CLINICAL NURSE SPECIALISTS
Purposes and Definitions
(1) Purposes of these rules:
(a) To implement the provisions of ORS 678.370 to 678.372 governing the certification of Clinical Nurse Specialists (CNS) by the Oregon State Board of Nursing.
(b) To define the scope of practice of the CNS.
(c) To establish standards for safe practice for the CNS.
(d) To serve as a guide for the Board to evaluate CNS practice.
(2) Definitions as used in these rules:
(a) "Assessment" means a process of collecting information regarding a client's health status using tools, techniques, and methodologies based on nursing theory and research. The skills employed during the assessment process include collecting, analyzing and evaluating data in order to diagnose symptoms, functional problems, risk behaviors and health status, and to develop interventions and plans of care.
(b) "Client" means the recipient of CNS services for whom the CNS has established a provider relationship. A provider relationship is established through assessment and planning for the recipient.
(c) "Clinical Nurse Specialist" (CNS) is a registered nurse who has been approved and certified by the Board to provide health care in an expanded specialty role.
(d) "Collaboration" is a process involving the CNS and one or more members of the health care team working together to achieve common goals, each responsible for their particular area of expertise.
(e) "Consultation" means interaction between the CNS and the consultee for the purpose of transmitting or obtaining information or advice.
(f) "Continuing Education hours" are contact hours of education. One contact hour is equal to 60 minutes of instruction. Ten contact hours are equal to one Continuing Education Unit (CEU).
(g) “Diagnosis” means identification of actual or potential health problems or need for intervention, based on analysis of the data collected.
(h) "Medical equipment" means medical supplies and durable or disposable equipment ordered by the CNS which are related to or required for self-care, or the plan of care.
(i) "National Certification" means a certificate of recognition in a specialty area issued by a national nursing organization.
(j) "Order" means written or verbal directives by the CNS to other members of the health care team.
(k) "Organization" means a system or network that provides patient care.
(l) "Population" means the collection of individuals in a community or a group of individuals defined by age, health status, lifestyle, disease and/or geographic location.
(m) “Prescribe” means written, verbal, or electronic legal directive to procure or designate for use legend drugs or controlled substances.
(n) "State Certification" means certification to practice advanced nursing as authorized by the Oregon State Board of Nursing.
Stat. Auth.: ORS 678.150
Stats. Implemented: ORS 678.370 & 678.372
Hist.: BN 4-2001, f. & cert. ef. 2-21-01; BN 11-2006, f. & cert. ef. 10-5-06; BN 14-2010, f. & cert. ef. 9-30-10
Use of the Clinical Nurse Specialist Title
As of 10-01-2001 an individual shall meet the requirements and receive state certification as a Clinical Nurse Specialist in order to use the title Clinical Nurse Specialist or CNS. Pursuant to ORS 678.370, no person shall hold themselves out to the public as a Clinical Nurse Specialist or CNS without recognition and certification from the Oregon State Board of Nursing.
Stat. Auth.: ORS 678.370, ORS 678.372 & ORS 678.150
Stats. Implemented: ORS 678.370, ORS 678.372 & 678.150
Hist.: BN 4-2001, f. & cert. ef. 2-21-01
Clinical Nurse Specialist Scope of Practice
The Clinical Nurse Specialist (CNS) independently provides advanced theory and research-based care to clients, and facilitates attainment of health goals. Within the practice of advanced nursing, the CNS provides innovation in nursing practice, based upon clinical expertise, evidence-based decision making, and leadership skills. The CNS practices within three spheres of influence. These three spheres of influence are: individual clients and populations; nurses and other multidisciplinary team members; and organizations. Practice may target one or more spheres of influence.
(1) The CNS may practice with individual clients and populations of clients.
(a) Individual client care includes, but is not limited to:
(A) Assessing the client using tools, techniques, and methodologies based on theory and research;
(B) Diagnosing symptoms, functional problems, risk behaviors, and health status of the client;
(C) Developing a mutually derived therapeutic plan of care with the client;
(D) Designing, implementing, and evaluating nursing interventions by using data, research, and theoretical knowledge;
(E) Selecting, recommending, and ordering medical equipment, laboratory and screening or diagnostic tests for the client;
(F) Selecting, recommending and ordering prescription medications and devices as authorized per division 56 consistent with specialty and scope of practice.
(G) Establishing standing orders related to nursing interventions and specific plans of care;
(H) Encouraging disease prevention, health promotion and health maintenance;
(I) Providing referrals for the client to other health care services or providers as indicated.
