NACNS is committed to working with policymakers, healthcare organizations, other professional groups, non-governmental organizations, and industry to promote an agenda addressing the most pressing issues facing quality patient care and the nursing profession. Clinical Nurse Specialists (CNS) are advanced practice nurses (APRNs) who are educated at the masters or doctoral level to independently care for patients within their scope of practice. To promote the healthcare interests of our profession, our patients, and communities, CNSs must recognize the importance of becoming politically engaged. It is our professional responsibility to advocate for our role and on behalf of our patients for healthcare policies that will promote access to care, reduce costs, and improve quality. Multiple critical issues demand our attention, in particular, legislation impacting full practice authority, workplace violence, the opioid epidemic, and chronic disease management.
The goal of the NACNS Legislative Committee is to represent the CNS perspective effectively in all aspects of the practice environment through our advocacy efforts. The 2018-2020 Public Policy Agenda reflects the current priorities of the NACNS membership and the issues on which the board of directors initiate actions. In response to a dynamic health care legislative and regulatory environment NACNS may also need to address other emerging healthcare issues.
NACNS’s Legislative Regulatory Committee has identified the following three priority areas to address in support of the mission of NACNS for 2018-2020
Clinical Nurse Specialist and Nurse Workforce
Health Information Technology
Clinical Nurse Specialist and Nurse Workforce
- Support policies and programs that build and strengthen capacity for interprofessional practices in education and health care
- Collaborate with other organizations, including state and federal partners, to ensure that proposed legislative and regulatory changes: (1) Recognize full scope of practice and prescriptive authority for CNSs in all healthcare settings including those at the Veterans Health Administration; (2) Improve patient access to care; (3) Improve patient safety; and (4) Remove barriers to CNS practice.
- Advocate for CNS supportive language especially around grandfathering in the proposed APRN Compact provisions currently proposed by the National Council of State Boards of Nursing.
- Advocate for the Department of Labor to recognize the clinical nurse specialist as a “detailed occupation” in the Standard Occupation Classification.
- Promote increased funding for policy initiatives, such as Title VIII ─ Nursing Workforce Development Programs, to help alleviate nurse and nurse faculty shortages and increase retention and recruitment of registered and advanced practice registered nurses and nurse faculty.
- Support efforts of federal agencies, such as the Centers for Medicare and Medicaid Services (CMS), the Departments of Defense and Veterans Affairs and the Indian Health Services, to ensure a high quality and appropriately educated federal nursing workforce that maximizes the clinical nurse specialist role.
- Collaborate with other nursing organizations to support the CMS‐directed Graduate Nurse Education Demonstration Project that provides reimbursement for the reasonable cost of providing clinical education to APRN students.
According to the Bureau of Labor Statistics (BLS), demand for registered nurse (RN) will grow 16% from 2014 to 2024, outpacing the 7% average for most other occupations.1 Several factors will contribute to this increase, including a large number of newly insured patients resulting from healthcare legislation, the growing prevalence of chronic disease, increased emphasis on preventive care, an aging population, and retirement of nurses in the baby boom population. Increased demand is projected to result in 439,300 job openings, representing one of the largest increases for all occupations. In addition, with more than 500,000 seasoned RNs anticipating retirement by 2022, the U.S. Bureau of Labor Statistics projects the need to produce 1.1 million new RNs for expansion and replacement of retirees.2
The Graduate Nurse Education Demonstration Project 8 is an innovative strategy designed to increase the number of APRN students across the country by providing from CMS for the cost of clinical training through reimbursement to eligible hospitals. Providing support for this initiative will increase the APRN workforce and help achieve the goal of meeting the demand for primary healthcare services. This has direct impact on the growing problems associated with chronic disease and the elderly. Advocating for the inclusion of CNS students as one of the four APRN roles being trained at future participating clinical sites is critical.
Quality healthcare delivery in the U.S. is threatened on multiple fronts. Today’s shortage of appropriately prepared nurses still outpaces the level of investment necessary to meet the nation’s growing healthcare demands. CNSs are prepared to provide care to at risk populations with increasingly complex health needs, such as our aging populace, and to support a nursing workforce that will have fewer seasoned nurses taking direct care of those complex patients. The CNS also serves as a resource for novice through expert nurses in our healthcare workforce.
NACNS believes that the deepening health inequities, inflated costs, and poor quality of healthcare outcomes in this country will not be reversed until the concurrent shortages of RNs, APRNs, and qualified nurse educators are addressed. Without national efforts of some magnitude to match the healthcare reality facing the nation today, it will be difficult to avoid the adverse effects on the health of our nation especially from under resourced nursing education programs to produce sufficient numbers of highly qualified and engaged RNs and APRNs.
