CNS for Later?

Trauma Columnist · Mar 25, 2019

You have put a lot of thought into this as evidenced by your reasons for pursuing a CNS. Thats great.

I don't know that the CNS is still a viable option. However, I can only speak to Illinois where I live. What role is it that you see yourself doing?

Advanced practice?

Case management?
Change agent?

imenid37 · Mar 25, 2019

Go for nursing education or an NP role. Peds NP if no NNP programs in your area. CNS roles are a bust for most areas. Been there. Done that. Argued with the state BON. I am actually licensed as a CNS. I have the title, but it means little. I am not treated like an APRN. Now really burned out and teaching in an ASN program.

adventure_rn, MSN, NP · Mar 25, 2019

29 minutes ago, traumaRUs said:
You have put a lot of thought into this as evidenced by your reasons for pursuing a CNS. Thats great.
I don't know that the CNS is still a viable option. However, I can only speak to Illinois where I live. What role is it that you see yourself doing?
Advanced practice?
Case management?
Change agent?

Thank you so much for your response, traumaRUS. Those all sound like fabulous opportunities. Honestly, at some point in my career, I'd be interested in many of those roles (depending on what's available). I could see myself in the same role as many of the CNSs that I've worked with in the past, reviewing/updating unit policies and practices, ensuring we are up-to-date with national standards and EBP, evaluating and advocating for the best supplies and equipment.

I sit on my hospital ethics committee, and I'm very passionate about ethics and end of life care. In my Children's Hospital, palliative care patients are often followed by our Pediatric Quality of Life team. The team is composed of physicians and NPs. I could definitely see myself being an advanced practice provider on a Quality of Life or a Palliative Care team.

I could also see myself in ancillary roles that are often filled by experienced nurses: Inpatient Care Coordinator for kids who are followed by tons of different subspecialties. A Discharge Planning/Transition of Care Coordinator for when these kids go home and require complex interdisciplanary follow-up. Developmental Care Coordinator for kids who are seen at developmental follow-up clinics and require extensive PT/OT/speech follow-up. A Transplant Coordinator for babies listed for transplant. A Family Liaison for babies with prolonged, complex inpatient courses. I've even known nurses who are hired by the hospital to be unit-based coordinator with various national neonatal organizations (like a March of Dimes Coordinator or a VON Coordinator).

I also love teaching, and I could see myself teaching as a part of my CNS role (whether it's teaching families, teaching bedside staff, or teaching in an academic setting).

There are so many amazing opportunities that are aligned with the CNS role! Although I don't know exactly how I'd want to use my CNS degree, I'm sure I could find an appropriate avenue. But at this moment in time, I'm still in love with bedside NICU nurse and I'm not ready to leave. If I could do any of these jobs and continue to work at the bedside that would be ideal, but I don't think it would be realistic to work full-time Monday through Friday as a CNS and pick up 12-hour PRN shifts on the weekends. I'm trying to figure out if there's a way that I can use a CNS background to augment my bedside nursing practice for now without replacing it.

Many of the opportunities I described don't require CNS licensure/certification, or even a masters degree. However, even if the CNS isn't required for a lot of these roles, surely it would be beneficial!

In addition, even if the 'CNS' role itself is phased out, that doesn't necessarily mean that these ancillary roles will necessarily be phased out, right? Even if I wouldn't technically be working with the title 'Clinical Nurse Specialist,' many of these jobs would embody the intention of the CNS degree.

adventure_rn, MSN, NP · Mar 25, 2019

6 minutes ago, imenid37 said:
Go for nursing education or an NP role. Peds NP if no NNP programs in your area. CNS roles are a bust for most areas. Been there. Done that. Argued with the state BON. I am actually licensed as a CNS. I have the title, but it means little. I am not treated like an APRN. Now really burned out and teaching in an ASN program.

I'm so sorry to hear that imenid!

I guess my greatest concern for completing an NP program is that NNPs perform such a different role from what I want to do. They are so highly inpatient, intensive-care focused; I'd learn a lot about resuscitation, intubation/line placement, and day-to-day management of micro-preemies, but that isn't really what I'm interested in.

I suppose that I could get a primary care PNP, but having a peds degree really isn't honored at all in the NICU; it's just such a different, specific population that I worry I wouldn't even be considered as an appropriate candidate.

However, as an NNP with no actual NNP experience, I don't think I'd have a lot of clout either. I just have zero interest in actually working in an NNP role.

