and make decisions about how to incorporate the feedback. CNS educators representing many different academic programs who attended one of two CNS Education Summits (2003; 2004) provided feedback about the usefulness of the second edition of the Statement in designing and updating CNS curricula. The NACNS Board of Directors reviewed at least two of the near final drafts and provided input. Appendix E includes one of the thoughtful critiques received from one national organization and explains how the comments were used to improve the document.

The core competencies listed in the second edition of the Statement represent basic skills needed by all CNSs regardless of specialty. The second edition of the Statement received an unsolicited endorsement from the American Organization of Nurse Executives (AONE). The National League for Nursing (NLN) officially endorsed the Statement and currently uses it for accreditation of graduate programs.

NACNS continues a process of ongoing validation of the core competencies to assure they reflect the needs of the current practice environment. NACNS is currently evaluating the usefulness of the core competencies in a variety of CNS specializations/ subspecializations. The competencies have also been presented at several national nursing meetings. Approximately 25 participants have completed an evaluation tool thus far. Preparation is being made for online completion of the survey by CNSs. The human subject’s protection process is underway at a major university for this online survey in order to publish the findings.

Assessment of CNS Practice Competence

It is NACNS’ position that the core competencies, as articulated in the NACNS Statement on CNS Practice and Education (2004), provides a framework for a first level assessment of core CNS competencies regardless of specialty. The validation of specialty knowledge would be defined by the specialty organization responsible for professional validation of that specialty. Assessment of these two essential elements may be done through written examination alone, or a written examination of the core competencies with a psychometrically sound and legally defensible assessment method, such as portfolio validation, conducted by the specialty organization.

Guiding Principles of CNS Certification

NACNS ascribes to the Accreditation Standards set forth by the American Board of Nursing Specialties, which are based on the ANA criteria for definition of a specialty. Two standards are particularly relevant to the positions set forth in this paper:

Standard 1: Definition and Scope of Nursing Specialty

“The certification examination program is based on a distinct and well-defined field of nursing practice that subscribes to the overall purpose and functions of nursing. The nursing specialty is distinct from other nursing specialties and is national in scope. There is an identified need for the specialty and nurses who devote most of their practice to the specialty.”

Standard 2: Research Based Body of Knowledge

“A tested body of research/data-based knowledge related to the nursing specialty exists. Mechanisms are established for the support, review, and dissemination of research in the specialty. Activities within the specialty contribute to the advancement of nursing science within the specialty.”

Consistent with these two ABNS standards, NACNS supports the examination of CNSs that includes two essential elements:

1) Measures of core CNS competencies that differentiate CNS practice from the other groups of advanced practice nurses.
2) Use of specialty science in the assessment, diagnosis and interventions with clients served by the specialty.

This recommendation is predicated upon the recognition that CNSs have unique practice competencies (core competencies) distinguishing them from other advanced practice nurses. Also, CNSs apply these unique core competencies in a delimited area of care such as pediatrics, geriatrics, oncology, wound care, end of life, or populations of families or communities.

Proposed Strategies for Testing Core CNS Competencies

NACNS and the American Nurses Credentialing Center (ANCC) propose to lead the development of an economically feasible, psychometrically sound, and legally defensible assessment of core CNS competencies. We will also seek guidance from leaders of regulatory bodies. Further, we will collaborate with other organizations and certification boards with CNS members to develop alternative strategies that will provide all CNSs access to certification in specialty competencies.

We propose to explore the following strategies to move this initiative forward. Additional strategies may emerge during the exploratory phase as collaborating partners participate in the process:

1. NACNS and ANCC, in partnership with specialty organizations, will develop a written examination of core CNS competencies based upon common competencies elucidated and validated through role delineation studies. The framework for the core competencies will be the NACNS Statement on Clinical Nurse Specialist Practice and Education (2004), the ANA description of CNS practice as found in the Scope and Standards of Practice (ANA, 2004), and the scopes of practice of the specialties participating in the collaborative partnership. Clinical content used to test the competencies will be developed from the core content. Those participating in the partnership will develop the framework for the core clinical content.
2. Partnerships will be sought from specialty nursing certification boards and organizations that have CNSs as defined members of the specialty professional organization. It is recognized that some certifying boards already offer certification for the advanced practice of CNSs. The proposal strategy is not intended to replace what already exists but to offer a methodology for certifying CNSs core competencies in specialties that do not currently offer certification. NACNS supports the use of both examination and other legally defensible alternative strategies, such as the portfolio (ANA/Black, 2004), to provide professional validation of CNS knowledge and competencies.
3. Participating specialty organizations will choose the best methodology to test the CNS specialty competencies and content. Organizations are not required to use the same methodologies. This methodology could be an add-on feature to the specialty examination for core competencies or core competency content could be cross-walked with existing specialty examinations. This would result in a CNS taking one examination to validate both core and specialty competencies.

