What allows one more independence? NP or CNS?

Dr. Tammy, FNP/GNP-C · Dec 27, 2009

Yes I have read the stuff on the CA BRN website, but I would rather someone who just knows from first hand experience to tell me if they can do NP stuff also. I still dont think the BRNs info is specific enough... its just all this general terminology that does not tell me anything more than what I already sort of know. Thanks for the info and websites anyway, though :)

I'm a California NP and this is quite a tricky subject.

First, NP's as well as CNS do not have a separate scope of practice in California above that of a RN. Essentially, NP's in California are medical technicians similar to California Emergency Medical Technician-Basics and Emergency Medical Technican-Paramedics (I'm one of those too) in that NP's have to operate by using standardized procedures (SP's) when practicing advanced nursing, which is dictated by the physician and agreed upon by nursing and administration.

This stems from California legislature that is driven by two different, yet interrelated phenomenon. First and foremost, nurse practitoners in California, mostly speaking, feel they are medical providers and practice medicine and not advance practice nursing, thereby abandoning their nursing roots. Ask 10 nurse practioners here in California, "Do you practice medicine as a NP or do you practice advanced nursing?" I bet 9-10 out of 10 will tell you they practice medicine and what they do for their patients has little if nothing to do with nursing. To give you a fuller and deeper understanding of the disconect between NP's and nursing, ask the same people, "Do you use any form of nursing theory or framework to guide the care you provide to patients?" If all 10 do not laugh at you it will be a mirracle.

As a direct consequence between the disconect between Nurse Practitioners and Nursing, the second part of the phenonenon takes root, which involves the medical model-driven legislature. This is where the state defines what the scope of practice of medicine is and it includes functions of advanced practice nursing, such as diagnosing, prescribing drugs and devices, ordering tests and whatnot. Next, the legislature states that a nurse may not perform anything within the definition of medicine unless the nurse has a SP protocol dictated by the physician and supervised by the physician. In technical form, there is no difference in regards to SP's between a RN and a NP or CNS.

So to answer your question, to practice as a NP or CNS in California has no autonomy independent of the supervising and dictating physician. In fact, NP's in California may not even "prescribe" drugs--they have to "furnish" drugs because NP's are not educated, experienced or trained to do essentially the same function that other providers do, such as dentists, optometrists, and oh yeah--the physician. Fundamentally, though, furnishing is the same function as prescribing, but in keeping with the medical modle-based legislature, the physicians could not handle alowing NP's to prescribe.

The main difference between California and other states that have indpendent practice is that NP's in those states have claimed the profession of nursing as thier own and stated very clearly to the medical modle-based legislature they are not medical assistants and nursing does not belong to, nor is controled by medicine and that the practice of NP's is nursing-guided, nursing-directed and nursing-informed.

Hope this has helped.

allsmiles2008 · Dec 27, 2009

Thank you so much for the valuable info!!!

elkpark · Dec 27, 2009

I'm a California NP and this is quite a tricky subject.
First, NP's as well as CNS do not have a separate scope of practice in California above that of a RN. Essentially, NP's in California are medical technicians similar to California Emergency Medical Technician-Basics and Emergency Medical Technican-Paramedics (I'm one of those too) in that NP's have to operate by using standardized procedures (SP's) when practicing advanced nursing, which is dictated by the physician and agreed upon by nursing and administration.
This stems from California legislature that is driven by two different, yet interrelated phenomenon. First and foremost, nurse practitoners in California, mostly speaking, feel they are medical providers and practice medicine and not advance practice nursing, thereby abandoning their nursing roots. Ask 10 nurse practioners here in California, "Do you practice medicine as a NP or do you practice advanced nursing?" I bet 9-10 out of 10 will tell you they practice medicine and what they do for their patients has little if nothing to do with nursing. To give you a fuller and deeper understanding of the disconect between NP's and nursing, ask the same people, "Do you use any form of nursing theory or framework to guide the care you provide to patients?" If all 10 do not laugh at you it will be a mirracle.
As a direct consequence between the disconect between Nurse Practitioners and Nursing, the second part of the phenonenon takes root, which involves the medical model-driven legislature. This is where the state defines what the scope of practice of medicine is and it includes functions of advanced practice nursing, such as diagnosing, prescribing drugs and devices, ordering tests and whatnot. Next, the legislature states that a nurse may not perform anything within the definition of medicine unless the nurse has a SP protocol dictated by the physician and supervised by the physician. In technical form, there is no difference in regards to SP's between a RN and a NP or CNS.
So to answer your question, to practice as a NP or CNS in California has no autonomy independent of the supervising and dictating physician. In fact, NP's in California may not even "prescribe" drugs--they have to "furnish" drugs because NP's are not educated, experienced or trained to do essentially the same function that other providers do, such as dentists, optometrists, and oh yeah--the physician. Fundamentally, though, furnishing is the same function as prescribing, but in keeping with the medical modle-based legislature, the physicians could not handle alowing NP's to prescribe.
The main difference between California and other states that have indpendent practice is that NP's in those states have claimed the profession of nursing as thier own and stated very clearly to the medical modle-based legislature they are not medical assistants and nursing does not belong to, nor is controled by medicine and that the practice of NP's is nursing-guided, nursing-directed and nursing-informed.
Hope this has helped.

