brianprimm 1,318 Views
Joined: Sep 24, '10;
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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.
I have been reading posts about CNLs, and it sounds like most people are fearful of Direct Entry MSN graduates not having the leadership/experience/training of a traditional nurse. They won't. No one expects them to. The programs are not anticipating having leadership positions handed to new grads. You get your MSN, you get your CNL cert, you work as a staff nurse, you learn, you charge, you learn some more, and then you are already qualified to do the higher level CNL functions.
If your intent is to work at the bedside and hand out meds forever, then an ADN will suit you well. You will make the same bedside money as a BSN or MSN. If you ever intend on working as a manager, get your BSN or MSN. Most hospitals are at some phase of obtaining Magnet, and they will push all leadership to obtain higher degrees. If you want to teach, look at DNP or PhD. Most CNOs and admins have or are working towards their doctorate.
Higher degrees don't make better nurses. It does teach you to think differently, to encompass the whole picture, to approach a problem with outside the box solutions. You start to think not just in terms of what but why. Read a book by Spencer Johnson called "Who Moved my Cheese?" - it's about complacency in a complex work environment and how you need to constantly adapt, told through the story of two mice trapped in a maze. It's cute. Healthcare needs people at the "lower" levels of hierarchy (bedside) to solve complex problems and think about systemness and efficiency from the ground up, not the traditional top down approach. It works better that way. Who knows a nurse's practice better than the nurses themselves? The problem is time. How many of you have time to pull an understaffed 12 hr shift, plus huddle, plus a code, handle your patient families and then sit down to map the admissions process? I'm betting none. Which is why all of the changes are handed from the top down. And that's why we still use outdated modalities and procedures. "Acedemia" (which seems to be held in the highest regard) is right - let's redesign the maze itself. Forget the traditional ways and lets get nurses to start asking why. We can transform healthcare, have better outcomes for our patients and save a lot of money in the process.
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.
An old topic, but I feel the need to weigh in.
University of Toledo's CNL program is great, I graduated in 2009. Our class was about 31, down from 35 in the start. (8 of which were man-nurses) as I recall there were about 80-90 applicants that year. The following year there were only about 17 admitted, and about 30-40 applicants. I passed my CNL exam before my RN, both on the first try.
For the most part, our class was comprised of 25-30 year olds that had finished a degree, headed out and got a job, and shifted gears. Several of us were second career types, and I think the mix is helpful. There was a large spread of undergrad degrees, from arts to business and science.
I would guess that the GRE and GPA is less important than being motivated during your interview, and making sure you have all the prereqs. The few that I talked to averaged about 1000 GRE, and 3.2 and up GPA.
Having a good reason for becoming a nurse helps: "A bigger paycheck" is not the answer they are looking for. And even though you will get out with an MSN, expect to grind it out for at least two years as a staff RN to get your feet wet, and catch flak from the ADN-BSN crowd who are disappointed that you skipped a few steps.
But I wouldn't change it for a second! I plan on applying to CRNA schools next year. Good luck!
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