As a CNS with experience in both inpatient and outpatient settings, I understand the impact that the current limitations have on our practice. Due to my training as a clinical nurse specialist with advanced certification in both adult health, and adult oncology, I have been able to work closely with physicians to improve the care of cancer patients. I'd like to share a little bit about this to help others better understand why allowing CNS's to practice to the full extent of their training is not only safe, but also beneficial.

In the outpatient practice, I was responsible for a cohort of aproximately 100 cancer patients at any given time. These patients were on clinical trials. As patients came in for their scheduled treatments and assessments, I was able to use my advanced assessment skills to perform complete or focused physical and mental assessments, monitor their exam and test results, assess for adverse effects, grade the adverse effects, determine the attribution of any adverse effects, and council the patient on issues that might help improve quality of life and health such as diet, lifestyle and behavior, medication adherence, etc. . I worked with a bachelors trained RN and an LPN who assisted with gathering and recording health assessment data. The care that the patients received was guided by standard protocols of care developed by oncology experts. In a quality review of ths cohort in comparison with other patients, we learned that despite similarity of age, race, social and economic status, types and stages of cancer, patients in my cohort had aproximately only about a 10th of the incidence of ER visits and hospitalizations, as the other patients managed in the normal way. 

As is typical of the CNS role, I also filled other roles such as genetic testing education and counseling, worked closely with the organization to achieve certifications, improve safety and quality of care through implementation of evidence-based practice changes, training and education of staff, ensuring physicians and APP's are educated to practice standards and maintain those standards, and so on. 

The limitations that I felt so keenly during these nine years,  due to the Virginia regulations, caused delays in treatment and unnecessary extra expenses, steps for providers and/or patients, and interruptions of care due to the need to get an order or signed paperwork for DME, tests, or treatments. Many of the interventions that could be implemented by the CNS in combination with the advanced level of care are typical, standard of care, and protocol guided within the specialty. The patient whose labs are slightly abnormal needs to come to have them re-checked,  the patient who is experiencing a side effect such as diarrhea needs some temporary adjustments in medication management, the patient who is experiencing fatigue and would benefit from specialized rehabilitation or cancer therapy programs, and the patient who would benefit from some DME at home to improve quality and safety should all be able to have that care ordered in a seemless, efficient, manner. 

In the inpatient setting, similar circumstances occur every day as CNS's intervene for physicians as members of the care team to aide in management of patients in special populations and/or with special needs. Patients in pain, or with complicated wounds, diseases that require close attention and monitoring and other situations where a CNS can work closely with bedside nurses, and ancillary staff to improve quality, safety, and efficiency of care. Although there are many things that we can do, and do well, physicians in our facilities who rely on the CNS to assist with special populations often request an additional service we cannot perform because of our limitations.

In conclusion, as CNS's work with physicians and other APP's, we gain their trust and become valued team members through the consultation processes and the manner in which we engage with them to fill the gaps in patient care. Our value becomes clear as our other team members and the organizations see the impact that we have on quality and safety and improved patient outcomes. Allowing us to practice to our full training, will only improve the efficiency and availability of the already great care we provide to our patients.

Thank you for the opportunity to comment.