CNS and Clinical/Practicum

Trauma Columnist · Oct 15, 2009

I completed an adult health CNS in 2006 and did clinicals as advanced practice nurse, not in a true CNS role:

1. Large outpt surgical practice - made rounds with NP, placed central lines, art lines, did H&Ps, consults, discharges.

2. Level one trauma center where I saw pts as a mid-level with an MD as a preceptor.

3. Rounded in-pt with adult health CNS that worked with a thoracic surgeon - she did a lot of teaching and case management type duties.

4. Rounded with an FNP who ran the "wean team" to get folks off ventilators.

5. Worked with an ICU ACNP - very interesting!

So...that was most of my clinical. I currently work with a large nephrology practice as a mid-level provider. They have 3 FNPs, a PA and me and we all do the same job.

Of course, I live in IL where CNS's are APNs.

mona b RN, BSN, RN · Oct 15, 2009

Thanks for the information traumaRUs. I live in NJ and CNS and NP are pretty much the same. I also want to focus on primary care and am curious how many CNSs there are in this area. I realize to be well rounded all the spheres should be included but there are many ways to do that in the primary care setting. Tons of educational opportunities with health promotion, for example.

The program I am looking into is flexible with regard to clinical placements which is really nice but I am curious how one sets up their own objectives in this setting since as you said it is pretty non-traditional approach for CNS. I like how you put it best-pursued it as an "advanced practice nurse".

Did your program include prescriptive/pharmacological content integrated into the curriculum or did you just have to complete an advanced pharmacology course to be able to prescribe?

Trauma Columnist · Oct 15, 2009

I actually did my adult health CNS as a post-MSN certificate and had to do:

Advanced pharm

Advanced assessment

Advanced pathophys

And 576 hours of clinical.

I'm currently doing a peds CNS (so I can see the full spectrum) and have to do the same courses but only 506 hours of clinical. Same school, just new requirements.

I do have prescriptive authority, my own DEA number and my own NPI number (so I can see/treat Medicare/Medicaid pts).

For my peds clinicals - I'm focusing on the ER because that's where I work prn and they need me to see peds. I did do 40 hours of pediatric assessment though in a peds office where I saw well-child visits. Very informative.

mona b RN, BSN, RN · Oct 19, 2009

You mentioned that you have to do the same courses. Did the school require you to retake the physiology, assessment and pharmacology courses for the post master's?

Trauma Columnist · Oct 19, 2009

My first post-MSN certificate is as an adult health CNS. I'm now in the second post-MSN certificate for peds CNS and yes, I do have to repeat the adv pathophys, adv assessment and advanced pharm for peds. There is a lot of repeat material in the pharm - lol.

ROLO · Dec 18, 2009

I completed an adult health CNS in 2006 and did clinicals as advanced practice nurse, not in a true CNS role:
1. Large outpt surgical practice - made rounds with NP, placed central lines, art lines, did H&Ps, consults, discharges.
2. Level one trauma center where I saw pts as a mid-level with an MD as a preceptor.
3. Rounded in-pt with adult health CNS that worked with a thoracic surgeon - she did a lot of teaching and case management type duties.
4. Rounded with an FNP who ran the "wean team" to get folks off ventilators.
5. Worked with an ICU ACNP - very interesting!
So...that was most of my clinical. I currently work with a large nephrology practice as a mid-level provider. They have 3 FNPs, a PA and me and we all do the same job.
Of course, I live in IL where CNS's are APNs.

Let me start off by saying that I am really glad that I found allnurses.com! :yeah: The dialogue has been invaluable...an incredible eye-opener.

If I could describe my ideal clinical experience (I am a CNS student), and then job description, they would be identical to those of traumaRUs! Interestingly though, and sadly, I have yet to find anyone, except for a gentleman in Indiana, near Chicago, who has "seen" pts and given me "permission" to see pts as a CNS.

In trying to get an idea of what my future might hold for me, if I continue with my CNS program (as opposed to changing to an NP program), I have contacted "VIP" CNSs around the country, asking that they please help me understand the role of the ED CNS. And, so far, none of them have described such an active participation in pt care (assessment, workup, dx, tx, etc.). I have e-mails and published literature from the creme-de-la-creme, and except for an occasional pt "consult," they have more less cautioned me about being a CNS and working more like an NP.

Currently, there is an ENA task force who is working on the ED CNS role. The ENA has already put together guidelines for the ED NP, however, ED CNS guidelines have yet to materialize. I contacted a member of the task force who is working on the ED CNS guidelines, and I specifically asked about "seeing" pts. I was not told that that would be impossible, but I did interpret their feedback to mean that that would probably be unlikely. "Consulting on 'difficult' patients" would be more along the lines of an ED CNS; but, regularly "seeing" patients would not.