(b) Population care includes, but is not limited to:
(A) Planning, implementing and evaluating data collection;
(B) Selecting, ordering, and recommending screening and diagnostic tests for individuals within the population;
(C) Interpreting and analyzing population data to formulate diagnoses in the area of needs, functional problems, risks, and health issues;
(D) Reviewing and revising diagnoses based on subsequent data collection;
(E) Innovating, implementing, guiding, evaluating, and revising population-focused plans and programs;
(F) Encouraging disease prevention, health promotion and health maintenance;
(G) Establishing criteria for referral within a population;
(H) Establishing algorithms, standing orders, or practice guidelines related to specific populations;
(I) Informing the population about its health and promoting other community systems that influence health;
(J) Assessing need for and participating in activities to change health and social policies that affect the health of the community.
(2) The CNS may practice with nurses and other members of the multidisciplinary care team to advance the practice of nursing and improve client care. This practice includes, but is not limited to:
(a) Consulting and collaborating to identify and manage health care issues;
(b) Providing leadership in the utilization of research in practice;
(c) Coaching nursing staff in clinical practice development;
(d) Identifying knowledge deficits of target groups providing health care;
(e) Developing, providing and evaluating educational and other programs that enhance the practice of nursing personnel and/or other members of the health care team.
(3) The CNS may practice with organizations to provide clinical expertise and guidance. This practice includes, but is not limited to:
(a) Using system-wide change strategies based on an assessment of the needs and strengths of the organization;
(b) Initiating collaborative relationships among teams to facilitate interdisciplinary practice;
(c) Collaboratively developing and evaluating research-based and client-driven systems and processes;
(d) Creating, advising, and influencing system-level policy that affects programs of care;
(e) Evaluating and recommending equipment and products being used in patient care for efficacy, efficiency, cost-effectiveness, and client/consumer satisfaction.
(4) The CNS may provide expertise that includes, but is not limited to:
(a) Summarizing, interpreting, and applying research results;
(b) Teaching, coaching, and mentoring health care members in the evaluation and use of research;
(c) Planning, directing, and evaluating multidisciplinary programs of care for clients;
(d) Evaluating client outcomes and cost effectiveness of care to identify needs for practice improvement;
(e) Conducting and participating in research and research protocols;
(f) Designing and establishing standing orders related to nursing interventions.
(5) The CNS scope of practice may include:
(a) Prescribing, ordering, administering and dispensing medications per division 56 regulations and requirements.
(b) Receiving and distributing drug samples.
(c) Obtaining DEA registration for controlled substances in Schedule II-V.
Stat. Auth.: ORS 678.150
Stats. Implemented: ORS 678.370, 678.372
Hist.: BN 4-2001, f. & cert. ef. 2-21-01; BN 11-2006, f. & cert. ef. 10-5-06
Standards for Clinical Nurse Specialist Scope of Practice
The Clinical Nurse Specialist (CNS), shall meet the standards for Registered Nurse practice, and shall also meet the practice standards of advanced practice, including but not limited to:
(1) Recognize and practice within the limits of knowledge and experience of the individual CNS, and consult with or refer clients to other health care providers when indicated;
(2) Develop and practice within jointly derived statements of agreement, or jointly derived practice protocols, pre-printed orders, or algorithms to facilitate interdependent practice when CNS practice overlaps with the scope of medical practice;
(3) Provide and document nursing services within the scope of practice and specialty for which the individual CNS is educationally prepared, and for which competency has been established and maintained. Educational preparation includes academic coursework, workshops or seminars, or other supervised, planned learning, provided both theory and clinical experience are included.
Stat. Auth.: ORS 678.370, ORS 678.372 & ORS 678.150
Stats. Implemented: ORS 678.370, ORS 678.372 & 678.150
Hist.: BN 4-2001, f. & cert. ef. 2-21-01
Eligibility for Initial Certification
(1) An applicant for certification as a Clinical Nurse Specialist (CNS) shall:
(a) Hold or obtain an active unencumbered registered nurse license in Oregon;
(b) Hold a graduate degree in nursing, or a post-masters certificate in nursing demonstrating evidence of CNS theory and clinical concentration. The program shall meet the following educational standards:
(A) The program shall be at least one academic year in length;
(B) There shall be faculty and/or clinical instructors who are academically and experientially qualified in nursing, and who maintain expertise within the CNS scope of practice;
(C) NLNAC or CCNE accreditation or documentation of a Board approved credentials evaluation for graduates of programs outside of the U.S. which demonstrates education equivalency to a NLNAC or CCNE graduate degree in nursing.
(D) Applicants who graduate or obtain a post-masters certificate on or after January 1, 2007 shall have completed 500 hours of clinical practice within the program; or prior to state certification:
(i) Complete a formal academic program offering any remaining hours of clinical practice; or
(ii) Complete a Board approved clinical continuing education course offering supervised clinical practice for any remaining hours.
