By Juliana Mower, MSN, RN, CNS, CNS-CP, CNOR

As hospitals strive to meet the twin challenges of controlling costs and providing quality patient care, surgical services managers rely on expert practitioners to provide safe patient care. This article describes how adding a Clinical Nurse Specialist to the perioperative department staff is an efficient and cost-effective way to improve perioperative patient outcomes.


Anyone involved in the care of perioperative patients is aware that the current health care environment requires working with less: less staff, less resources, less budget, less time. At the same time, accrediting bodies, regulatory agencies, insurance companies, and patients are expecting a quality patient care experience at a reasonable cost and with optimal outcomes. Wouldn’t it be wonderful if one person could cover multiple roles that would meet all these expectations? The ideal candidate would need to be an expert clinician, educator, leader, researcher, and consultant. Fortunately, this person already exists as a Clinical Nurse Specialist (CNS).

Definition of CNS

A CNS is one of four advanced practice roles which also include Certified Nurse Practitioners (CNPs), Certified Registered Nurse Anesthetists (CRNAs) and Certified Nurse Midwives (CNMs). CNSs are prepared at either the master’s or doctoral level in one of six population foci: family across the lifespan, adult/geriatrics, women’s health/gender specific, pediatrics, neonatal, or psych/mental health. A significant component of both CNS education and practice is focused on direct patient care. Based on advanced education, training, and experience, the CNS performs assessments, diagnoses and treats patient problems, and prescribes pharmacologic and non-pharmacologic interventions.1

The Value of the CNS in the Perioperative Department

CNSs have the expertise to design and implement interventions that reduce hospital costs by decreasing length of stay; preventing or initiating early treatment of inpatient complications; and increasing patient satisfaction with nursing care.2

Coordinating the care of complex patients, facilitating change at the systems level, and assisting staff in applying best practices to patient care are only three of the many skills that make the CNS so attractive to a perioperative department. Of additional value is the CNS who also functions as a Registered Nurse First Assistant (RNFA).3 The RNFA who is educated as a CNS has the advanced skill set to care for the patient throughout the entire continuum of the perioperative experience, from completing the history and physical and ordering laboratory and diagnostic tests preoperatively, to serving as the RNFA during the operative procedure, and then facilitating discharge and postoperative recovery. Examples of CNS core competencies and their implications for perioperative practice at the organizational, departmental, and staff levels are provided in Table 1.

Maximizing the Expertise of the CNS

In its landmark report on the future of nursing, the Institute of Medicine recommended that organizations remove scope of practice barriers specific to advanced practice nurses which would enable them to practice to the “full extent of their education and training.” 5(p1) Organizational and perioperative department leaders can assist CNSs to reach their full potential as advanced practice nurses by:

  • Supporting primary population and secondary specialty certification to ensure initial and continuing competency. Many specialty nursing organizations provide a certification for APRNs. The Competency and Credentialing Institute (CCI) offer a CNS-specific specialty certification, the CNS-CP.7 Specialty certification adds additional depth to professional practice beyond that required for practice in the primary population and is strongly recommended.1
  • Expanding hospital privileges to allow CNSs to bill Medicare for patient services.5
  • Advocating for prescriptive authority privileges if allowed by individual state board of nursing.6 Note: Currently not all state boards of nursing approve prescriptive authority for CNSs.

Conclusion

In our rapidly changing health care environment, the multi-skilled CNS is ideally suited to serve as a change agent to improve the provision of safe, cost-effective, and efficient perioperative patient care. CNS effectiveness can be measured in cost savings and enhanced staff, surgeon, and patient satisfaction.   

Juliana Mower, MSN, RN, CNS, CNS-CP, CNOR, is a Nurse Manager, Credentialing and Education, Competency and Credentialing Institute.

References

1. APRN Consensus Work Group, National Council of State Boards of Nursing APRN Advisory Committee. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. 2008. https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf.  Accessed March 9, 2017

2. Gordon JM, Lorilla JD, Lehmaan CA. The Role of the Clinical Nurse Specialist in the Future of Health Care in the United States. Perioperative Nursing Clinics. 2012;7:343-353.

3. AORN. Position Statement on Advanced Practice Registered Nurses in the Perioperative Environment. 2014.  http://www.aorn.org/guidelines/clinical-resources/position-statements.  Accessed March 6, 2017.

4. The National CNS Competency Task Force. Clinical Nurse Specialist Core Competencies. 2010. http://www.nacns.org/wp-content/uploads/2017/01/CNSCoreCompetenciesBroch.pdf. Accessed March 8, 2017.

5. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington DC: The National Academies Press. 2010. http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.  Accessed March 8, 2017.

6. NACNS. Position Statement on Prescriptive Privilege for the Clinical Nurse Specialist. http://nacns.org/advocacy-policy/position-statements/national-association-of-clinical-nurse-specialists-position-statement-on-prescriptive-privilege-for-the-clinical-nurse-specialist/. Accessed March 9, 2017.

7. Competency and Credentialing Institute. CNS-CP. http://www.cc-institute.org/cns-cp. Accessed March 10, 2017.