CNS vs. CNL - Page 4

I have seen the utilization of the CNL vary from institution to institution. Some use the title of "CNL", but most in my area do not use those particular words. One local Magnet hospital calls them 'Clinical Care Coordinators'. At UVa's own Health System, they do not use the job title even though they have several dozen RNs with that certification currently on staff. There, the CNO views the CNL as a bedside nurse with an enhanced skill set who contributes to enhancing outcomes in a unit/clinic. But s/he is part of the regular clinical ladder (Clinician I, Clinician II, Clinician III, etc).

One 'system' which is actively using the CNL job title is the Veterans Administration. There is a VA mandate to have a CNL on every inpatient unit nationwide by 2014 or 2015 throught the Veterans Administration network.

My background: BSN with 10 years of experience in my specialty area. Function as a resource to administration and less-experienced staff. Am frequently, "in charge."

Question: How does a CNL function differently from what I do?

Not trying to be a troll or jerk, I just want to understand why we are adding increased role confusion in our profession.

I am a CNL working in Dallas/Ft Worth for a large system with 14 entities.

The biggest difference here is that I focus my efforts on my clinical microsystem. A CNS will cover a certain disease process or area. Think about a Wound Care CNS. Travels all over the hospital and an expert at treating wounds. All kinds. Educates the nurses on how to treat them, validates wound care orders, educates patients, etc. May go to L&D if a mother has a wound, etc.

I only work on my floor. I am an expert on my UNIT. I have to be knowledgable about everything that touches my patients, and the patterns and processes of how things get done. Split the manager role into business and clinical, and I work essentially as a clinical manager. We don't use that title because I don't have direct employees beneath me. I answer only to the ACNO (aka med-surg director at many places). That allows me to work as a patient advocate, team/outcomes manager, information manager, risk, etc all at the same time, and I sit on committees that impact my floor. I work to bring the system (big picture) ideas/principles to my unit and the nursing perspective (small picture) to the large corporate functions. I am included in multidisciplinary projects (such as ED-Admission-Discharge throughput) because we look at things differently thanks to our backgrounds and education.

The title of the role and the certification are two different things. CNLs who are working in the role but are still in school are labelled PCFs or Patient Care Facilitators here until they pass their exam. The majority of my classmates are not working in a CNL role, due to the lack of them in Ohio. You may see someone with CNL after their name, but not in an CNL role. They may have graduated and not sat for the exam. The company you work for may just call it something different. You have to go through a MSN CNL program or post masters cert program to sit for the test. 1/3 of my class enrolled in NP school right after graduation.

CNL classes focus on everything from EBP, Research, Statistical Analysis, you name it. Direct Entry programs are not easy. Mine was 68 hours long and had 400 clinical hours the last semester alone. You are essentially learning how to transform healthcare at the same time you are learning how to start an IV.

There are CNL programs out there for nurses with experience. Direct entry is only one way to go. I have never heard of a direct entry nurse with zero experience being placed in an actual CNL role. You need to learn to be a nurse first. I worked in Neuro ICU, charged, etc to get my feet wet. Our system is growing their own CNLs through an academic partnership. Most of the nurses in that school have 6-10 yrs of experience.

My day consists of patient rounding (POC, education, service recovery when needed, and advocacy) followed by a briefing with all of the nurses, charge, CM, SW in the early afternoon. I am contacted by the quality department/PI people all the time. I try to focus my "project" time in the afternoon on EBP initiatives, and process improvement. I also am a data guru for anything the manager needs. Right now we are focused on HCHAPS, LOS, and post op infection. Projects are determined by an annual assessment I conduct on my unit to determine where the low hanging fruit lies...

I am salaried, M-F 8-5 but I give my cell # to patients, and routinely work 50hrs/wk. Pay is just under unit manager pay, but much better than what I was making at the bedside. Salary pay is nothing like hourly. There is no clinical ladder, shift diff, etc. It is what it is. The flip side is that I can come and go as I please, as long as I put in my hours, just like a manager.

Brian - thanks so so much for that description - that really brings the picture home. You sound like you have a very interesting job. Just curious - do you find the roles being blurred between CNS and CNL in your area?

Not really. The CNS folks are usually attached to a service line. We have quite a few working with Wound/Ostomy Care some Stroke CNS (Stroke Coordinators), CV Specialists, etc. There really aren't that many around. They are only on the floors when there is something that pertains to them or they have been consulted.

The mixing of titles isn't helpful. CV Specialist, Nurse Navigator, CNL, Clinical Coordinators all do similar things in different ways. The largest "blurring" was between case management/social work and myself. They felt like we were stepping on their toes. The bigger picture stuff that CNLs focus on is more the WHY. CM/SW will figure out where this patient can go post D/C. I'm looking for patterns among the noise. Why did this patient return after only 10 days at home? What education did we provide on his last discharge? Why did that facility send him back? It's like doing miniture root cause analysis. Those insights get shared among all of the other disciplines, and can affect how changes are rolled out, orders are placed, etc.

The hardest part is keeping focused on my unit. People have found my analysis helpful, and I get pulled in 100 directions at once. I should be an expert on my floor, so if it's related to clinical issues then I get brought in to help elaborate. It's not always good news either. It's easy to forget my main role, which is patient rounding. I try to meet with every patient in my assignment (15 peeps) daily, but if I can't then I focus on the more complex patients.

CNLs have it tough, we are going through the same trials that the CNS nurses did 20 yrs ago. Trying to fit into a system that has very little money to go around. You have to remember that most of the work we are trying to do has never been done before. Data on PICC line placement was collected but no one ever used it for anything. People were reactive, not proactive. True change takes years, and that gets expensive to sustain a CNL program. I find myself having to justify myself by working on cost savings projects more often than not. The cost benefit of a CNL is great, but we are most effective in larger hospital systems and focusing on the 12 bed model. 12-15 is ideal. Most smaller hospitals can't afford to hire nurses that don't contribute to "productivity" i.e. don't have a direct patient assignment.

Agree with what you are saying Brian. In my area (central IL) we have one HUGE system that has a college of nursing that shoots out FNPs, CNSs, and CNLs. Then we have several other local colleges that graduate FNPs, ACNPs, PNPs, etc. The CNS is only a good idea in IL because we can function as APNs and bill for our services. You are so correct in that you (CNL or CNS or anyone who doesnt bill for their services) must be very proactive to show their worth.

It is so good to hear of new advanced roles for nurses. there was an article recently on Medscape about the "Nurse Attending"at Massachusetts General Hospital in Boston which sounds like a similar role to yours. The roles sound so right but also vulnerable to cost cutting.
Thanks for your post.