I have considered getting an education MSN or DNP with a neonatal CNS certificate add-on (like a post-masters). Maybe that degree would be more hireable?

imenid37 · Mar 25, 2019

I wish you luck. Your passion is admirable. I would say if you get the CNS degree and don't practice as a CNS immediately, it could be an issue. There also may be issues finding a preceptor. Doing something like nursing professional development may keep your hand in the clinical area while allowing you to work on quality projects, serve on committees and represent your specialty at the institutional level. The CNS could be a very influential role right now, but it is "out of vogue." The other problem with many specialties is lack of a certification exam and lack of APRN designation depending on the state where you practice. It is like being a unicorn. Everyone agrees that you have many wonderful attributes, but you don't quite fit in anywhere.

Trauma Columnist · Mar 26, 2019

11 hours ago, imenid37 said:
I wish you luck. Your passion is admirable. I would say if you get the CNS degree and don't practice as a CNS immediately, it could be an issue. There also may be issues finding a preceptor. Doing something like nursing professional development may keep your hand in the clinical area while allowing you to work on quality projects, serve on committees and represent your specialty at the institutional level. The CNS could be a very influential role right now, but it is "out of vogue." The other problem with many specialties is lack of a certification exam and lack of APRN designation depending on the state where you practice. It is like being a unicorn. Everyone agrees that you have many wonderful attributes, but you don't quite fit in anywhere.

So true. Also, you must consider what you could bring to the table in terms of cost savings. As nurses, we don't always think about the business side of healthcare but it IS a business.

Many of the roles you discussed could and probably would be filled by an experienced RN which would be much cheaper than a CNS. In your state is CNS=NP=APRN? You have to be a profitable entity in order to get hired.

Although many of the tasks you discussed like case management, discharge planner and patient coordinator can actually be filled by a social worker and they get less pay than an RN. (This is what happened locally).

While I wish I had NP behind my name, APN works too because I can bill for my services and in the end thats what the people in suits who sit in the ivory tower want.

WestCoastSunRN, MSN, CNS · Mar 26, 2019

You're getting a lot of great feedback here. I am a adult-gero CNS student -- and I chose this degree for the flexibility of it. I'm not saying I'll never fill provider shoes (if the right CNS job comes along and includes that I will be OK with it), but I'm much more interested in supporting what is happening at the inpatient bedside. Like you, I enjoy bedside nursing and all the nuts and bolts attached to it.

Translating research (and conducting) effectively really does require a master's degree -- this is where we have to pitch our value as CNSs -- as change and cost-saving agents -- because Trauma is right -- healthcare is business. And CNSs are educators with advanced practice education and certification -- this presents a higher level of knowledge and expertise than your BSN clinical nurse educator -- so large hospital systems need CNSs running that show.

It's good you don't care if you are called a CNS or not. It's good you are looking for an affordable program. If you have the chance to get an MSN for 2K, I say go for it.

As for maintaining certification, I think you can take the test every couple of years (pain!), but you need to check with AACN. And sadly tests do phase out as we've seen.

But curiously, why are you not considering the pediatric CNS? It seems better suited to the work you say you want to do. Neonatal is only preparing you for that very narrow population. You sound like a peds nurse waiting to take care of kiddos! Maybe you should consider a move into pediatrics -- or at least cross train into PICU. Is that an option?

I would guess there is also more Pediatric CNS programs available. My school offers one and there are several in my cohort.

adventure_rn, MSN, NP · Mar 27, 2019

Thank you all so much for your responses! I sincerely appreciate the insight from people who have been through the process and know the challenges. I'm fortunate that I know a handful of practicing CNSs who I think would be on board with precepting me. To be honest, I've actually been surprised that many of are encouraging me to pursue a CNS given all of the information I've read on this site.

23 hours ago, traumaRUs said:
So true. Also, you must consider what you could bring to the table in terms of cost savings. As nurses, we don't always think about the business side of healthcare but it IS a business.
Many of the roles you discussed could and probably would be filled by an experienced RN which would be much cheaper than a CNS. In your state is CNS=NP=APRN? You have to be a profitable entity in order to get hired.
Although many of the tasks you discussed like case management, discharge planner and patient coordinator can actually be filled by a social worker and they get less pay than an RN. (This is what happened locally).
While I wish I had NP behind my name, APN works too because I can bill for my services and in the end thats what the people in suits who sit in the ivory tower want.

traumaRUs, if I may, could you elaborate a bit on the billing side? That piece of the equation is so nebulous to me! I have a decent understanding of how NPs bill for their services, and I definitely understand your point that it's cheaper to hire an RN or LCSW to perform many of the roles I described.

