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     Brenda Moffitt is the current NWCNS President. She recently retired after being in nursing for over 40 years. During the majority of that time, Brenda practiced as a CNS and in various nursing leadership roles. No matter what the role was, her CNS education and knowledge served her well.
     Since retirement, Brenda is enjoying time gardening, organizing, spending time with family, and walking.

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Email: moffittb7@gmail.com
Phone: 620-242-4658
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Leadership Project: Development of a CNS Position Statement on the APRN Compact

A project submitted
in partial fulfillment of the requirements for the degree of
Doctor of Nursing Practice
Seattle Pacific University
June 2, 2024

Leadership Project: Development of a CNS Position Statement on the APRN Compact

Summary

Interest is growing to enact an Advanced Practice Registered Nurse (APRN) Compact to allow APRNs to practice across state lines under a single license (National Council of State Boards of Nursing [NCSBN], 2024a). As of May 2024, four states have enacted the APRN
Compact and two are pending legislation. Seven states must enact legislation for the Compact to take effect. Several Nurse Practitioner (NP) organizations have published position statements opposing the current APRN Compact, raising concerns about practice hour requirements and limitations placed on controlled substance prescribing (ARNPs United Washington State, n.d.; American Association of Nurse Practitioners, 2023). In addition, there are issues unique to Clinical Nurse Specialist (CNS) practice that the APRN Compact fails to address such as the disparities among states that do not recognize CNSs as APRNs or do not grant CNSs prescribing authority. Yet no CNS position statement has been published to date. To address this gap, a CNS position statement on the APRN Compact was developed to give voice to the APRN Compact situation, issues unique to CNS practice, and how best to move forward.

Background

Despite several benefits of a multistate license, the proposed 2020 APRN Compact has raised concerns regarding the limitations placed on APRN practice. The APRN Compact makes no mention of the APRN Consensus Model as the standard for all party states joining the Compact, places limitations on prescribing controlled substances, and requires 2,080 APRN practice hours prior to multistate licensure (NCSBN, n.d.). Additionally, the Compact has vague language on whether NPs can practice independently in states that require physician collaboration (NCSBN, n.d.; NCSBN, 2020). The practice implications are even more unclear for the CNS. Despite these concerns, a CNS position statement has not been published to date.

Intervention

This project aimed to create a CNS position statement and provide a policy evaluation on the APRN Compact using the plan-do-study-act (PDSA) cycle for process improvement
(Institute for Healthcare Improvement, n.d.). First, research was conducted on the relevant issues and practice implications for the CNS role. Next, a CNS position statement was drafted and presented at the April 2024 NWCNS Affliate meeting of the National Association of Clinical Nurse Specialists (NACNS). A brief literature review was performed to determine the fiscal impact of CNSs to strengthen the statement through evidence demonstrating CNS-led cost avoidance and improved patient outcomes. The draft was revised based on stakeholder feedback and an updated version presented at the May 2024 NWCNS meeting. Finally, the position statement will be disseminated to the NWCNS Affiliate, NACNS, the Washington State Nurses Association, and the Washington Board of Nurses APRN Subcommittee.

Results

Research for the CNS position statement revealed significant variability in APRN practice authority between states and between APRN roles. The four APRN Consensus Model
roles are not recognized in all 50 states and U.S. Territories (NCSBN, 2024b: NCSBN, 2024c). The CNS role is not recognized as an APRN in Mississippi, New Hampshire, New York, Pennsylvania or American Samoa (New York State Education Department, n.d.; NCSBN, 2023b). In contrast, NPs are recognized as APRNs in all 50 states and five U.S. Territories (NCSBN, 2024c). Prescriptive authority for NPs is also well established and recognized in all U.S. states and Territories (NCSBN, 2023a). Conversely, CNS do not have any prescriptive authority in eight states (Commonwealth of Massachusetts, 2024; NCSBN, 2023c). The current APRN Compact language fails to address these practice disparities for the CNS.

Implications

By failing to address the variations in CNS practice nationally, it is unclear how CNSs in
home states with full practice and prescribing authority will navigate practicing in states with limited scope. This puts the CNS at risk and the onus on the APRN to know each individual party states’ law to ensure they are not practicing outside their scope of practice for that state.

The variations in CNS practice authority also raise questions about patient safety. For
CNSs that graduated and completed their clinical practicum experiences in home states that do not have any prescriptive authority, but could through the APRN Compact, prescribe in party states that have full prescriptive authority, the Compact does not address or take steps to validate that CNSs from states with limited scope have the knowledge and experience to safely prescribe in full practice authority states.

