Given the Institute of Medicines Future of Nursing report spelling out the essential role of nurse leaders in advancing evidence-based healthcare, clinical nurse specialists increasingly are in high demand, particularly in the critical care setting.
CNSs are key to developing the culture of quality mandated by healthcare reform that will help hospitals meet heightened requirements for reducing infection rates and improving outcomes, nurse leaders say.
The CNS role attracts nurses who love research and like to teach outside an academic environment. Their expertise is extremely specialized, they educate clinical staff, patients and families, and they help build staff satisfaction in their roles as mentors.
In New Jersey, where masters degree nursing programs are heavily focused on nurse practitioners, CNSs are sometimes hard to find when openings arise.
Masters programs for CNSs also were disappearing in New York, says Kimberly Glassman, RN, Phd, NEA-BC, senior vice president of patient care services and CNO at NYU Langone Medical Center in Manhattan. But now, she says, universities are responding to renewed demand for these positions, and within the past few years have started to add the CNS masters programs back in.
Spots Hard to FillWilliam Roberts, RN
Cathy Lubliner, RN, MSN, APN-C, CCRN, is a clinical nurse specialist for the cardiothoracic ICU and step-down unit at Newark (N.J.) Beth Israel Medical Center, an affiliate of the Saint Barnabas Health Care System. She also is covering the cardiac care unit for another advanced practice nurse. She says its taking increasingly longer to fill CNS spots at her hospital.
CNSs must have masters degrees, and those in critical care are expected to have their CCRN, which shows the nurses are certified in critical care according to the American Association of Critical-Care Nurses, Lubliner says. Those requirements and the lack of true CNS masters programs in the area add to a limited pool of applicants.
In New Jersey, there are few to no masters programs focused on the clinical nurse specialist role. Almost everything is focused on the nurse practitioner role, Lubliner says.
At Newark Beth Israel, the distinction between a CNS and an NP is well-defined, Lubliner says: I would be far more involved in policy and research, education and staff follow-up, whereas an NP is focused on diagnosing and treating patients directly. An NP role is more one-on-one, whereas a CNS would focus on a patient population, she says.
New Credential Gains MomentumKimberly Glassman, RN
In hospitals and states where the role is prominent, CNSs in critical care increasingly are being expected to get a relatively new credential, Lubliner says.
Hospitals are increasingly looking for CNSs to have a CCNS credential certified as a critical care clinical nurse specialist through AACN. Years back that was not so important. I think thats a good trend, says Lubliner, who is working on her CCNS certification this year.
Not all states have approved the CCNS credential for qualifying nurses for advanced practice licensure. All nurses intending to use the CCNS to obtain AP licensure in their state first should check with their state boards of nursing for licensing requirements.
One of the hospitals where the CNS role is front and center is Stony Brook (N.Y.) University Medical Center on Long Island. William Roberts, ACNP-BC, DNSc, associate director of nurse quality, research and nursing support services, credits the redesign of the CNS role there with helping to reduce central line-associated bloodstream infections and pressure ulcers, both costly and avoidable complications.
He says Lee Xippolitos, RN, PhD, dean of the school of nursing and CNO at Stony Brook (N.Y.) Hospital decided years ago to redesign the CNS role and move away from the focus of educating the nursing staff and more toward nursing care quality, patient safety and oversight of evidence-based practice. CNSs were paired with nurse managers, and those duos have been important, particularly in the critical care setting, Roberts says.
Stony Brook has 20 CNSs, and seven of those are in critical care, Roberts says. The hospital has seen direct success in the way CNSs are attacking the pressure ulcer problem with a new program called Bed, Fed, Red, Tread. The four-word checklist means CNSs check to see whether the patient is in the right kind of bed based on risk factors; they check whether the patient is eating the right kind and amount of food; they check for any red or darkened areas on the skin; and they work toward early ambulation.
The division of labor has had direct results, Roberts says. He says the hospital-acquired pressure ulcer rate at Stony Brook went from 8% in 2008 to 1.45% at the end of 2010, largely because CNSs were directly assigned to monitor these process points. And CLABSIs now are close to zero, he says.
This model really works to drive costs and quality together, Roberts says. (CNSs) dont come and then go away. They live on these units and drive these processes every day.
States Differ on APN DesignationMary McKiernan, RN
State laws differ on scope of practice, Glassman says. In New Jersey, CNSs are considered advanced practice nurses. In New York, they are not. States also differ on whether CNSs can gain prescriptive privileges. That may be why some hospitals have been quicker to hire NPs, who can prescribe in all 50 states and often are seen as the nurses who will bridge the physician shortage gap.
But something has been lost in that emphasis on NPs, Glassman says. Weve lost that professional who was highly educated and knowledgeable about a particular patient population. They are also very important in bringing evidence-based medicine to the bedside.
She says at NYU, hospital leaders view CNSs as precious gold and will be adding a couple of positions in the near future.
These nurses often deal with some of the most complex patient populations. Thats certainly the case at Westchester Medical Center in Valhalla, N.Y., says Mary McKiernan, RN, MSN, vice president of nursing professional development. Of the nine CNSs there, six are dedicated to critical care.
They are really that resource for the bedside clinician, McKiernan says. With evidence-based practice and the constant changes in treatment, its really crucial to have someone there to educate the bedside nurse, and work with the interdisciplinary teams.
The biggest change in the role has been that they are much more hands-on in improving quality standards such as pressure ulcer prevalence and CLABSI rates, McKiernan says.
As health reform brings changes in transparency and quality standards, CNSs will play a vital role in educating the nursing staff and optimizing patient care systems, nursing leaders say. CNS specialization assures that a portion of the profession has in-depth knowledge and advanced competencies in emerging and narrow health concerns. Their focus can be a particular disease, a population type or a particular practice setting, such as critical care or neurosurgical nursing.
As we move forward in a pay-for-performance world, you really need the CNS holding steady in evidence-based practice, Roberts says. Hospitals are seeing the need to hire more of them, and at Stony Brook the goal is a CNS on every unit. Were close; were only seven to nine away, he says.