The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists. The purpose of this publication is to keep our members updated on the NACNS headquarters news; connect our members with fast-breaking clinical news; and update clinical nurse specialists on state and federal legislative actions.

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Featured Articles

  1. National Association of Clinical Nurse Specialists Endorses Specialty Education and Certification for Clinical Nurse Specialists

Headquarters News

  1. NACNS Seeks Project Consultant
  2. Student Poster Abstract for NACNS Conference
  3. NACNS 2014 Conference, The Best Kept Secret- The Clinical Nurse Specialist Contribution to Quality Care  March 6 – 8, 2014
  4. NACNS Journal – Clinical Nurse Specialist – App for the iPad

CNS Foundation

  1. CNS Scholarships
  2. CNS Foundation Silent Auction

Association News

  1. New! CCI Announces CNS Specialty Exam for Perioperative CNSs
  2. Canadian Journal Seeking Manuscripts on Advanced Practice Registered Nurse Outcomes

Clinical Headlines

  1. FDA defines “gluten-free” for food labeling
  2. NIH-funded study suggests brain is hard-wired for chronic pain

Federal and State Policy News

  1. Community Paramedicine:  What Does It Mean for Nursing?
  2. Medical Homes and the CNS
  3. CMS Postpones DME Requirement for Physician Documentation
  4. Practitioners Can Document Hospital Admission Orders
  5. AHRQ Health Care Innovations Exchange

Featured Articles

1. National Association of Clinical Nurse Specialists Endorses Specialty Education and Certification for Clinical Nurse Specialists

As advanced practice registered nurses (APRNs), clinical nurse specialists (CNSs) ensure high quality nursing care that is evidence-based and promotes patient safety, while improving patient outcomes and lowering health care costs. We play this important role across a variety of specialties based on patient population, setting, condition or type of care.
The National Association of Clinical Nurse Specialists (NACNS), the only national association representing CNSs regardless of specialty, today released a position statement that recommends that CNSs achieve documented competency in their specialties through certification and graduate nursing education. This new position statement expands on the APRN Consensus Model, which NACNS has also endorsed. It suggests strategies to ensure CNSs achieve specialty competencies, and provides recommendations for graduate education to ensure specialty content in CNSs education,

  • Formalized master’s-level study that may include academic course work, approved advanced continuing education course work or other structured learning experience (such as a fellowship or mentorship).
  • Requiring CNS students with master’s degrees to have achieved both population and specialty competencies upon entering a doctor of nursing practice (DNP) program. The program should include adequate clinical practice hours so students can continue to develop expertise in their specialties.
  • Requiring CNS students with BSNs who are pursuing DNPs to develop both population and specialty competencies through a curriculum that includes content and clinical practice hours and includes content relevant to specific populations and specialties.
  • Requiring CNS students with BSNs who are pursuing PhDs to take master’s level courses that include the requirements for CNS practice as specified in the APRN Consensus Model. Students knowledge of their specialty should be enhanced by coursework related to their dissertation topic.

NACNS also recommends requiring documentation proving that a CNS has achieved competency in his or her specialty, regardless of academic preparation, such as an academic transcript, an earned certificate or a portfolio.
“Specialty practice is the hallmark of the CNS role,” said Carol Manchester, MSN, ACNS, BCADM, CDE, President of NACNS. “As such, it is important that we ensure that all CNSs have achieved competency in their areas of specialty so that they are best able to fulfill their roles guiding nursing practice to improve patient outcomes and reduce costs.”

Headquarters News

12. NACNS Seeks Project Consultant

NACNS’ Board of Directors has approved a project which will analyze the available pediatric and adult/gerontology CNS competencies in light of the Family Across the Lifespan population that is noted as a population option for licensure in the APRN Consensus Model. This project is slated to begin after January 1, 2014. Please send your curriculum vitae or resume to and reference the project consultant opportunity. Please send any questions to

3. Student Poster Abstract for NACNS Conference

While the Call for Abstracts deadline for our 2014 Conference, The Best Kept Secret - The Clinical Nurse Specialist Contribution to Quality Care to be held in Orlando, FL from March 6-8 is Wednesday closed on September 11, 2013… students still have an opportunity to respond!Student poster abstracts may be submitted through Monday, December 2, 2013. All submissions must be made online through our Abstract Management System. Please visit the submission site for all instructions and guidelines. 