Once the initial partners in this endeavor are identified, solutions for common and specialty- specific issues will be mutually agreed upon. Input of regulators will be continuously sought. Financial commitments to support the core competency measure, ‘ownership’ of core competency methodology and specialty methodology, and reporting strategies are some of the issues to be addressed.

References

American Board of Nursing Specialties (2005). Accreditation Standards. Accessed from http://www.nursingcertification.org/standards.htm on July 5, 2005.

American Board of Nursing Specialties (2005). A position statement on the value of specialty nursing certificaton. Approved by the ABNS March 5, 2005.

Accessed from www.nursingcertification.org on June 25, 2005.

American Nurses Association (2003). Nursing’s Social Policy Statement. 2nd Edition, Washington, D.C.: Author.

American Nurses Association (2004). Nursing: Scope & Standards of Practice. Washington, D.C.: Author.

American Nurses Association. Black, R. M. (2004). Genetics Nursing Portfolios: A New Model for Credentialing, Black, Rita Monson, Editor, Washington, D. C.:Author.

Mick, D. J. and Ackermn, M. H. (2002). Deconstructing the myth of the advanced practice blended role: Support for role divergence. Heart and Lung, 31(6), 393-

398.
National Association of Clinical Nurse Specialists (2004). Statement on Clinical

Nurse Specialist Practice and Education. 2nd Edition, Harrisburg, PA: Author. National Association of Clinical Nurse Specialists (1998). Statement on Clinical

Nurse Specialist Practice and Education. 1st Edition, Harrisburg, PA: Author.

APPENDIX A
REVIEWERS FOR THE FIRST EDITION OF THE STATEMENT
1997 List of Invited External Reviewers
National Nursing Leaders
Tom Ahrens
Linda Aiken
Carol Alverez
Donna Arena
Suzanne Blancett
Rebecca Blue
Donna Boland
Debbie Boyle
Dorothy Brooten
Peter Buerhas
Gloria Bulechek
Joyce Clifford
Linda Cronenwett
Leah Curtin
Susan Dean-Baar
Dorothy Del Bueno
Joyce Fitzpatrick
Karen Forbe
Mary Ann Fralic
Anna Gawlinski
Leslie Kern
Hurdis Griffith
Ann Gurka
Ann Hamric
Rosanne Harrigan
Janice Hawkins
Janet Heinrich
Frieda Holt
Susan Houston
Dorothy Jones
Imogene King
Joellyn Koerner
Norma Lang
Madeline Lenininger Colleen Lucas
Joann McCloskey
Pam Minarik
Linda Morgante
Mary Beth Parr
Hildgard Peplau
Suzanne Prevost
Joan Quinn
Mariah Synder
Pat Sparacino
Judith Spross
Margaret (Peg) Stafford
Sally Rafael
Margaretta Styles
Christine Talmadge Gail Wolf
Joyce Yasko

National Nursing Organizations

American Association of Colleges of Nursing
American Association of Nurse Executives
American Association of Critical Care Nurses
American Nurses Association
American Nurses Credentialing Center
American Association of Rehabilitation Nurses
National Association of Orthopedic Nurses
National Council of State Boards of Nursing
Oncology Nursing Society

APPENDIX B
QUOTES RECEIVED ABOUT THE FIRST STATEMENT WITH PERMISSION TO SHARE

Name: Gloria Bulechek, Ph.D., RN, FAAN
Quote: “Description of [the} role and articulation with other policy statements is on target”

Name: Leah Curtin, Sc.D., RN, FAAN
Quote: “. . .that it is an excellent, well-thought-out definition/explanation of the CNS’s role and the education/competencies needed to fulfill it adequately. As such it is an enormous contribution to the profession . . .”

Name: Ann Hamric, Ph.D., RN
Quote: “. . . I think the competencies in the three spheres are very good, and help delineate CNS practice from that of other APNs . . .”