This is an excellent example of why there's no single, definitive answer to the kind of question that started this thread -- there is so much variation from state to state ...

My state, for example, is one in which CNSs do not have Rx authority, so the role and scope of practice for NPs and CNSs are entirely different. In other states, there's hardly any reason to call them different titles any more, because they essentially function exactly the same.

ROLO · Dec 27, 2009

WOW! Some very interesting insight, Tammy! Your reminder of some NPs forgetting their nursing roots is one reason the CNS role was attractive to me...seemed more nursing-based.

As an ED RN for almost 19 years, I, for example, know CHF when it walks in the door. If one of my ED physicians is not at the bedside when I have finished my "nursey" things, and I am ready for meds, I usually find him and tell him, "my patient is in CHF, and I am giving x, y, z meds...I'm also starting BIPAP..."

99.9% of the time this is OK, and my patient has already been turned around (signs of improvement) by the time my doc has made it into the patient's room. I DON'T play doc...DON'T want to BE doc...but, again, after 19 years in the ED, I am comfortable with my "diagnosis" of CHF and my "treatment." And, honestly, if some of these patients were to have waited for a physician to make it to bedside before the doc formally saw the patient and wrote orders, the first business at hand probably would have been intubation.

With that being said, I guess I look at the CNS & NP roles as sort of being blended, and I know some programs are doing just that...blending them. BUT, both roles are certainly ADVANCED PRACTICE. And, if I (not yet an APN), and very experienced nurses all over this country, are able to function at the expert level (Benner's novice to expert) by recognizing disease states and preparing for their treatment, then it would be my expectation that both CNSs and NPs be able to recognize and treat...but sometimes consulting with the MD first, and as needed.

I have already don tons of research on the CNS & NP roles. In Indiana, where I live and work, there is no differentiation between the CNS & NP roles --the only limitations are those set down by the MD with whom you are practicing (generally speaking). BUT, there are so few CNSs here, especially where I am, that it is pretty discouraging explaining that I want to be a CNS and what a CNS does...SO, consequently, I am changing my track from CNS to NP.

I am glad though that I have done the extensive research into the CNS role though. I hope that I can be of assistance to CNSs as they venture into my community (I HOPE they do!). Also, if they should not venture into my community, having learned about the important roles of being a change agent, bringing evidence based practice into practice, etc., maybe I could assist with those things being done in my community.

I am rambling...

core0 · Dec 27, 2009

Thank you for bringing this up... I had been meaning to ask, as I have not found this in any literature: IS there a trend for dropping any differentiation between CNSs and NPs? I am really not sure and cannot tell. I have done much research into the CNS role. I started out in an NP program...changed to CNS, as I found a CNS program that looked really "humane"... but now I think I am changing BACK to the NP program, as they already seem to be doing what I would like to do (see patients), eventhough I DO like the other spheres of practice the CNS can address, things the NP has not been typically trained to do.

It depends on what you look at. If you look at the DNP white paper the tend is to merge all APRN roles with differentiation based on skill set and training.

http://www.aacn.nche.edu/DNP/pdf/Essentials.pdf

The state BONs statement on APRN roles essentially said the same thing.

On the other hand NACNS' position paper disagreed with this especially as one traditional role of the CNS (nursing experts) is not addressed.

http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=592873

My interpretation (for what it is) is that NONPF would like that portion of the CNS role to merge with the CNL so there is a differentiation between APRNs (those that provide patient care as an APRN) and non-APRNs who do not.

David Carpenter, PA-C

elkpark · Dec 27, 2009

My interpretation (for what it is) is that NONPF would like that portion of the CNS role to merge with the CNL so there is a differentiation between APRNs (those that provide patient care as an APRN) and non-APRNs who do not.
David Carpenter, PA-C

Many of us object strenuously to the idea, however, that only performing medical acts counts as "advanced practice" -- one can make the argument that the CNS role is the true advanced practice nursing role (and the psych CNS was the first, original advanced practice nursing education and role), and the others are more like "medicine lite." I assure you that I provide direct, hands-on patient care (in my specialty) and practice nursing at an advanced level (beyond the scope of practice of generalist RNs) every day without prescriptive authority.

core0 · Dec 27, 2009

Many of us object strenuously to the idea, however, that only performing medical acts counts as "advanced practice" -- one can make the argument that the CNS role is the true advanced practice nursing role (and the psych CNS was the first, original advanced practice nursing education and role), and the others are more like "medicine lite." I assure you that I provide direct, hands-on patient care (in my specialty) and practice nursing at an advanced level (beyond the scope of practice of generalist RNs) every day without prescriptive authority.