Many of the CNSs I know work full-time to implement evidence-based practice at the bedside through policy updates and education. Do they bill as APRNs for that? Or are APRNs only able to bill for services if it's directly related to the care of a specific patient? I always assumed that the CNSs I worked with were salaried by the hospital the same way that an educator or manager might be.

This may be a really ignorant question, but what are the things that a CNS can do within the APRN role that non-APRNs cannot? Again, I'm very clear on what NPs can do that RNs (or LCSWs) can't; however, I'm pretty unclear on what CNSs can do that RNs can't. In theory, it seems like some of the duties performed by the CNSs I know could be performed by RNs without an graduate degree (although probably not as well). Does the primary clarification actually have to do with billing (i.e. CNSs getting reimbursed at a higher rate than RNs), is it a legal distinction, or is it primarily just semantics? (I hope that doesn't come across as offensive, I definitely don't mean to undermine the role!! I'm just not sure how else to phrase what I'm trying to ask.)

16 hours ago, WestCoastSunRN said:
Translating research (and conducting) effectively really does require a master's degree -- this is where we have to pitch our value as CNSs -- as change and cost-saving agents -- because Trauma is right -- healthcare is business. And CNSs are educators with advanced practice education and certification -- this presents a higher level of knowledge and expertise than your BSN clinical nurse educator -- so large hospital systems need CNSs running that show.

WestCoastSun, love translational research! I'm one of those crazy people who enjoys reading study abstracts just for the heck of it. I absolutely love your point about CNSs functioning as cost-saving agents to prevent waste and error--that is such a great way to pitch the importance of your role to admin. It kills me when I approach management with EBP suggestions from some of these studies and they tell me, "That's just not how we do things here." In that situation, I feel like the CNS can be an advocate for change.

16 hours ago, WestCoastSunRN said:
But curiously, why are you not considering the pediatric CNS? It seems better suited to the work you say you want to do. Neonatal is only preparing you for that very narrow population. You sound like a peds nurse waiting to take care of kiddos! Maybe you should consider a move into pediatrics -- or at least cross train into PICU. Is that an option?
I would guess there is also more Pediatric CNS programs available. My school offers one and there are several in my cohort.

Oh boy. Well, I've been working in a PICU for the last year, and I've found that it is not my cup of tea (to be fair, my unit sees the sickest kids in the state and the majority are actively dying, so it's probably more depressing than most inpatient peds.)

The trickiest part is that in the inpatient world, NICU and peds seem to be mutually exclusive (even though we have some overlap in our patient population). As someone who has done both, there is just a dramatically different paradigm in the way each specialty manages patients. When I first started in PICU after working in the NICU, sometimes I'd make a suggestions and the providers would look at my like I had two heads. It kind of reminds me of the ED vs. the ICU: each specialty sees high-acuity patients, but their nursing approach is fundamentally different.

It's too bad because I think that a peds CNS would actually open a lot of doors for me that a neonatal CNS would not. Unfortunately, I worry that if I got my peds CNS I'd be shut out of a lot of NICU opportunities, and as I said, NICU has my heart.

Trauma Columnist · Mar 27, 2019

@adventure_rn absolutely no offense. Its very refreshing to have someone put so much thought into their career goals!

I practice in IL where CNS=NP as to scope of practice. I do not do the traditional CNS role, I'm in the APRN role. I see pts on my own, assess, diagnose, treat, f/u, etc., just as my NP/PA colleagues do.

My services to a specific pt are billable at 85% of the MD rate so I'm profitable for my practice because I don't make 85% of what the MDs make ?

If I was in the traditional CNS role in a hospital as a change agent or educator, I could not bill for my services. At least in my area (with several large hospital systems) the bottom line is that you would have a job which an RN could do at a cheaper pay rate. That, IMHO makes you expendable. The CNSs in my area are all APRNs that bill for their APRN services. No CNS (again in my area) works in a position where they don't bill for services.

And...please don't get me started on CNS certifications that they continually start and stop - its totally ridiculous. I'm an adult health and peds CNS - and neither of these certs exist anymore. So, IMHO the writing is on the wall - CNS is not a viable option for younger nurses or those who don't already have an MSN.

WestCoastSunRN, MSN, CNS · Mar 27, 2019

CNSs bill for patient services like the other APRNs.

Trauma has given you good reasons to walk away from a CNS degree, if you want to be a provider. She is a provider only -- really the equivalent of an NP. I have no doubt she is well versed in the ins and outs of CNS certification -- as she has had to deal with that headache personally. And everyone knows a hospital system will try to get more for less (ie., pay undergrad prepared nurses to do MSN work). That said, many many functioning institutions have discovered, thank goodness, the value of the MSN.