I called the Indiana BON at one point. I was told my practice as a CNS would depend on the physician(s) with whom I had a collaborative agreement.... so, I imagine I could practice much like traumaRUs in Illinois, WHICH I WOULD LOVE TO DO! BUT, I am wondering if I will have ENA (Emergency Nurses Association) support? What would the implications be if I were to have a collaborative agreement allowing me to do much, but the ENA taking a more restrictive stance? :cry:

Trauma Columnist · Dec 18, 2009

The ENA is based in IL and IL holds out the CNS role as that of advanced practitioner. I have a DEA number (in order to write narcotics) as well as an NPI number (so that I can bill). I also order home care services. I'm credentialled at five hospitals for my nephrology role and one hospital for the ED.

I would sincerely hope that the ENA would not take a restrictive role stance on the CNS in the ER.

ROLO · Dec 18, 2009

The ENA is based in IL and IL holds out the CNS role as that of advanced practitioner. I have a DEA number (in order to write narcotics) as well as an NPI number (so that I can bill). I also order home care services. I'm credentialled at five hospitals for my nephrology role and one hospital for the ED.
I would sincerely hope that the ENA would not take a restrictive role stance on the CNS in the ER.

With the current state of healthcare, I, too, would hate to see restrictions. As a CNS student though, I am just trying to understand. I would love to have a practice that mirrored yours, but when I mention "seeing" pts (to instructors and those who are working on CNS guidelines in general & in the ED), I am reminded of the different functions of the CNS (the "spheres") with little emphasis on "seeing" pts...I am spoken to as someone who probably has not done any research on the role, and it is suggested that I consider NP programs... I would not mind being a change agent, for example, implementing evidence based practice in EDs for example, but considering my education consists of assessment, pharm, & patho, in preparation of obtaining prescriptive authority, why would I NOT aspire to see pts as needed? Now, if my educational track were administration or education, that would be a different story... I am not sure that those tracks would prepare one to see pts, nor are they considered APN roles.

I live in a moderately-sized town in central Indiana, an hour north of Indy, where APNs in general are non-existent... I think I asked you previously, but I would really like to hear your thoughts on HOW I would go about MAKING my way in this little town. My ED is screaming that they want to start using more mid-level providers...they are throwing around the terms "nurse practitioner" & "PA," so how do I get CNS mentioned?! My docs are asking me, "When are you going to be done with school?!" How do I convince them to use me with my specialty as a CNS? :sniff:

Trauma Columnist · Dec 19, 2009

What does your nurse practice act say you can do....its strange we moved to central IL from Indy in 1996 when my husband retired at Ft Ben....we almost stayed when he was offered a job in Muncie - I'm gathering that the area you are in. I went to Marian College for the LPN to ADN bridge - small world.

Anyway...I would tell your doc....hey there, I can do what an NP or PA can do and I already know the ins and outs of this particular ER so that would cut down on the learning curve.

(IF this is true per the IN BON).

ROLO · Dec 19, 2009

What does your nurse practice act say you can do....its strange we moved to central IL from Indy in 1996 when my husband retired at Ft Ben....we almost stayed when he was offered a job in Muncie - I'm gathering that the area you are in. I went to Marian College for the LPN to ADN bridge - small world.
Anyway...I would tell your doc....hey there, I can do what an NP or PA can do and I already know the ins and outs of this particular ER so that would cut down on the learning curve.
(IF this is true per the IN BON).

Again, I want to thank you for your responses! YOU ARE MY IDOL! And, I mean that sincerely.

So, is that what you did when you were trying to establish your practice...tell the docs that they needed to hire you? I've thought about it! They are aware of what I can do, and who I am. And, I know that they are interested in me. I very much want to "see" pts, but I do really appreciate the change agent role of the CNS. I personally do not see why the CNS could NOT see pts, unless one's education was strictly research- or education-based. All of my courses are the same as the NP, until, of course, I am ready to do my CNS classes & clinicals.

Would you be willing to talk to the Indiana BON? (can't blame a guy for asking). I'd like to get your first-hand impression on the role of the CNS. When I called, the lady that answered the phone was able to help me, and it only took a few minutes. I purposely repeated what she had told me, to make sure that I understood correctly, because it WAS what I wanted to hear --that the CNS was only limited by the physician with whom they were practicing (collaborative agreement). The role was pretty open. Unfortunately, or fortunately, (depends on how you look at it), I would have to be the trailblazer in the area, cause there just aren't any CNSs to provide any guidance.

Trauma Columnist · Dec 19, 2009

Hmmm - you are so kind!