(c) Meet the practice requirement through verification of:
(A) Graduation from a CNS educational program within the past five years; or
(B) Practice within the CNS scope of practice for at least 960 hours within the five years preceding the application. Verification of practice hours is subject to random audit.
(2) If an applicant does not meet the practice requirement in 851-054-0040(1)(c), the applicant shall:
(a) Obtain a limited license as a registered nurse in the State of Oregon; or hold an active Oregon registered nurse license;
(b) Submit for Board approval, a detailed plan for precepted practice that includes: competencies that support the CNS scope of practice; names and qualifications of CNS preceptor(s); and a description of the nature of the proposed unpaid, voluntary, precepted clinical experience.
(A) If the applicant has practiced at least 960 hours within the six years prior to the date of application, the practice plan shall provide for 250 hours of preceptorship. Documented practice hours within the CNS scope for the past two years may be recognized and may reduce the required hours, except that, in no case shall the precepted practice be less than 120 hours.
(B) If the applicant has practiced at least 960 hours within the CNS scope for the ten years prior to the date of application, the practice plan shall provide for 400 hours.
(C) If the applicant has not practiced at least 960 hours within the CNS scope for the ten years prior to the date of application, the practice plan shall provide for 500 hours.
(c) Obtain a limited CNS state certification for precepted practice. The limited state certification shall be issued only upon receipt of a completed CNS application, application for limited state certification, Board approval of the plan for supervised practice, and payment of all applicable fees. The limited state certification is valid only for precepted practice that has been approved in advance by the Board, and will be valid for one year from the date of issue. One extension of the limited state certificate may be granted upon approval and payment of fee, provided there is a current valid application for state certification on file and no disciplinary action has been taken against the applicant. This extension will be valid for one year from date of approval.
(d) Successfully complete the precepted hours of practice supervised by the CNS preceptor. Successful completion shall be verified by a final evaluation submitted by the supervising CNS to the Board to verify that the applicant is competent to practice in the CNS scope at a safe and acceptable level, and that the number of required hours of precepted practice was completed.
(e) Submit evidence of continuing education related to the CNS role to total 20 contact hours for each year out of practice with no less than 50% obtained from accredited providers of continuing nursing education (CNE), continuing medical education (CME), or continuing pharmacology education (CPE). Continuing education taken concurrent with the reentry plan may be applied towards the total continuing education requirement, provided all hours are complete by the end of the preceptorship.
(3) The applicant shall submit all fees required by the Board with the application. The fees are not refundable. An application that remains incomplete after one year shall be considered void.
(4) Clinical Nurse Specialists seeking prescriptive authority will need to meet all additional requirements in Division 56. These requirements may be obtained as part of a re-entry program plan approved by the Board.
Stat. Auth: ORS
678.050, 678.370 & 678.372
Stats. Implemented: ORS 678.050, 678.370 & 678.372
Hist.: BN 4-2001, f. & cert. ef. 2-21-01; BN 10-2001, f. & cert. ef. 7-9-01; BN 6-2006, f. & cert. ef. 5-8-06; BN 11-2006, f. & cert. ef. 10-5-06; BN 3-2007, f. & cert. ef. 3-13-07; BN 14-2010, f. & cert. ef. 9-30-10; BN 8-2013, f. 5-6-13, cert. ef. 6-1-13
Renewal of Clinical Nurse Specialist Certification
Renewal of the Clinical Nurse Specialist (CNS) certification shall be on the same schedule as the renewal of the registered nurse license. The requirements for renewal are:
(1) Active license as a registered nurse in Oregon; and
(2) Practice as a CNS for no less than 960 hours within the five years prior to renewal or have completed a preceptorship as established in OAR 851-054-0040(2); and
(3) Forty contact hours of continuing education accumulated during the current certification period. At least 50% shall consist of formal academic or structured continuing education obtained from the following continuing education accrediting bodies: American Nurses Credentialing Center (ANCC), Accreditation Council for Continuing Medical Education (ACCME), American Academy of Continuing Medical Education (AAOCME), Accreditation Council for Pharmacy Education (ACPE), state boards of nursing and state nursing associations.
(4) Proof of national board certification as a CNS in a specialty may be used to meet structured continuing education requirements for the current renewal cycle for up to 50% of the total continuing education requirement.
(5) A CNS with prescriptive authority must meet additional CE requirements as specified in Division 56.
(6) The CNS shall affirm and document completion of the continuing education and practice hours on the application renewal or delinquent renewal form. Verification of all hours and credits is subject to random audits by the Board. Falsification of continuing education or practice hours is grounds for disciplinary action.