Name: Dr. Frieda Holt
Quote: “You have done a fantastic job-Thank you.” “Excellent document that will have wide use and impact.”

Name: Mary Beth Parr, MSN, RN, CCRN
Quote: “The description of the nondisease and disease based illnesses are clear and help to focus the CNS on nursing practice instead of medical practice. This model is useful when comparing CNS’s and NP’s the Statement identifies the competencies [the] CNS must possess and expected outcomes. I am very impressed!! This framework gives CNS’s a unified base that can then be personalized based on the focus of their role i.e., population or disease or nondisease.”

Name: Catherine Dunnington, RN, MS
Quote: “The document is a very sound, accurate portrayal of the CNS role From my 15 years of experience as a CNS. Thank you!”

APPENDIX C
NATIONAL ORGANIZATIONS AND LEADERS FROM WHOM FEEDBACK WAS SOUGHT FOR THE 2004 EDITION OF THE STATEMENT

APPENDIX D
EXAMPLE OF FEEDBACK RECEIVED FROM ONE NATIONAL ORGANIZATION AND HOW THE FEEDBACK WAS USED TO REFINE THE DRAFT DOCUMENT LETTER FROM AACN-CRITICAL CARE:

8 October 2003

Re: Review of Proposed Updates for NACNS Statement on Clinical Nurse Specialist Practice and Education.

To Whom It May Concern:
The American Association of Critical Care Nurses has completed a comprehensive review of the

Statement on Clinical Nurse Specialist Practice and Education.

We found this updated version to be comprehensive in its scope. However, we noted that this version and the previous version were developed using a consensus model to validate and recommend practice. The questions and concerns we have regarding this draft (see below) rise from the diversity and variability in practice, in educational preparation, roles and job expectations. It is our recommendation that perhaps NACNS should consider doing an extensive study of practice across specialties with the goal of writing the Scope and Standards document for the Clinical Nurse Specialist to fully describe this professional role in the United States.

Comments/Recommendations:

• Each section begins with an historical perspective that overlaps in content. Perhaps a single exhaustive section of historical framework without repeating a historical context throughout the document would provide a better flow, decrease redundancy and provide clarity of the following sections.
• The use of “clinical expertise” as the “hallmark” of CNS practice is ambiguous. Is ‘clinical expertise in a specialty’ truly the identifying hallmark of CNS practice? Without an operational definition, there isn’t a clear understanding of the difference between a CNS and an expert bedside clinician. For example, the bedside clinician with multiple years of practice with a specific population has likely attained clinical expertise in a specialty area. Clinical expertise, skills, knowledge and clinical information are not gained by graduate education. From our study of practice experience it is the advanced degree that gives the CNS the critical thinking/clinical decision making within the framework of an expanded world view and allows him/her to visualize the individual, the nursing personnel and the system. This world view, critical thinking and decision making is what separates clinical expertise from expert CNS practice (which would include clinical expertise as well).
• It is unclear as to whether you are describing entry-level competencies or expert competencies. We understand that there should be baseline-entry-level competencies for all CNSs. And there are skills, knowledge and competency that come from expertise, area of specialization and time which fully defines the CNS role. In this document there is an inconsistency in expectation of “entry-level” competency. For example: Can all CNSs be expected to gain expertise in being able to testify to a legislative body/committee? Or should the competency be an ability to communicate in appropriate means, scope, role and function of the CNS?
• In the Professional Attributes section, these do not seem to be truly unique to the CNS role and practice. These should and could be expectations of all professional nurses. If the CNS is being held to a higher standard, what does that knowledge, skill or competency look like? Perhaps a separate document or section which describes measurement criteria in which to evaluate achievement of the competency would be more helpful.
• We are in full support of the change recommending that all educational preparation for CNS practice include the 500 hours of clinical hours.

Thank you for the opportunity to review this document. It is evident that the authors have put much thought and time into its preparation. We would like to be available for any questions or clarification you may have regarding our evaluation of this document. Please contact Linda Bell (Linda.bell@aacn.org) or Justine Medina (Justine.medina@aacn.org) at your convenience.

RESPONSES TO THE CRITIQUE INCLUDED THE FOLLOWING REVISIONS:

1. The historical information was condensed.
2. More content on critical thinking and decision-making was added in several areas. A definition of expertise was added to the Glossary.
3. Further clarification was added that the competencies were intended as entry-level and a rationale was provided. All of the competencies were reviewed again by the working group with this in mind.