CNS vs NP?

Trauma Columnist · Apr 18, 2008

Much depends on your state's nurse practice act. My goal in becoming a CNS was to be an advanced practice nurse. In IL, a CNS, NP, CNM (cert nurse midwife) and CRNA (cert RN anesthetist) are ALL equally APNs. However, this is not the case in all states. I work in a large nephrology practice and we have 3 PAs (physician assistants), 3 FNPs (family nurse practitioners) and me - an adult health CNS. We all do exactly the same job. I have daily pt contact and in fact see myself as a strong pt advocate. I do examine, assess, treat and diagnose patients just as my other colleagues do.

There is another poster here, llg who is also a CNS - she will probably be along shortly to give some more details into what she does. She has more the "true" CNS role.

However, this all points to doing your homework before you commit to a program. Very important to check out what type of jobs are available for the various APNs in your area, unless you are free to relocate.

Good luck.

elkpark · Apr 18, 2008

re: the reference to the "true" CNS role, I'd just like to point out that psych CNSs (who were the original CNSs and developed the concept initially) have always been educated and used as direct care providers -- I have had jobs where I did some limited staff education, case management, etc., but those aspects of the job were incidental and my primary role was to provide psychiatric assessment/dx/treatment. It was only after I started hanging out here at allnurses that I found this is very different from CNSs in other specialties.

Trauma Columnist · Apr 18, 2008

elkpark - thanks for the info. I didn't know that.

elkpark · Apr 18, 2008

I was very surprised to learn (only from conversations on this board!) that other CNSs aren't primarily doing hands-on, clinical, direct client care ... :)

Trauma Columnist · Apr 18, 2008

I think much depends on what your state's nurse practice act dictates. In IL, I am an APN and do basically hands-on care. However, in other states a CNS is NOT an APN and is more in the educator role.

elkpark · Apr 18, 2008

I think much depends on what your state's nurse practice act dictates. In IL, I am an APN and do basically hands-on care. However, in other states a CNS is NOT an APN and is more in the educator role.

(Yes, but that's a newer trend, with the blurring/blending of the CNS and NP roles in a lot of places. I meant historically/traditionally ...)

Trauma Columnist · Apr 18, 2008

Yes, you are right. May I ask how long you've been a CNS? When I decided to pursue this post-MSN CNS, I only did it because it was an APN role. I did not want an educator role but rather an APN role.

elkpark · Apr 18, 2008

I've been a child psych CNS for almost 15 years. The psych CNS role seems lately to be dying out in favor of the new psych NP role. I'm v. sad about that, personally, but realize that I am apparently an outlier on that. I've never had Rx authority, don't want it, and wouldn't take it if someone tried to give it to me (although I have practiced in states where that was available to CNSs). I pursued education as a psych CNS in order to become a psychotherapist, and am not interested in pushing pills. It seems I am in the minority on that question. I have applied for jobs in the state next to me, where CNSs do have Rx authority, and was told in the interview process that the employer would expect me to get Rx authority as quickly as possible and they would be using me as a physician extender, to see clients for 10 minute Rx-refill appts. I was also told that no employer in that state would be willing to hire me to do anything other than write Rxs, because I'm so much more valuable as a prescriber than as a psychotherapist ... Fortunately, my own state doesn't offer Rx authority to CNSs, so it's not an issue, but the jobs have still dried up in favor of psych NPs -- for the same reason. It seems that the idea of the nurse psychotherapist is going the way of the dodo.

I'm deeply offended by the recent moves to redefine "advanced practice nursing" as requiring Rx authority, and the idea that those of us who don't have Rx authority aren't really advanced practice nurses. To me, prescribing is "medicine lite," not advanced nursing practice -- and (traditional) CNS practice is true advanced practice nursing.

Well, that's my rant for today! :chuckle Sorry -- this issue really touches a nerve for me.

llg, PhD, RN · Apr 18, 2008

Hi, friends. I'm here!

I've got my first CNS job in 1981, that's 27 years ago. I was at the meeting of CNS's in the early 1980's to which which the ANA came to recruit us to form a Council of CNS's within the ANA (rather than form a separate nursing association). And I have practiced in CNS or CNS-type roles in several different parts of the country. So ... as some of you know, I've been around.

As elkpark said, the psych role was one of the first to use that title. However, other MSN prepared nurses were practicing in CNS-type roles early, too. I remember meeting people back in the mid-1970's when I was in school who were calling themselves things like "clinicians" or "nurse specialists" etc. They had a variety of functions, such as serving as a consultant on the care of particularly challenging patients, developing protocols, staff development, etc.

All those folks merged together in the 1970's and early 1980's to come to a consensus on the CNS role -- a nurse with an MSN in a clinical specialty to provided direct patient care, consultation, research, staff education, and project management for an identified patient population. So, there was a clear distinction between the CNS group and the NP group (who focused as "physician extenders" in the field of primary care.) Generally, CNS's worked for hospitals to enhance the nursing care provided by that institution ... and NP's worked in clinics, physician's offices, etc. providing primary care under the supervision of a physician.

With budget woes and few nurses educated at the MSN level -- people started experimenting with merging the roles. In some parts of the country, the merged role really caught on. In other places, it didn't. Then it all got very messy -- as some CNS's (such as the psych CNS's) wanted some of the privileges that NP's had, such as prescriptive authority. But other CNS's didn't want that type of role. Some State Boards made a combined role, the APN, to cover both roles and to give both groups the same privileges. However other people (such as me) hated that because we were never educated to do primary care, do medical diagnosis, etc. and didn't want to. We felt disenfranchised by that development.

So ... those of us who didn't want those NP functions ... pressured our states to not require all advanced practice nurses to be APN's. We wanted to maintain the traditional CNS role in the hospital, serving to support the nursing staff and provide services to the staff and to the patients that did not involve medical diagnosis and treatment. We wanted to focus on enhancing the nursing care provided by the nursing staff.

So, some states readjusted their licensing categories ... and some people simply made up new titles to cover what used to be the jobs that were the old CNS jobs. Some of those functions are now being filled by "Clinical Nurse Leaders" "Nurse Clinician IV (on some clinical ladders)" "Pain Specialists" "Would Care Specialist" "Nurse Specialist" "Clinical Practice Specialist" etc. Back in the 1980's and 1990's, these people might have been called CNS's. Some of them still are. But in states where the BON has delineated a specific CNS role, most people just avoid using that title and make up a new job title.

I think it is sad that we have screwed up this very fine role. The old CSN role was/is a valuable one and we should have protected it better as a separate entity.

elkpark · Apr 18, 2008

I think it is sad that we have screwed up this very fine role. The old CSN role was/is a valuable one and we should have protected it better as a separate entity.

I could not agree more. It is very sad, and, I think, a real loss for nursing.

Advanced Practice Columnist / Guide · Apr 18, 2008

Just a question, do you think that one of the reasons why some CNS' sought prescriptive authority was because by adding this responsibility, they felt that it legitimized their advanced practice standing as nurses? I wonder because although I completely agree and believe in the benefits of keeping traditional CNS in all health care settings, the roles of a traditional CNS are still within the scope of professional nursing practice leaving one to question whether this is really advanced practice at all.