Clinical Nurse Specialists

Leaders in Managing Patients With Chronic Conditions

Mary P. Hansen; Mitzi M. Saunders; Cynthia R. Kollauf; Ludmila Santiago-Rotchford


Nurs Econ. 2019;37(2):103-109. 

In This Article

CNS as Independent Practitioner

The CNS has emerged as an expert nurse and independent practitioner. This emergence may be due in part to the impact of the Affordable Care Act (ACA). Although the ACA increased insurance coverage to citizens who had been uninsured, this did not translate into equitable access for all. Increased volumes of persons with multiple chronic comorbidities coupled with a lack of a sufficient number of providers has created a healthcare system driven by penalties for increased length of stay and avoidable hospitalizations (Gaffney & McCormick, 2017). To assist in the management of this population, many states have endorsed CNSs to provide care as independent practitioners with prescriptive authority (Brush et al., 2015; NACNS, 2016; National Council of State Boards of Nursing, 2015; Ray & Mittelstadt, 2016). This expansion in scope of practice has created an opportunity for CNSs to fill a growing deficit of primary care providers (PCPs) in ambulatory care settings (Johnson & Garvin, 2017).

Governing bodies as well as legislative movements at the federal, state, and local levels endorse the CNS as an APRN and independent practitioner (APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee, 2008). The IOM recommends healthcare systems and regulatory bodies break down barriers that hinder nurses from practicing to the full extent of licensure (IOM, 2011). CNSs support policy that enables them to practice as independent providers with prescriptive authority and desire a greater role in prescribing to facilitate care in patients with chronic conditions (Saunders, 2015). When CNSs practice with prescriptive authority, access to care is streamlined (Klein, 2015) and provides a significant intervention for vulnerable populations. As CNSs treat patients in critical access sites, their referrals, to and within the larger system, align with the organizational strategic plans and generate income while utilizing a business case approach to care (Ellis, Embree, & Ellis 2015).

CNS practice across all healthcare settings has demonstrated positive quality outcomes including a decrease in complications, reduced readmissions, lower costs of care in patients with chronic conditions (Bryant-Lukosius et al., 2015; Negley, Cordes, Evenson, & Schad, 2016; Ulch & Schmidt, 2013) and improved nurse/staff satisfaction (DeJong & Veltman, 2004; Saunders, 2015). Table 2 provides evidence from the literature supporting the productivity of the CNS when full scope of practice is employed across the continuum of care.