While I agree with you, unfortunately the only thing that the payors care about is the ability to diagnose and treat. As you stated the psych CNS role predates the NP and the APN (as it was used then) role predates that by several years. However, in the current nursing environment APN is the umbrella term used for those nurses who can (by law) diagnose and treat.

The other issue is that regulators like delineated boxes. The term APN in its broadest term is a messy one. For example a PICC nurse is clearly using a skill that is nursing at an advanced level. However, payors do not recognize that particular skill set as a "provider" skill set. Similarly I have to sign orders for the WOCN nurses treatment plans because, while there nursing skill set is certainly advanced, the specialty lies in that middle ground which is not quite APRN (as described by the BONs). In part its a measure of the tradeoffs that nursing made to get Medicare reimbursement. Like it or not those patterns now describe what is advanced practice nursing.

David Carpenter, PA-C

elkpark · Dec 28, 2009

While I agree with you, unfortunately the only thing that the payors care about is the ability to diagnose and treat. As you stated the psych CNS role predates the NP and the APN (as it was used then) role predates that by several years. However, in the current nursing environment APN is the umbrella term used for those nurses who can (by law) diagnose and treat.
The other issue is that regulators like delineated boxes. The term APN in its broadest term is a messy one. For example a PICC nurse is clearly using a skill that is nursing at an advanced level. However, payors do not recognize that particular skill set as a "provider" skill set. Similarly I have to sign orders for the WOCN nurses treatment plans because, while there nursing skill set is certainly advanced, the specialty lies in that middle ground which is not quite APRN (as described by the BONs). In part its a measure of the tradeoffs that nursing made to get Medicare reimbursement. Like it or not those patterns now describe what is advanced practice nursing.
David Carpenter, PA-C

I CAN, BY LAW, DIAGNOSE AND TREAT -- just not with medication. (There are lots of other modalities out there, you know ... :)) If I wanted to be in private practice, I could independently bill and get paid by third parties as a psychotherapist. I am clearly practicing outside the scope of generalist nursing practice. I just don't (and don't want to) Rx drugs -- I prefer to leave that to physicians, and stick to nursing practice.

foreverLaur · Dec 28, 2009

My aunt is an acute care CNS in Southern California. She runs a cardiac ICU.

sailornurse · Dec 28, 2009

Yes, but more and more states are dropping any differentiation (from a licensure/scope of practice perspective) between CNSs and NPs, and treat them basically the same. To some extent, it would depend on which specific state one is talking about.

Well that's new info, can you be specific as to which states and please list a source? The Consensus Model for APRN regulation lists 4 separate roles, and specifically states reasons that CNS & NP's are different.

In fact the original draft from the National Council of State Boards of Nursing (March 06) wanted to delete the CNS role and change the titles of the CNS to NP's. This "vision paper" drew fire from both CNS & NP organizations against this proposal to eliminate the CNS role.

It is my understanding that about 20 states do not recognize CNS as advance practice and consider the CNS as a RN. Not all CNS have prescriptive is one of the issues, (sticky point). I was not able to find a list of which states do/do not recognize the CNS role.

However, NP's in some states do have independent practice, free from collaboration or supervision from a physician. I believe all NP's have prescriptive as part of the basic education, if I am incorrect, someone please correct me. It is also my understanding that all 50 states recognize NP's as APRN's. :twocents:

So to the OP, it depends on where you live & what the board of nursing/practice act says.

Dr. Tammy, FNP/GNP-C · Dec 28, 2009

Well that's new info, can you be specific as to which states and please list a source? The Consensus Model for APRN regulation lists 4 separate roles, and specifically states reasons that CNS & NP's are different.
In fact the original draft from the National Council of State Boards of Nursing (March 06) wanted to delete the CNS role and change the titles of the CNS to NP's. This "vision paper" drew fire from both CNS & NP organizations against this proposal to eliminate the CNS role.
It is my understanding that about 20 states do not recognize CNS as advance practice and consider the CNS as a RN. Not all CNS have prescriptive is one of the issues, (sticky point). I was not able to find a list of which states do/do not recognize the CNS role.
However, NP's in some states do have independent practice, free from collaboration or supervision from a physician. I believe all NP's have prescriptive as part of the basic education, if I am incorrect, someone please correct me. It is also my understanding that all 50 states recognize NP's as APRN's.
So to the OP, it depends on where you live & what the board of nursing/practice act says.

To true. In California, the BRN "certifies" the CNS, but they are not eligible for a furnishing number (eg: Prescribe) such as the NP/CNM/CRNA. My buddy in Indiana is a DNP/Psych CNS. She had to take some pharm course so she could Rx.

ROLO · Dec 28, 2009

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