4. NACNS 2014 Conference, The Best Kept Secret - The Clinical Nurse Specialist Contribution to Quality Care  March 6 – 8, 2014

It is time to consider your plans to attend the NACNS 214 Conference. The conference offers the opportunity for you to network with your colleagues as well as enjoy the sunny resort environment of the Orlando World Center Marriott and of course, the many activities in Orlando. Conference registration and lodging information will be available soon. Room rates at the Orlando World Center Marriott will be available for $189/night for single or double rooms. For specific questions about registration or hotel accommodations, please contact the NACNS office at 215-320-3881 or

We hope to see you in Orlando, FL in March, 2014!

5. NACNS Journal – Clinical Nurse Specialist – App for the iPad

Beginning September 30, Clinical Nurse Specialist for the iPad will be restricted to members and subscribers to the Journal. Your subscription to CNS includes 6 print issues per year, full online access to, including archived issues, and now exclusive access to the CNS iPad App! As a member, it’s easy to continue access to issues of CNS for the iPad. 

  • Open the CNS app on your iPad, click “Sign In” at the top left of your screen, and follow the instructions

Activate your subscription today to continue to access CNS for the iPad

If you haven’t seen Clinical Nurse Specialist for the iPad, download today - and join your colleagues who have already chosen CNS as their professional journal of choice.

Have questions? Need assistance? LWW Customer Service can help. Contact them at or call 1-800-638-3030. 

CNS Foundation

6. CNS Scholarships

The CNS Scholarship applications now have a due date of December 31, 2013. Winners will be notified by January 31, 2014. A poster identifying the winners will be able to be viewed at the CNS Foundation Silent Auction table in the Exhibit Hall. Please visit the CNS Foundation page to review the application criteria.

7. CNS Foundation Silent Auction

The CNS Foundation will host another Silent Auction at the 2014 NACNS Conference. We ask individuals and affiliates to submit prizes to be auctioned off during the conference. Electronics, jewelry, gift cards and crafts have sold well in the past. Please bring you items to the conference or mail them Kathy Baldwin, the foundation chair (7029 Brierhill Court, Fort Worth, TX 76132). Small, easily transportable items are recommended.

Association News

38. New! CCI Announces CNS Specialty Exam for Perioperative CNSs

Be part of the first class of perioperative CNSs to take the CNS-CP exam between March 17 - April 16, 2014. Applications open October 1, 2013. If you test during this time, the fee is only $125, providing you significant savings over the regular exam fee. Listen to the CNS-CP webinar, where our team reviews eligibility, the application process, and the major subject areas that will be covered. 

It is important that each and every eligible perioperative CNS consider taking the exam during the inaugural testing period. Find out more about the deadlines, fees and testing locations here

Do you have questions about your eligibility? Please call 888-257-2667 to speak to one of CCI’s credentialing specialists. Are you eligible to sit for the CNS-CP exam, but cannot take it in the inaugural testing window and still want to be involved? Sign up to volunteer on our CNS-CP Cut Score Committee.

9. Canadian Journal Seeking Manuscripts on Advanced Practice Registered Nurse Outcomes

Nursing Research and Practice, Hindawi Publishing Corporation has put out a call for papers on the Impact of APNs on Patient, Providers and Health Systems Outcomes. Please click on this link to learn how to submit your manuscript.

Clinical Headlines

10. FDA defines “gluten-free” for food labeling

The U.S. Food and Drug Administration published a new regulation defining the term "gluten-free" for voluntary food labeling. This will provide a uniform standard definition to help the up to 3 million Americans who have celiac disease, an autoimmune digestive condition that can be effectively managed only by eating a gluten free diet.