Just as America’s growing and aging population needs the high‐quality care that CNSs provide, numerous federal and state policy barriers continue impairing the ability of CNSs to practice to the full extent of their education. Improper and costly barriers to CNS services include unnecessary and burdensome “supervision” requirements, inappropriate discrimination in credentialing and recognition, and unsupported payment differentials that encourage use of higher‐cost providers without improving quality.
- Monitor state and federal healthcare bills to ensure that the clinical nurse specialist is a full partner in healthcare delivery.
- Ensure that proposed health care legislation includes clinical nurse specialists as high-quality licensed independent practitioners
- Advocate for reimbursement for clinical nurse specialist services across all healthcare delivery settings, including home health services.
- Work to ensure that all CNSs who are licensed as an APRN apply for a National Provider Identifier number to uniquely identify their contributions to health care.
- Advocate and support legislation to include Doctor of Nursing Practice (DNP) prepared APRN’s to apply and receive National Institute of Health grants for evidence-based translation research.
- Advocate and support legislation requiring employers to implement comprehensive healthcare workplace violence prevention programs that will help employees recognize, de-escalate, and minimize disruptive or threatening incidents.
- Advocate and support legislation to prosecute individuals assaulting healthcare professionals
- Support efforts to validate advanced practice nursing contributions in value‐based purchasing, accountable care organizations, and medical (primary care) homes, among other models of care.
- Advocate for community-based care models that increase access, affordability, and quality of care
- Advocate for population health management and the inclusion of CNSs as providers in related programs and pilot projects
- Advocate and support legislation for expanded coverage of non-pharmacological pain management and the role of the APRN in advancing structures, process, and outcomes.
- Advocate, monitor and inform legislation influencing the opioid crisis and substance use disorders
Tremendous attention has been focused on efforts to meet the recommendations contained in the Institute of Medicine’s (IOM) The Future of Nursing: Leading Change, Advancing Health4, that APRNs be allowed to practice to “the full extent of their education and training” (p. 29). NACNS must work collaboratively with stakeholders such as the American Association of Nurse Practitioners 5, the American Nurses Association, and the American Association of Retired Persons to support APRNs in seeking removal of legislative and regulatory barriers to practice.
Workplace violence is an escalating problem in health care facilities across the country. According to the Bureau of Labor Statistics violence is a more common cause of injury in healthcare than in any other industry.3, 6 NACNS must work with OSHA, American Nurses Association, American Association if Critical Care Nurses and other stakeholders in implementing legislation mandating guidelines for preventing workplace violence for healthcare and social service employers based on industry best practices.7
Research and demonstration projects have shown that the CNS role is uniquely suited to lead implementation of evidence‐ based quality improvement actions that also reduce cost throughout the health care system. This leadership has been demonstrated in the following areas, but not limited to, providing pre‐natal care, preventive and wellness care, behavioral health care, care to those with chronic conditions and facilitating transitions in care.
Drug overdose deaths, rates of opioid and drug misuse continue to rise 9, 10 making the opioid crisis a critical area of focus. CNSs with expertise in pain management, mediated assisted treatment, and non-pharmacological pain treatments can support implementation of non-opioid and non-addictive treatments in the community, primary care, ambulatory, and acute care. The information in the literature is confusing and complicated for society and healthcare professionals. The CNS can be central in translating this research to practice, developing evidence-based education and competencies that focus on benefits and risk, and advocating for expanded healthcare legislation to cover cost of non-pharmacological treatments.
Health Information Technology (HIT)
- Advocate for increased access to healthcare through the use of technology.
- Support efforts to expand the use of telehealth, remote patient technology, and communication technology-based services to assist in health care delivery and the inclusion of Clinical Nurse Specialists (CNS).
- Advise on the use of Clinical Decision Support Systems (CDSS) in optimizing health care outcomes.
- Effectively represent the role of the Clinical Nurse Specialist in the legislative and policy arenas of health information technology (HIT).
As digital innovation explodes, so does our ability to provide access to quality healthcare regardless of traditional time and distance constraints. According to the Office of the National Coordinator on Health Information Technology, the advent of digital systems for health records has a number of benefits: (1) improved patient care; (2) improved care coordination; (3) practice efficiencies and cost savings; (4) increased patient participation; and (5) improved patient diagnostics and outcomes.11
At the federal and state level, HIT policy is focused on promoting person‐centered care, value, innovation, research utilization, and healthcare accessibility through the proper storage, dissemination, protection, transfer, and analysis of health information. While much of the discussion to date has been on organizational reimbursement and on improving an individual’s access to their protected health information, nursing’s contribution to meaningful use of HIT remains challenging due to factors such as cumbersome documentation systems and lack of knowledge regarding current technology. This situation is detrimental to the health of the nation and the advancement of nursing practice in terms of knowledge generation, both practice evaluation as well as evolution, and the standardization of evidence‐based care.
