Special Interest Group Update
In each issue, one of NANN's special interest groups shares information in their area of focus.
The Neonatal Clinical Nurse Specialist
Gail A. Bagwell, DNP APRN CNS; NANN President
In the world of neonatal nursing, the neonatal nurse practitioner (NNP) is the most recognized and well known advanced practice registered nurse (APRN). But did you know that there is another APRN that functions in the neonatal intensive care units? The other APRN is a neonatal clinical nurse specialist (NCNS): a clinical nurse specialist (CNS) who has specialized in the care of neonate and infants up to 2 years of age.
In 2008, the National Councils of State Boards of Nursing published Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education which recognizes four APRN roles: CNS, certified nurse practitioner, certified nurse-midwife, and certified registered nurse anesthetist (APRN Joint Dialogue Group, 2018). Like all APRNs, the CNS has been recognized to participate in Medicare Part B, Title 18, Medicare Primary Care Incentive Program in the Patient Protection and Affordable Care Act and has prescriptive authority in 39 states (National Association of Clinical Nurse Specialists, 2020).
The CNS is an APRN who is an expert clinician in their field of nursing practice and has attained a master’s or doctor of nursing practice (DNP) degree to expand their knowledge and skills. In addition to being a clinical expert, the CNS provides education and support to nursing and interdisciplinary staff and facilitates change and innovation in healthcare systems. The CNS role operates in the three spheres of influence: the patient/family direct care, nurse/nursing practice, and organization/systems (National Association of Clinical Nurse Specialists, 2019).
The CNS’s competencies fall into the seven competencies of APRNs described by Tracy & O’Grady (2014) of direct clinical care, evidence-based practice, consultation, leadership, collaboration, coaching and guidance and ethical decision making. The CNS advanced level competencies are unique among the four categories of APRNs and have been set for CNSs by the National Association of Clinical Nurse Specialists (NACNS). NACNS incorporated the competencies of specialty practice, skills, knowledge, and standards of practice along with knowledge of healthcare environment, healthcare policy, interprofessional collaboration, and societal needs into the three spheres of influence (patient/family direct care, nurse/nursing practice, and organization/systems). A CNS can practice in a single sphere, two, or all three, depending on factors that include the facility of employment of the NCNS, the needs and desires of the NICU or hospital, and where the NCNS is in their career and role development.
Examples of how the spheres of influence can be implemented are discussed below.
Direct Patient/Family Care
The direct patient/family care sphere encompasses not only the patient and family but the healthcare surrogate, community, and population. This sphere is implemented through direct contact and involvement with these groups to promote health and/or well-being to improve quality of life. The holistic perspective of the management of health, illness and disease is the core strength of CNS practice (National Association of Clinical Nurse Specialists, 2019).
Examples of this sphere in the NCNS practice are consulting on complex neonatal patient care issues; preparing and coordinating the patient transition to home, especially the complex NICU patient; working with bedside nurses to develop care plans for the complex patient, working with families to improve their knowledge and skills in caring for their infant with complex needs, facilitating meetings between team members and family for decision making to address ethical and complex medical issues, performing follow-up home visits, assisting bedside nurses in providing culturally appropriate care, and prescribing treatments and medications in states in which NCNSs have prescriptive authority.
Nurse/nursing practice sphere focuses on the CNS advancing nursing practice to achieve the best outcomes by ensuring that nursing personnel utilize evidence-based practice to meet all the needs of patients, families, and populations (National Association of Clinical Nurse Specialists, 2020). Examples of a NCNS implementing their competencies in this sphere are being a consultant on unit issues; collaborating with unit educators on the development of orientation program and educational plans for new technology; consulting on clinical issues; coaching bedside nurses on care issues; leading evidence-base practice (EBP) changes at the unit or organizational level; mentoring nurses on professional development; precepting NCNS students; presenting projects at local, state and national conferences; and collaborating with community agencies on neonatal issues, such as infant mortality.
The organization/systems sphere referes to the CNS's ability to:
- articulate the value of nursing care to organizations' decision-making leaders
- influence changes at the unit and system level through quality improvement that leads to cost-effective patient outcomes
- advocate for professional nursing issues
The NCNS can execute this sphere by leading quality improvement initiatives; leading and collaborating with interdisciplinary teams to implement new programs or EBP guidelines; leading initiatives to determine cost-benefit analysis of new technologies to be implemented; advocating on the local, state and national level for issues related to maternal and neonatal care as well as nursing; and collaborating with community organizations to improve the care of neonates.
A Complex Role
As demonstrated, the NCNS role is complex, though full implementation depends on an NCNS’s specific unit or health system. Working with their physician and nursing colleagues to ensure the highest quality of care is provided to all patients and their families, the NCNS brings unique competencies to help hospitals and health systems improve quality outcomes and reduce costs associated with patient care.
APRN Joint Dialogue Group. (2008). Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. National Council of State Boards of Nursing. https://ncsbn.org/aprn-consensus.htm
National Association of Clinical Nurse Specialists. (2019) Statement on clinical nurse specialist practice and education (3rd ed.). https://nacns.org/resources/practice-and-cns-role/cns-competencies
National Association of Clinical Nurse Specialists. (2020, September 8). Scope of practice. https://nacns.org/advocacy-policy/policies-affecting-cnss/scope-of-practice.
Tracy, M. F. & O’Grady, E. T. (Eds.) (2014). Hamric and Hanson’s Advanced practice nursing: An integrative approach (5th ed.). Elsevier.