This new federal definition standardizes the meaning of “gluten-free” claims across the food industry. It requires that, in order to use the term "gluten-free" on its label, a food must meet all of the requirements of the definition, including that the food must contain less than 20 parts per million of gluten. The rule also requires foods with the claims “no gluten,” “free of gluten,” and “without gluten” to meet the definition for “gluten-free.” 

The FDA recognizes that many foods currently labeled as “gluten-free” may be able to meet the new federal definition already. Food manufacturers will have a year after the rule is published to bring their labels into compliance with the new requirements. 
The term "gluten" refers to proteins that occur naturally in wheat, rye, barley and cross-bred hybrids of these grains.  In people with celiac disease, foods that contain gluten trigger production of antibodies that attack and damage the lining of the small intestine. Such damage limits the ability of celiac disease patients to absorb nutrients and puts them at risk of other very serious health problems, including nutritional deficiencies, osteoporosis, growth retardation, infertility, miscarriages, short stature, and intestinal cancers.  

The FDA was directed to issue the new regulation by the Food Allergen Labeling and Consumer Protection Act (FALCPA), which directed FDA to set guidelines for the use of the term “gluten-free” to help people with celiac disease maintain a gluten-free diet. 

11. NIH-funded study suggests brain is hard-wired for chronic pain

The structure of the brain may predict whether a person will suffer chronic low back pain, according to researchers who used brain scans. The results, published in the journal Pain, support the growing idea that the brain plays a critical role in chronic pain, a concept that may lead to changes in the way doctors treat patients. The research was supported by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health.

“We may have found an anatomical marker for chronic pain in the brain,” said Vania Apkarian, Ph.D., a senior author of the study and professor of physiology at Northwestern University Feinberg School of Medicine in Chicago. Chronic pain affects nearly 100 million Americans and costs the United States up to $635 billion per year to treat. According to the Institute of Medicine, an independent research organization, chronic pain affects a growing number of people.

In this study, scientists used the structure of the brain’s white matter to predict whether a subject would recover from low back pain. “Pain is becoming an enormous burden on the public. The U.S. government recently outlined steps to reduce the future burden of pain through broad-ranging efforts, including enhanced research,” said Linda Porter, Ph.D, the pain policy advisor at NINDS and a leader of NIH’s Pain Consortium. “This study is a good example of the kind of innovative research we hope will reduce chronic pain which affects a huge portion of the population.” Low back pain represents about 28 percent of all causes of pain in the United States; about 23 percent of these patients suffer chronic, or long-term, low back pain.

Scientists have thought the cause of low back pain could be found at the site of injury. However, recent studies suggest that the brain may be more involved with chronic pain. Dr. Apkarian and his colleagues addressed this by scanning the brains of 46 people who had low back pain for about three months before coming to the hospital but who had not had any pain for at least a year before. The researchers scanned the subjects’ brains and evaluated their pain with doctor’s examinations and questionnaires four times over a period of one year. About half of the subjects recovered at some time during the year; the other half had pain throughout, which the researchers categorized as persistent.

Previously, the Apkarian laboratory showed that the volume of grey matter in the brains of the same subjects who had persistent pain decreased over the same year. Grey matter describes the area of the brain where the central bodies and branched antennae, or dendrites, of nerve cells reside. They also showed that brain activity could be used to predict whether a subject recovered or experienced persistent pain.

In this study, the researchers used a scanning technique called diffusion tensor imaging (DTI) which measures the structure of white matter, the nerve cell wires, or axons, which connect brain cells in different parts of the brain. They found a consistent difference in white matter between the subjects who recovered and the subjects who experienced pain throughout the year.  “Our results suggest that the structure of a person’s brain may predispose one to chronic pain,” said Dr. Apkarian.  In agreement with this idea, the researchers also found that the white matter of subjects who had persistent pain looked similar to a third group of subjects known to suffer from chronic pain. In contrast, the white matter of the subjects who recovered looked similar to that of healthy control subjects.