By failing to address the disparities in CNS practice, the APRN Compact is missing the
value the CNS brings to the healthcare system. Unlike NPs, who generate revenue through feefor- service billing, CNSs produce financial benefit through evidence-based interventions that lead to cost avoidance and improved patient outcomes. For example, a CNS team at a medical center in the United States developed a CNS scorecard to standardize and evaluate the fiscal impact of CNS-led projects and programs (Toth et al., 2024). At the end of FY’22, the CNSs had generated a revenue totaling $29,890 and demonstrated a cost avoidance of $2,854,807.30. Another study demonstrated cost avoidance by implementing a CNS-led tracheostomy care management program for patients with new tracheostomies (Richardson et al., 2023). The CNSled care resulted in a statistically significant decrease in time between tracheotomy placement and discharge and reduced overall length of stay and tracheotomy-related pressure injuries, resulting in an estimated cost savings of $2.2 million (Richardson et al., 2023). The evidence from the literature demonstrates that when CNSs are recognized as APRNs and full practice scope supported, the results are demonstratable cost savings and improved patient outcomes. The CNS role must be recognized and supported in the APRN Compact language.

Conclusion

Clinical Nurse Specialists should support an APRN Compact in theory, however, the
current version has vague language that fails to address the variations of CNS practice in several states which threatens full-practice authority for the CNSs working in states with independent practice. Until the APRN Compact language is revised to address these issues, the Compact cannot be supported.

References

American Association of Nurse Practitioners [AANP]. (2023). APRN compact licensure: The American Association of Nurse Practitioners® (AANP) opposes the revised APRN
compact. https://www.aanp.org/advocacy/advocacy-resource/position-statements/aprn-compact-licensure

ARNPs United Washington State [AUWS]. (n.d.) AUWS opposed the APRN compact.

https://auws.enpnetwork.com/page/38397-auws-opposes-the-aprn-compact

Commonwealth of Massachusetts. (2024). Learn about advanced practice registered nurses (APRN). https://www.mass.gov/info-details/learn-about-advanced-practice-registered-nurses-aprn

Institute for Healthcare Improvement [IHI]. (n.d.). Model for improvement: Plan-do-study-act (PDSA) cycles. https://www.ihi.org/how-improve-model-improvement-testing-changes

National Council of State Boards of Nursing [NCSBN]. (n.d.) APRN compact: Key provisions.

https://www.aprncompact.com/files/APRN_Key_Provisions-2022.pdf

National Council of State Boards of Nursing [NCSBN]. (2020, August 12). Advanced practice registered nurse compact.
https://www.aprncompact.com/files/FINAL_APRNCompact_8.12.20.pdf

National Council of State Boards of Nursing [NCSBN]. (2023a, May 22). CNP independent prescribing map. https://www.ncsbn.org/nursing-regulation/practice/aprn/aprn-consensus-implementation-status/cnp-independent-prescribing-map.page

National Council of State Boards of Nursing [NCSBN]. (2023b, June 8). CNS independent
practice map. https://www.ncsbn./nursing-rorgegulation/practice/aprn/aprn-consensus-implementation-status/cns-independent-practice-map.page

National Council of State Boards of Nursing [NCSBN]. (2023c, June 8). CNS independent
prescribing map. https://www.ncsbn.org/nursing-regulation/practice/aprn/aprn-consensus-implementation-status/cns-independent-prescribing-map.page

National Council of State Boards of Nursing [NCSBN]. (2024a). APRN compact: The best way forward. https://www.aprncompact.com/about.page

National Council of State Boards of Nursing [NCSBN]. (2024b). APRN consensus model.

https://www.ncsbn.org/nursing-regulation/practice/aprn.page

National Council of State Boards of Nursing [NCSBN]. (2024c, January 17). APRN roles map:
APRN roles recognized. https://www.ncsbn.org/nursing-regulation/practice/aprn/aprn-consensus-implementation-status/aprn-roles-map.page

New York State Education Department. (n.d.). Frequently asked license questions for clinical
nurse specialists. https://www.op.nysed.gov/professions/clinical-nurse-specialists/faqs

Richardson, J., Girardot, K., Powers, J., & Kadenko-Monirian, M. (2023). Clinical nurse

specialist tracheostomy management improves patient outcomes. Journal of Nursing
Care Quality, 38(3), 251-255. https://doi.org/10.1097/NCQ.0000000000000691

Toth, C., Miller, K., Hart, A., & Kidd, M. (2024). Clinical nurse specialist role advocacy:

Quantifying the financial contributions via development of a scorecard. Clinical Nurse
Specialist, 38(2), 91-97. https://doi.org/10.1097/NUR.0000000000000802