Linda D Urden, DNSc, RN, CNS, NE-BC, FAAN Professor and Director Master’s and International Nursing Programs Hahn School of Nursing and Health Science University of San Diego

 There are four types of advanced practice nurses: ◦ Clinical Nurse Specialist (CNS) ◦ Nurse Midwife ◦ Nurse Practitioner ◦ Nurse Anesthetist  CNSs are licensed registered nurses who have graduate preparation at the master’s and doctoral levels  CNSs have additional certifications or licenses as a CNS

 CNSs are expert clinicians who work in a variety of clinical practice settings ◦ Population: pediatrics, geriatrics, women’s health ◦ Setting: critical care, emergency room ◦ Disease or medical subspecialty: diabetes, oncology ◦ Type of Care: rehabilitation, home health, mental health, palliative care ◦ Type of Problem: pain, stress, wounds  CNSs are independent practitioners and may form their own practice

 Patient ◦ May coordinate the care of a certain specialty population, e.g., HF, transplant ◦ May manage clinics for specialty ◦ May be consulted to provide teaching, support for a newly diagnosed condition  Staff ◦ Mentor, role model for staff ◦ Teach, rounds, consultant for complex cases  Organization ◦ Lead system wide initiatives, multidisciplinary teams ◦ Instrumental in managing change of practice (EBP)

 CNSs practice in a variety of health care settings ◦ Per 2010 survey, 70% practice in some type of inpatient care setting ◦ Remainder indicated home health care, long term care, public health centers, ambulatory care, correctional facilities, and private industry  CNSs teach in schools of nursing….increasing numbers with full time CNS practice while teaching courses in the schools

 Leaders of teams in organizations to improves quality and safety of care  Developers of programs to prevent avoidable complications  Coaches of those with chronic diseases to prevent hospital readmissions  Consumers of evidence-based practice to ensure best care and services (MSN, DNP)  Researchers to create new knowledge to improves outcomes of care (PhD).

 CNSs are uniquely positioned due to their expertise and skills to be leaders as we move forward with new models of care ◦ Improving the quality and safety of care ◦ Eliminating unnecessary care ◦ Improving the care for those with chronic illnesses ◦ Reducing the costs of care

 Increase effectiveness of transitioning care from hospital to home and prevent readmissions (create a Medicare benefit that would support providing transitional care)  Improve the quality and safety of care and reduce health care costs (leading EB system- wide changes: med errors, HACs, etc.)  Educate, train, increase the nursing workforce needed for improved health care system (EB orientation programs, mentor new and tenured staff)

 Increase access to community-based care through the expansion of Nurse Managed Health Care Centers (slow down progression of chronic disease  Increase the availability of effective care for those with chronic disease (promote self care and manage symptoms)  Improve access to wellness and preventive care (wellness company owned/managed by CNSs reduce costs)

 Make rounds on high risk cases  Coordinate/attend multidisciplinary care conference  Consult with staff on complex cases (anywhere in the organization)  Discuss cases with MDs, other care team members  Teach a specialty class  Meet with nurse residency program participants

 Attend leadership meeting  Meet with pharmacist on join EBP project  Meet with Director regarding new orientees  Consult with another CNS  Conference call with professional organization committee meeting  Intervene with new equipment that appeared with a patient from the OR- that staff had never seen before  Meet with staff who is presenting an inservice for the first time

 Work on revising one of the many procedures that need updated  Discuss with faculty the CNS student who you will be precepting next semester  Prepare for the system-wide EBP team meeting that you will lead tomorrow  Did anyone say lunch ?????

 Clinical experts in diagnosis and treatment of illness in specialties across the continuum of care  Provide evidence- based care in a variety of settings  Direct providers of Medicare services  Prescribers of medications (38 states)  Coordinators of care across settings  Leaders and facilitators of change among large groups and organizations  Researchers in identifying effective interventions with proven outcomes