To test this idea further, the researchers asked whether the white matter differences they saw during the initial brain scans predicted whether the subjects would recover or continue to experience pain. They found white matter brain scans predicted at least 80 percent of the outcomes.  “We were surprised how robust the results were and amazed at how well the brain scans predicted persistence of low back pain,” said Dr. Apkarian. “Prediction is the name of the game for treating chronic pain.”  The nucleus accumbens and the medial prefrontal cortex are two brain regions thought to be involved with pain. Further examination of the brain scans suggests that the white matter structure connecting these brains regions is different between the subjects who recovered and those who had persistent pain.
“Our results support the notion that certain brain networks are involved with chronic pain,” said Dr. Apkarian. “Understanding these networks will help us diagnose chronic pain better and develop more precise treatments.”  This study was supported by a grant from NINDS (NS35115) and an anonymous foundation.

Federal and State Policy

12. Community Paramedicine: What Does It Mean for Nursing?

Over the past decade, in some sections of the country emergency medical services has piloted an expanded role for paramedics, that of “community paramedic” (CP). This role builds on the skills and preparation of the paramedic, with the intention of fulfilling the health care needs of those populations with limited access to primary care services.  Although the origin of the CP is rooted in rural settings in Canada, Australia and New Zealand, some of the CP practice in the United States are taking place in cities like Fort Worth, Pittsburgh, Raleigh-Durham, and San Francisco. The CDC reports that 46,000 public health jobs have been lost in the last four years.  Use of the CP is perceived as innovative and filling an unmet need - taking care of those frequent users of the health care system who are uninsured or underinsured/Medicaid.

Currently, all CPs work under the direction of a physician and generally with the use of protocols - use of protocols is not evident in clinic settings. This expanded role might include helping frequent 9-1-1 callers access primary care or social services instead of emergency department (ED) care; making home visits to check on patients recently discharged from the hospital or ED; checking on individuals with certain types of chronic conditions, or providing immunizations or other disease prevention services. Funds to support demonstration projects have come from the federal Office of Rural Health Policy and from CMS Innovation Grants. 

The legislative/regulatory activity related to community paramedicine has picked up significantly in the past three to four years. Minnesota became the first state to recognize this role in statute in 2011 (effective 2012) and was successful in it being added to the list of Medicaid-approved services. In 2013, a similar bill was signed into law in Missouri, as well as a resolution passed in the North Dakota legislature authorizing a study of the feasibility and desirability of the practice. Pennsylvania has formed a task force to recommend the best model for this role in that state.

The CP movement continues to pick up steam.  In a new report released this month, the University of California - Davis Institute for Population Health Improvement recommends that California launch pilot programs to test a new model of community-based health care that would expand the role of paramedics under certain circumstances.  In a new model of community-based care, paramedics, after undergoing additional training, would function outside of their usual emergency response and transport roles to facilitate more appropriate use of emergency departments and to increase access to primary care for medically underserved populations.  The complete report - "Community Paramedicine: A Promising Model for Integrating Emergency and Primary Care" - is available on the UC Davis Institute for Population Health Improvement website.

Interestingly, the EMS community is moving away from using the term "community paramedic." The newer concept that is being promoted is "mobile integrated healthcare". Apparently, it is not EMS-centric.  It is community-based and multidisciplinary including physicians, RNs, APRNs, home health, hospice, PAs, PT/OT type services, and, yes, EMS/paramedics.

13. Medical Homes and the CNS

In 2010 the National Committee for Quality Assurance (NCQA) that developed the Patient Centered Medical Home decided to open the program to nurse-led practices in states that allow these clinicians to provide the full range of primary care and practice independently. NCQA states on its website that Physician Assistants and Nurse Practitioners are eligible to be listed as part of a recognized practice if they manage their own panel of patients.

Recently NACNS has written to NCQA to request that they recognize CNSs as eligible practitioners to become recognized as a Patient Centered Medical Home (PCMH). The CNS provides care from a wellness to illness perspective and may contribute much in the care of chronic medical conditions in the Medical Home. NCQA has stated that if a practice can demonstrate that it provides whole person care and meets the other elements of the joint principles (see below) for most of its patients (at least 75 percent), it can be eligible for PCMH recognition by NCQA even if it is not a traditional primary care practice.

