Working in tandem does the job better for two critical nursing positions

Clinical nurse specialist and nurse practitioner: Room for both

Two positions that help form the backbone of a hospital's nursing expertise may find that they're not competing against each other but rather are becoming complementary.

Despite concern from some quarters that facilities may want to replace the clinical nurse specialist (CNS) with an acute care nurse practitioner (ACNP), what is starting to happen is that the two positions are working in tandem. This approach has created a "blended model" for the ICU, where the CNS and ACNP collaborate on coverage and ideas for research and education.

"Some people think they can replace a CNS with an ACNP, but important functions like quality assurance and education, staff orientation, and research would fall by the wayside," says Ruth Kleinpell, PhD, RN-CS, CCRN, associate professor and faculty member of the acute care nurse practitioner program at Rush University in Chicago.

Lynn Kelso, MSN, RN, ACNP, CCRN, assistant professor and acute care nurse practitioner with the pulmonary critical care unit at the University of Kentucky-Chandler Medical Center in Lexington, agrees. "In some cases the ACNP will do some case management work, and the CNS will take on patient management duties," she says. The focus for the ACNP remains on the management of patients, while the CNS looks at the whole system. "The CNS can see how the patient flows through the system as well as ensure that nurses are well educated and recertified, and constantly facilitate the continuity of care," Kelso says.

The nurse practitioner role

The acute care nurse practitioner role began out of a need in the late 1980s for an advanced practitioner to oversee direct patient care. One of the primary reasons was a decrease in medical resident coverage in the ICUs. ACNPs have a totally different function on the ICU than a CNS, says Kleinpell, because they are involved with direct patient care, monitoring the results of tests, ordering treatments under physicians protocols, interacting with families, and coordinating the care of the patient. A typical ACNP will spend 80% to 100% of his or her time on direct patient management issues.

Kelso says the ACNP is responsible for providing holistic patient care across the continuum, maintaining constancy with the medical care management team, and coordinating resources for acceptable outcomes. According to Kleinpell, the ACNP role is moving into many different care settings, such as tertiary units, subacute care, urgent care, long-term care, and multispecialty practice clinic sites.

Clinical nurse specialists are responsible for education, orientation of new staff, research, development of policies and procedures, and quality assurance projects. The clinical nurse specialist role is shifting in some regions of the country to take on more case manger duties. "There are many hospitals that are changing the CNS role toward case management and out of direct patient care. However, the CNS is still responsible to be an educator and provide resources to the nursing staff," says Kelso.

Kelly Ernst, RN, MSN, clinical nurse specialist in the special care unit at St. Thomas Hospital in Nashville, TN, says her facility has 12 CNSs who function in a dual role of CNS and case manager. There are no ACNPs on staff.

Although case management duties are part of her job now, Ernst's role includes consulting with nurses on policies and procedures, conducting research in the library, providing orientation to graduate nurses, and speaking with preceptors in the ICU. She is a member of several committees and conducts formal and informal education for nurses.

One focus Ernst has is to ensure nurses in the units are familiar with high-risk procedures. "I review the nurses' skills, especially with new equipment that is not user-friendly. This education is especially important because so much new technology is evolving and nurses may not come in contact with it that often."

She helps transition and educate staff nurses to new technology and changes in procedures. "It is difficult for nurses to keep up with something new every day" she says. "If I give nurses the rationale behind the change, they will be more accepting of it."

Ernst also sees the CNS role moving toward becoming a liaison between the staff and nurse managers when the manager can't be on the unit.

"I see such value in being the clinical resource person in my job. Every day I hope I make a difference in someone's practice or have clarified information that was unclear," Ernst says. "I want to be the person with the entire picture of where a patient came from, what's happening while they are in special care, and where they go after they leave," she says.

Documenting the CNS role

How does a CNS document her effectiveness in the ICU? "No one has yet to find good tools to measure the outcomes of the CNS," says Kelso, but she and Kleinpell offer these examples to consider:

· Include information for feedback on patient and family satisfaction surveys.

· Gather data on lower incident rates for needlesticks or hepatitis and document the CNS' role in this reduction.

· Take part and document involvement in JCAHO accreditation tasks that help the hospital achieve accreditation.

· Maintain records on quality assurance programs that show results and the effectiveness of staff education.

· Measure length of stay in a cardiovascular unit and any reductions made due to managing patients in and out of the ICU.

· Show decrease in length of stay through more efficient movement through the system.

· Show patient compliance with their pathways.

· Show an increase in educational opportunities for staff.

· Correlate effective patient education and understanding with decreased hospital readmission rates.

· Evaluate equipment products and streamline them to save the hospital money.

· Review protocols to determine if the right treatment is being given at the right time.

"The role of the CNS is valuable to the institution. It is hard to prove that a CNS is of financial value, but it can be done," says Ernst.

"Patient care management is a full-time position," says Kleinpell. "So if a unit is considering a CNS or an ACNP, it has to focus on the needs of the unit." Hospitals can come up with creative ways to keep both types of nurses, such as:

· hiring an ACNP for each ICU and a CNS to cover several units;

· having physician practices hire an ACNP to see patients in the office and after surgery, while the CNS is hired through the hospital.