Advocacy: An Essential Competency of the Clinical Nurse Specialist

In 1956 Dr Hildegarde Peplau established the first Clinical Nurse Specialist (CNS) program, resulting in the first advanced practice nursing role.1 The CNS is one of 4 advanced practice registered nurse (APRN) roles prepared by education at the master’s or doctoral level. Clinical nurse specialists are APRNs who provide expert care with a population health focus and historically have practiced mostly in acute care environments including critical care, medical surgical care, maternal/child care, and mental health. The key responsibilities of the role are to assess, diagnose, and manage patient problems and to work with the health care team to manage the health care of a patient population. Inherent in this role is serving as an advocate, one who “proactively speaks for another to ensure certain needs or wishes are met.”2The American Nurses Association (ANA)3 promotes advocacy as a pillar of nursing. Additionally, the International Council of Nurses (ICN) Code of Ethics for Nurses4 states, “The nurse advocates for equity and social justice in resource allocation, access to health care and other social and economic services.” In contemporary CNS educational programs, the American Association of Colleges of Nursing Essentials of Masters and Doctoral Education guide the development of advocacy to ensure each graduate is prepared to “advocate for patients, families, caregivers, communities and members of the health care team”5 and to “advocate for social justice, equity and ethical policies within all health care arenas.”6The ANA states that it is a nurse’s responsibility to promote, advocate for, and protect the rights, health, and safety of patients.7 Advocacy can take many different forms, but all share the common threads of passion and action. To illustrate the importance of advocacy in the CNS role, this column focuses on the story of one nurse who advocates for policy change in the hope that others will not suffer her same loss. Her story shows how acute and critical care CNSs play a pivotal role in advocacy for local, state, and national policies and population health through examples such as preventing losses, mitigating the impact of trauma, and preventing never events through surveillance and health promotion.Former US Representative (D-New York) and nurse Carolyn McCarthy embodies the definition of advocacy. Her political career began through a tragedy when gun violence killed her husband and injured her son. Merging her anger and sadness with the determination and ethics she employed every day as a nurse, McCarthy evolved from a bedside critical care nurse into a nurse working to change laws and policies in the US Congress.Carolyn Cook McCarthy was the second of 5 children, born on January 5, 1944, in Brooklyn, New York, to Thomas and Irene Cook. She grew up in Mineola, Long Island, about 20 minutes outside of New York City and graduated from Mineola High School in 1962. After graduation, her high school boyfriend was in a serious car accident. McCarthy helped a private duty nurse care for him. The day after he died, she applied to the nearby Glen Cove School of Practical Nursing and graduated in 1964. For the next 30 years, McCarthy worked in the intensive care unit of the Glen Cove Hospital.McCarthy married Dennis McCarthy in 1967. They lived on Long Island and had a son, Kevin. The family’s pleasant suburban life was shattered on December 7, 1993, when a gunman killed 6 people and wounded 19 others on a Long Island Railroad commuter train. Dennis McCarthy was murdered, and Kevin was severely injured and paralyzed by the attack. Carolyn McCarthy turned the family nightmare into a crusade against gun violence. While she nursed her son back to health, she became a passionate advocate for gun safety. When her Congressman, Dan Frisa, voted to repeal the ban on assault weapons in 1994, McCarthy decided to challenge him in the upcoming election. Although she was a registered Republican, local Republican Party officials discouraged her from running, so she switched parties and ran as a Democrat. In 1997 McCarthy was successfully elected to the 105th Congress, becoming the first woman to represent voters on Long Island in the House of Representatives. She was reelected 8 times. Representative McCarthy shared her story during a telephone interview with the first author (see Table).The CNS education is based on 7 core competencies (direct care; consultation; systems leadership; collaboration; coaching; research; and ethical decision-making, moral agency, and advocacy) that build on registered nurse education to impact 3 spheres: the patient, the nurse, and the organization/system.8 Advocacy is a key competency for the CNS role. Cohen and colleagues9 cite the role of the CNS Synergy Model in successfully linking activities from a unit-based system to multisystem practice outcomes such as advocacy for patient preferences for life-sustaining treatment. In a study by Mick and Ackerman,10 the authors compared acute care CNS and nurse practitioner (NP) valuing of tasks within role functions. Interestingly, NPs placed a higher value on advocacy than did CNSs, although CNSs advanced advocacy more within a collaborative role.10Within each sphere of impact, the CNS works as an advocate for the betterment of nursing care, providing healthy work environments for the health care team, especially nursing, and for the development of impactful policy. Within the system sphere of influence, the CNS impacts care through policy at the micro, meso, and macro levels of care.11 At the micro and meso levels, the goal is improvement of health outcomes in delivery of clinical practice and in providing effective education to patients, families, and nursing personnel. At the macro level, the execution of policy within the system impacts the delivery of care including, of utmost importance, the measurement and management of costs for the delivery of care.To further the adoption of good policy at the macro level, CNSs continue to build a strong lobby in their national association to work with state legislation to gain autonomy and prescriptive authority across the nation. In addition, CNSs are at meetings when the Centers for Medicare and Medicaid Services make critical decisions about reimbursement and value-based purchasing. Clinical nurse specialists are involved in policy decisions in Washington, DC, through the National Association of Clinical Nurse Specialists (NACNS) and other national nursing associations to advocate for improvement of the health of all Americans and ensure safe, quality care.Representative McCarthy’s legacy as a nurse and as a legislator exemplifies advocacy in the context of public policy. She advocated for gun control for public safety and for the role of school nurses for public health screening and protection. In addition to the direct impact on public health and safety that gun policy has, it also affects health care workplace resources and safety; clinical nurse specialists experience the impact of escalating gun violence as hospital admissions and death rates increase due to gun violence.12 Like Representative McCarthy, CNSs can advocate at the macro level for state and national policies to reduce gun violence and firearm access. At the meso level, CNSs can advocate for health care worker safety as gun violence enters hospital and school settings. Increasing attention has be paid to healthy work environments as a strategy to reduce nurse turnover and increase retention of skilled nurses.13 In particular, CNSs can promote healthy work environments by ensuring health worker self-care and resiliency to diminish the toll of caring for victims and families of gun violence.13,14 At the micro level, CNSs can advocate for posthospitalization transition services and mental health needs for victims and families.Another CNS core competency is systems leadership.8 This competency refers to the ability of the CNS to manage change and empower others to influence clinical practice and political processes both within and across various systems. Part of the macro level of policy and regulation includes partnering with members of the health care team across the continuum of care to advocate for the patient. For example, CNSs can have a significant impact on opioid pain management as strong advocates for safe opioid prescriptive practices and the authority to distribute naloxone in the community. NACNS has established a public policy agenda to initiate action and respond to legislative and regulatory initiatives impacting CNSs such as medication-assisted therapies to treat opioid use disorders, CNS scope of practice, and Title VIII Nursing Workforce Reauthorization.15 Acute care CNSs are ideally suited to advocate for and facilitate population health by, for example, convening interprofessional groups focused on pain management including development of organizational policies,16 managing patients with chronic conditions from acute to postacute settings,17 or mobilizing a comprehensive stroke care program.18Health care is complex, and CNSs are in a key position to change and strengthen the formulation, implementation, and evaluation of care at all levels in the acute care environment. The spheres of impact and core competencies of the role clearly delineate the impact that can be made by the CNS. Nurses, as the largest segment of our nation’s health care work force, have the skills and obligation to influence public policy and improve population health.Representative McCarthy is an inspiration to us all. After being diagnosed with lung cancer and receiving treatment in 2013, McCarthy retired at the end of the 113th Congress in January 2015. Today she is cancer free and lives in Florida, where she spends time with friends and family while advising the next generation of gun safety advocates. CNSs and APRNs can use her as a role model to advocate for policies that aim to prevent trauma such as gun violence. CNSs can leverage their leadership skills to influence advocacy in the area of acute and critical care to optimize patient and organizational outcomes.