NACNS has reviewed the Joint Principles and indeed many CNSs meet most of the Principles. We will be following up with NCQA and keep you informed of their decision.
Medical Home Joint Principles

  • Personal physician (now accepts other practitioners). Each patient has an ongoing relationship with a personal physician who is trained to provide first contact, continuous and comprehensive care.
  • Physician-directed medical practice. The personal physician leads a team of individuals at the practice level who collectively take responsibility for ongoing patient care.
  • Whole-person orientation. The personal physician is responsible for providing all of the patient’s health care needs or for arranging care with other qualified professionals.
  • Care is coordinated and integrated across all elements of the complex health care system and the patient’s community.
  • Quality and safety are hallmarks of the medical home.
  • Enhanced access to care is available through open scheduling, expanded hours and other innovative options for communication between patients, their personal physician and practice staff.
Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home.

14. CMS Postpones DME Requirement for Physician Documentation

The Centers for Medicare & Medicaid (CMS) announced that they are postponing the implementation of the durable medical equipment (DME) face-to-face signature requirement until sometime in 2014.

Section 6407 of the Accountable Care Act established a face-to-face encounter requirement for certain items of DME. The law requires that a physician must document that a physician, nurse practitioner, physician assistant or clinical nurse specialist has had a face-to-face encounter with the patient. CMS has twice postponed implementation of this rule.

While this is a statutory requirement that CMS cannot change, NACNS stated in a letter written to CMS in September of 2012 that we “cannot support any of the proposed options because of this fundamental flaw, and urges reconsideration of this wasteful and unnecessarily narrow requirement.” In addition, “There is no evidence that requirements for physician oversight or supervision increases quality or reduces fraud. We do know that unwarranted requirements for physician supervision lead to delays in care and duplication of services.”

15. Practitioners Can Document Hospital Admission Orders

The Centers for Medicare & Medicaid Services (CMS) issued guidelines for admission and medical review criteria for hospital inpatient services under Medicare Part A. They clarified that individuals who are not physicians--such as physician assistants, residents or registered nurses–can write the order to admit a patient as long as the documentation of the order complies with state law, hospital policies and medical staff bylaws. This guidance applies to all inpatient hospital and critical access hospital (CAH) services.

CMS states that "At some hospitals, practitioners who lack the authority to admit inpatients under either State laws or hospital bylaws may nonetheless frequently write the sets of admitting orders that define the initial inpatient care of the patient.” In such cases, the order must identify the qualified "ordering practitioner" and have the ordering practitioner or another practitioner qualified to admit inpatients authenticate (sign, date and time) the order prior to discharge.

16. AHRQ Health Care Innovations Exchange

The Agency for Healthcare Research and Quality (AHRQ) has developed a new website, AHRQ Health Care Innovations Exchange with resources and tools for improving health care. The Innovations Exchange assists with solving problems, improving health care quality, and reduce disparities by providing evidence-based innovations and Quality Tools, viewing new innovations and tools published biweekly and learning from experts through podcasts, videos and articles.

The website allows one to identify solutions by Disease or Clinical Category, Setting of Care, Stage of Care, Organizational Process, QualityTool Topics, Patient Care Process, Patient Population, Quality Improvement Goals and Innovations by State.

The website is an excellent resource for CNSs leading quality improvement teams and implementing new processes to improve care. It is also a great resource for students. These innovations can also be used to write business plans.
For those who want to learn the latest about a particular topic, My Innovations allows you to save all your favorite subjects and view them on a single page. The site will also alert you by e-mail when new content is added or current content is updated.

This is a publication of the National Association of Clinical Nurse Specialists. You are receiving this publication because you are identified as holding a membership in NACNS. If you wish to unsubscribe from this publication, please email Please note, if you unsubscribe, this will remove you from all email communications from NACNS.
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The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists.
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