When I left IN in 1996, I was an ADN RN so wasn't really in to the APN role. Okay - here is what I found on the IN website:

http://www.in.gov/legislative/ic/code/title25/ar23/ch1.html

(b) "Advanced practice nurse" means:

(1) a nurse practitioner;

(2) a nurse midwife; or

(3) a clinical nurse specialist;

who is a registered nurse qualified to practice nursing in a specialty role based upon the additional knowledge and skill gained through a formal organized program of study and clinical experience, or the equivalent as determined by the board, which does not limit but extends or expands the function of the nurse which may be initiated by the client or provider in settings that shall include hospital outpatient clinics and health maintenance organizations.

AND this is from the APN subcommittee in 2008:

http://www.in.gov/pla/files/apn_subcommittee_July_9_2008_meeting_notes.pdf

(1) In the provision of direct care services the clinical nurse specialist:

A. integrates advanced knowledge of wellness, illness, self-care, disease, and

medical therapeutics in holistic assessment and care of persons while focusing

on the diagnosis of symptoms, functional problems, and risk behaviors that have

etiologies requiring nursing interventions to prevent, maintain, or alleviate;

B. utilizes assessment data, research, and theoretical knowledge to design,

implement, and evaluate nursing interventions that integrate medical treatments

as needed; and

C. prescribes or orders durable and consumable medical equipment and supplies

when such equipment and supplies are self-care assistive devices or assist in the

delivery of quality nursing care. Additional, the clinical nurse specialist who has

fulfilled the state requirements for prescriptive authority is authorized to

prescribe medications or pharmaceutical agents in collaboration with a licensed

practitioner.

(2) In the provision of indirect patient care services, the clinical nurse specialist:

A. Serves as a consultant to other nurses and healthcare professionals in managing

highly complex patient care problems and in achieving quality, cost-effective

outcomes for populations of patients across settings;

B. Provides leadership in conducting clinical inquiries and the appropriate use of

research or evidence for practice innovations to improve patient care;

C. Develops, plans, directs and evaluates programs of care for individuals and

populations of patients and provides direction to nursing personnel and others in

these programs of care;

D. Advances nursing practice through the use of evidence-based interventions and

best practice guidelines in modifying organizational policies and processes to

improve patient outcomes;

E. Evaluates patient outcomes and cost-effectiveness of care to identify needs for

practice improvements within the clinical specialty or program; and

F. Serves as a leader of multidisciplinary groups in designing and implementing

alternative solutions to patient care issues across the continuum of care.

(3) In all areas of clinical nurse specialist practice, the clinical nurse specialist shall do the

following:

A. Recognize the limits of individual knowledge and experience, and consult with or

refer clients to other health care providers as appropriate.

Indiana Administrative Code Page 4

B. Retain professional accountability for any delegated intervention, and delegate

interventions only as authorized by IC 25-23-1.

C. Maintain current knowledge and skills of clinical nurse specialist practice.

The Subcommittee also discussed a suggestion to streamline the rules by amending the 848 IAC

4-1-3 “Advanced practice nurse” definition. As part of this recommendation, the other rules

defining advanced nurse practice specialties will be amended to remove repetitive language.

Sec. 3. (a) "Advanced practice nurse" means a registered nurse holding a current license in Indiana

who:

(1) has obtained additional knowledge and skill through a formal, organized program of

study and clinical experience, or its equivalent, as determined by the board;

(2) functions in an expanded role of nursing at a specialized level through the application of

advanced knowledge and skills to provide healthcare to individuals, families, or groups in a

variety of settings, including, but not limited to:

(A) homes;

(B) institutions;

(D) industries;

(E) schools;

(F) community agencies;

(G) private practice;

(H) hospital outpatient clinics; and

(I) health maintenance organizations;

(3) makes independent decisions about the nursing needs of clients. ; and

(4) functions within the legal boundaries of their advanced practice area and shall

have and utilize knowledge of the statutes and rules governing their advanced practice

areas, including the following:

(A) State and federal drug laws and regulations.

(B) State and federal confidentiality laws and regulations.

(b) The three (3) categories of advanced practice nurses as defined in IC 25-23-1-1 are as follows:

(1) Nurse practitioner as defined in section 4 of this rule.

(2) Certified nurse-midwife as defined in 848 IAC 3-1.

(3) Clinical nurse specialist as defined in section 5 of this rule.

You might want to check out the website and you might find you want to join your state's APN organization. By having a voice in your state's governing body, you are in a prime location to influence change.

I'm kinda gathering that in IN, NP and CNS roles are not exactly the same as there seems to be quite a bit of wording differences. You might want to check this out. It does seem though that you can prescribe and obtain a DEA number and that you do have prescriptive authority.