CNS role questions

Trauma Columnist · Nov 2, 2016

Hi there and welcome!

- What are your daily responsibilities for patient care?

I practice in IL where CNS = APRN so I take complete care of my patients: assess, diagnose, treat, etc from start to finish. I work in a very large nephrology practice and am very autonomous. I can go weeks without communicating with a physician but that said, I've been doing this job for 10 years so am very comfortable in my role. (I communicated more often when I was a newer APRN)

- What are the advantages of being a CNS, in your opinion? The disadvantages?

Advantages: None

Disadvantage: Licensure: CNS is NOT an APRN in all states. Healthcare is a business and if you are a CNS who does not bill for your services, you run the risk of having your job on the chopping block as being too expensive for the hospital/practice to afford. Also, few people even know what a CNS is let alone know what we do. I would never ever ever make this career choice again. However, that said, I hope other CNS's come along that are happier with their career choice to share more positives than I have experienced. BTW I hold two CNS certificates: adult and pediatric and as ANCC has seen fit to retire both of them, if I were to let either of them lapse, I would no longer be able to practice. (I bet you are sorry you asked this question now, aren't you? lol)

- Who do you work with / interact with most often at work as far as other professionals?

I interact most with RNs.

karajoy · Nov 2, 2016

Thank you so much for your reply. I'm sure this is a super naive question, but - it seems to me that CNSs perform specialized roles similar to a NPs... Why has CNS become less popular? And are the credentials similar enough that CNSs could actually perform in the NP role? Or is there a huge difference that I'm just not seeing?

THANKS, again!!!

Trauma Columnist · Nov 2, 2016

lol - I'm the least sensitive of anyone - go ahead and ask me anything.

In IL where I practice I have the same exact scope of practice as an NP. In fact in my practice, we have 8 APP (advanced practice providers) and I'm the lead APP - I supervise NPs and we all do the same exact job.

The big (and only as far as I can see) advantage to being a CNS is that I did clinicals in the hospital as well as outpt so per the consensus model I can see pts both inpt and outpt.

SanDiFrangles, RN, NP, CNS · Nov 3, 2016

I found this helpful so thanks for starting (and answering!) this thread. As a recent new-grad CNS I'm very frustrated with how the role is laid out in a great number of states. I'm convinced I made a bad choice by furthering my career as a CNS, so I returned to the bedside for the time being. I did talk to a number of CNSs who were really passionate about their career and who were encouraging. It seems to be that a number of previous inpatient CNS roles are being transitioned out to the clinical nurse leader (CNL) role.

[h=5]I almost find our profession suffering from an identity crisis since its difficult to articulate what a CNSs role would be. My advice is that if you want to see patients at the advanced practice level, forgo the CNS role - and go straight for a NP. As for me, I'm now heading to the nurse anesthesia direction, since its been an interest of mine for some time.[/h]

All the best :)

karajoy · Nov 4, 2016

TraumaRus - that IS neat, that you did inpatient and outpatient clinical. I'm interested in both hospitalist work and FNP work... need to shadow more to figure out which route to take.

PennCCRN - Yes, I think I will go the NP route....

I'm just confused as to what the difference is in training between CNS and NP. Maybe you can tell me, since you went through school recently? Seems like since they can do the same work, they should roll both under one title / school program (maybe all CNS into NPs) and grandfather in those currently working as CNSs.

Also, where in the US are you located?

SanDiFrangles, RN, NP, CNS · Nov 6, 2016

Karajoy, I don't think your alone in trying to distinguish the difference between NP and CNS. I was educated in California so much I know about the CNS role is based on the function here. CNS practice varies from state-to-state ... in certain states CNS have prescriptive authority and function as NPs where they see patients in clinic and/or in the hospital setting. In other states, CNS's do not have prescriptive authority and are largely dependent in the institution to what their role would be.

Our board here in California defines fairly well what a NP and CNS are. But perhaps the best way someone explained it to me is this: 1) An NP takes care of one patient at a time 2) A CNS is a clinician who takes care of a great number of patients all at once. While crude, it does help distinguish the focus of a CNS. A CNS CAN (based on the state or institution) see patients they also do many more things such as clinical consultation, education, research analysis and policy review. As such, some of our clinical experiences diverge from NP, in that we might participate in a research project which counts as clinical hours. For NP, these experiences do NOT count towards the clinical hour requirement.

To illustrate on how CNSs are used, I'll highlight two university academic institutions say university X and university Y. At university X, CNS's as utilized as expert clinicians, educators and supporting the nursing staff. A typical day would be spent talking to nurses on the unit, providing clinical guidance and expertise and attending leadership meetings on how to best improve nursing practice. This usage of CNS is usually termed unit-based, meaning a CNS responsibility is for a particular unit in the hospital. While at university Y, CNS's are used in two different capacities, unit-based and service-line. Unit-based are CNS's that are assigned to a specific nursing inpatient unit or area - such as an ED or ICU. They oversee nursing practice for a particular unit, consult and collaborate with staff. Whereas, a service-line CNS works directly for a medical service such as neurosurgery, interventional cardiology or palliative care. In this role, they function as NPs performing H&Ps, start/stop/modify prescriptive drug therapy and treatment in both inpatient and outpatient settings.

When I was assigned to the interventional cardiology CNS, she saw patients and would do their H&P and would recommend if they should be taken to the cath lab. A few times we would see patient in the pre-procedural holding area prior to taking the patient back for a cardiac catherization. The difference between her role and the NP role is that a MD was required to "sign-off" on all her orders. The MDs would sign-off her orders but would rarely see the patient together, she would discuss the case with the MD in passing if there were any questions. Bottom line, for the most part the MDs would just sign-off since they were seeing their own patients.

Your follow-up question might be ... well how do CNS's get away with writing orders if they are determined not to have prescriptive authority in California? The best I can explain it to you is that the facility makes that determination. In the case here, University Y has determined that service-line CNS go thru credentialing and have prescriptive authority in there institution so that there supervising physician cosigns their orders. That is still in compliance of the nurse practice act. But I will tell you, this is very uncommon among hospitals in California - most hospitals do not permit CNS's to see and treat patients here in California.

As far as my program and comparing it to the NP program, I did a critical care CNS program so I took many courses along side our ACNP cohorts. Aside from a few courses, we took many of our courses together. In fact, our school offers a post-masters certificate to NPs and the only difference is that we have to do that NP clinical component and maybe one or two NP-specific courses. Many programs will actually offer the CNS and NP together where you will be eligible to sit for both NP and CNS boards.

But bottom line I agree with traumaRUs, in that if you can't bill for your services - your job will always be considered "eliminate-able" - the best thing to ensure career longevity is to be able to bring in money for the institution. CNS's are often seen as an "expense" and NOT as income generation.