Bottom line: I would not pursue CNS if you want to be a provider. You do not want to be a provider. While many of the things you want to do may be able to be carried out by a BSN prepared nurse, they will not be managed by one. The power hierarchy is a real thing in systems -- change agents need to have education and credentials not only to know how to bring about change, but often, just to get a real seat at the table.

The CNS degree is an MSN+ degree, in my opinion. Yes, it is possible you won't get a "real CNS" job -- though if you know your market, you really can. You may not want a "real CNS" job -- you may want to use the degree in a different way, because it will open more than one kind of door for you.

One of the most exciting things, to me, about the CNS is the educator aspect -- so I really considered an MSN in education (way less clinicals!!) -- but both degrees cost the same and so it became a NO BRAINER. I'm getting an APRN degree which will allow me to perform direct patient care as well as inform the education, policies and consults I create/am involved with.

If you have a chance to get this degree for almost nothing? And you don't really want to be a provider? It's a no brainer. As for certification, I suggest you reach out to your CNS mentors as well as AACN for clarification, and then know -- because the actual role is in flux - certification will be too, but the MSN you get will not.

DrAres · Mar 27, 2019

Adventure_RN,

As others have noted, it's great to see that you are doing your homework and due diligence on this matter. I will address multiple issues that have evolved on the thread from the standpoint of being CNS faculty (full disclosure).

You say you're not ready to leave the bedside for an advanced practice role. Remember that if you attend graduate school part-time it will take you about 3-4 years to complete an APRN program. If you were to start next year, your feelings about remaining at the bedside may change near the end of your education. It is also possible that the educational journey will continue to feed your affinity for ethics and research and you may be anxious to move into a different role (CNS or other) at the end of your education so that you can spend more time in those areas you love. If you are still feeling like you want to be at the bedside after your education, you can search for part-time CNS positions or I know many CNSs take a per diem position at another hospital to be able to work at the bedside. Another approach is to work at the bedside during crisis and holidays. This is typically well received by staff and as long as you don't have a Union there is often not concern about displacing a staff nurse shift if you volunteer to pick up "undesirable" shifts.

AACN does have a retest option that would not require the practice hours.
AACN does not address the option of volunteer hours doing APRN work, but ANCC has that option. So that would be something to check into as an alternative to employment in the role or taking the exam. Now that the APRN Consensus Model is in place and the APRN roles and populations are defined, I believe the AACN Neonatal CNS exam will continue. AACN has had exams for critical care Ped and Neonatal for many years and is the only certification organization for Neo CNSs. They updated their exam and qualifications to meet the APRN Consensus Model and I doubt they will discontinue the exam. However, they are a business so it also comes down to whether the exams are profitable or break-even.

CNS practice in hospital settings is typically executed within the advanced nursing arena rather than in the medical scope (as NP, CRNA, and CNM practice) - so within the nursing scope. As such, there is not as much legal differentiation of CNS and RN roles. This does make the role more vulnerable. That said, in some hospitals the CNSs do prescribe some meds, treatments, and DME. I can see some application in the NICU - particularly with a focus on discharge needs. Additionally, some follow patient populations into outpatient specialty care (such as the Developmental Clinic that you mention) and CNSs can bill for those outpatient services.
Use of the role varies, but it has been supported in Magnet hospitals and in CA the NICUs and PICUs are required to have a CNS in order to receive
supplemental state funding for children's health care. So in CA there is a good degree of job security.

Education competencies can lead CNS-prepared nurses to other types of positions. I have witnessed promotions within the organization (one of my CNS classmates is now a CNO). Also, a study that I did of CNS transition post-education showed that people did make choices to assume non-CNS jobs for personal reasons and because the CNS positions weren't available in their area. Interestingly, the Ped CNSs were the specialty most employed as a CNS (though they were a small fraction of the sample). See the publication for more detail on some of these issues.
Ares, T. L. (2018). Role transition after clinical nurse specialist education. Clinical Nurse Specialist: The International Journal for Advanced Nursing Practice, 32(2), 71-80. doi: 10.1097/NUR.0000000000000357

The university I am affiliated with is in the process of approving a Neonatal CNS MSN and post-master's certificate programs that will be available online. We believe there will be a continuing need for the role. So, you may find the NANN list is able to grow in the future, but I share your concern that
programs may also close. It is expensive to run them with so few students enrolled.

Last, once you have your MSN degree it is possible to add other specialties (e.g. Ped CNS or Educator) on top by attending a post-master's certificate program. If you find later that your choices are too limited, ongoing formal education can move you into a broader direction.

All the best as you sort through these important issues.