As advanced practice registered nurses, CNSs, are qualified to optimize patient outcomes, implement evidence‐based practice, close the access to care gap and enhance quality of care through cost‐effective and creative means. The CNS role has been strengthened by the availability of HIT, allowing enhanced analytic capabilities, mobile and cloud‐based service integration, and access to myriad databases to strengthen impacts on outcomes. One such new and upcoming technology is in the area of Clinical Decision Support Systems (CDSS).12 Benefits of CDSS for patients and healthcare providers include:
- Provision of timely information inserted into workflows that is consistent with evidence-based guidelines. 13
- Improvement in quality by increasing the diagnosis pace and accuracy.14, 13
- Improved efficiency, lower costs, and reduced patient inconvenience.12
- Provision of alert evaluation processes and algorithms.12, 15
- Increasing patient safety and reduction in medical errors.15
Active and ongoing involvement of CNSs in the development and evolution of these technologies at local, state and federal levels is important for optimal patient and nurse centered outcomes. HIT also brings the opportunity for patients across continuums and populations to receive care from CNSs ultimately increasing the impact of CNSs on the nation’s healthcare system. Technology is being used increasingly to provide greater access to care incorporating telehealth platforms. On the policy level, delivery of care by various provider groups using telehealth is controlled mostly at the state but also at the federal level (Walsh, 2018). Engaging in policy and rulemaking activities at the state and federal level is vital to preserving CNSs as reimbursable providers of healthcare in this new delivery platform ultimately increasing access to quality healthcare for all consumers.
- Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2016‐17 Edition, Registered Nurses, on the Internet at http://www.bls.gov/ooh/healthcare/registered‐nurses.htm.
- McMenamin, P. QuikStats – Projected State RN Job Demands by 2022. (2014 July 18). Community. American Nurses Association, on the Internet at http://community.ana.org/blogs/peter‐mcmenamin/2014/07/18/quik.
- Phillips, J. (2016). Workplace violence against healthcare workers in the United States. New England Journal of Medicine, 374, 1661-1669 doi 10.1056/NEJMra1501998
- Institute of Medicine. (2010). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; www.iom.edu.Reports/2010/The-Future-of-Nursing
- Summers, L. (2016). Update: Transition to full practice authority for APRNs. The American Nurse. www.TheAmericanNurse.org May/June 2016.
- U.S. Department of Labor Occupational Safety and Health Administration (2016). Guidelines for Prevention of Violence for Healthcare and Social Service Workers. www.osha.gov/SLTC/workplaceviolence
- Occupational Safety and Health Administration (2015). Preventing Workplace Violence: A Road Map for Healthcare Facilities. www.osha.gov
- American Nurses Association. (2017). ANA Issue Brief. The South Carolina Nurse, WWW.scnurse.org October 2017
- CMS (2012). Graduate Nurse Education Demonstration Project. https://innovation.cms.gov/initiatve/gne/
- Centers for Disease Control and Prevention. Policy impact: Prescription painkiller overdoses. www.cdc.gov
- The Office of the National Coordinator on Health Information Technology, (2017). Benefits of EHR. Accessed February 2017 at https://www.healthit.gov/topic/health-it-basics/benefits-ehrs
- Agency for Healthcare Research and Quality (AHRQ), Rockville, MD. Content last reviewed August 2018. Clinical Decision Support. http://www.ahrq.gov/professionals/prevention-chronic-care/decision/clinical/index.html
- Hummel, J. (2013). Integrating Clinical Decision Support Tools into Ambulatory Care Workflows for Improved Outcomes and Patient Safety. Rep. Qualis Health, 15-16.
- Alabdulkarim, A., Al-Rodhaan, M., Ma, T., & Tian, Y. (2019). PPSDT: A novel privacy-preserving single decision tree algorithm for clinical decision-support systems using IoT devices. Sensors, 19(1), 142.
- McCoy, A. B., Thomas, E. J., Krousel-Wood, M., & Sittig, D. F. (2014). Clinical decision support alert appropriateness: a review and proposal for improvement. The Ochsner Journal, 14(2), 195-202.
- Walsh, T., (2018). Telehealth industry trends. Accessed Jan 7th 2019, at https://www.advisory.com/research/market-innovation-center/resources/2018/telehealth-industry-trends