(7) The CNS shall maintain accurate records of any claimed CE hours and practice hours for no less than five years from date of submission to the Board.
(8) An applicant for renewal who has graduated from the CNS program less than two years prior to the first renewal will not be required to document the full 40 contact hours of continuing education. Continuing education will be prorated on a monthly basis based on the length of time between graduation and the date of the first renewal.
(9) The applicant shall submit the required fees with the application. Fees are not refundable. An application shall be void if not completed during the current biennial renewal cycle.
(10) An applicant for renewal up to 60 days past the expiration date shall meet all requirements for renewal and pay a delinquent fee.
(11) Any individual whose state CNS certification is delinquent may not practice as a CNS until certification is complete, subject to civil penalty.
Stat. Auth.: ORS
678.101, 678.370 & 678.372
Stats. Implemented: ORS 678.372
Hist.: BN 4-2001, f. & cert. ef. 2-21-01; BN 11-2006, f. & cert. ef. 10-5-06; BN 14-2010, f. & cert. ef. 9-30-10; BN 8-2013, f. 5-6-13, cert. ef. 6-1-13
Clinical Practicum in Oregon for Clinical Nurse Specialist Students Enrolled in a Non-Oregon Based Graduate Program
(1) A clinical nurse specialist student enrolled in a Non-Oregon Based Graduate Program may not participate in a clinical practicum in Oregon without prior Board authorization.
(2) Prior authorization will be predicated upon approval of the following:
(a) A completed registration form;
(b) Verification of a current, unencumbered registered nurse license in Oregon;
(c) Verification of enrollment in a graduate program accredited by a United States Department of Education or the Council of Higher Education Accreditation approved national accrediting body;
(d) Verification of regional accreditation and/or Board of Nursing approval from the state in which the program originates;
(e) Proof of approval by the Office of Degree Authorization of the Non-Oregon Based Graduate Program;
(f) Submission of a written signed agreement between the Non-Oregon Based Graduate Program responsible for the student and the Oregon licensed preceptor;
(g) Identification of the faculty advisor accountable for general supervision from the Non-Oregon Based Graduate Program; and
(h) Identification of the Oregon licensed clinical nurse specialist faculty providing direct clinical evaluation of the clinical nurse specialist student.
(3) Oregon licensed preceptors are responsible for validating that the student has registered and received Board authorization prior to participating in a clinical practicum in Oregon.
(4) A clinical nurse specialist student shall practice under the direct supervision of an approved Oregon licensed clinical nurse specialist, nurse practitioner, medical physician, or doctor of osteopathy who agrees to serve as preceptor, and general supervision of a faculty member as approved in the clinical practicum registration.
(5) Oregon faculty will be approved by the Board based on congruence of clinical scope and expertise to the student’s clinical placement.
(6) The student’s assigned preceptor may not simultaneously serve as their designated faculty of record. The faculty of record must provide on-site evaluation of both the student and the preceptor.
Stat. Auth.: ORS
Stats. Implemented: ORS 678.150
Hist.: BN 8-2012, f. 5-7-12, cert. ef. 6-1-12; BN 16-2012(Temp), f. & cert. ef. 11-15-12 thru 5-1-13; BN 5-2013, f. 2-28-13, cert. ef. 4-1-13
Disciplinary Action on Clinical Nurse Specialist Certification
(1) The Board may deny, suspend or revoke the authority of a Clinical Nurse Specialist (CNS) to practice under a limited or full certificate for the causes identified in ORS 678.111(1).
(2) Revocation, suspension, or any other encumbrance of a registered nurse license, or any special authority to practice as a CNS, in another state, territory of the United States, or any foreign jurisdiction may be grounds for denial of Clinical Nurse Specialist certification in Oregon.
(3) It shall be conduct derogatory to nursing standards for the CNS to:
(a) Charge the client or any third-party payer in a grossly negligent manner;
(b) Use ordering or prescriptive authority without sufficiently documented evidence of advanced nursing assessment and establishment of the client/provider relationship;
(c) Prescribe or dispense medications without specific authority under state or federal law;
(d) Practice as a CNS in a specialty area or scope of practice not supported by the licensee's clinical and didactic training.
Stat. Auth.: ORS
Stats. Implemented: ORS 678.150, 678.370, 678.372, 678.385 & 678.390
Hist.: BN 4-2001, f. & cert. ef. 2-21-01; BN 11-2006, f. & cert. ef. 10-5-06; BN 16-2012(Temp), f. & cert. ef. 11-15-12 thru 5-1-13; BN 5-2013, f. 2-28-13, cert. ef. 4-1-13
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