1. Murray, Theresa M. MSN, RN, CCRN, CCNS

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Caveat Emptor[horizontal ellipsis]Let the Buyer Beware

If I were to write a few thoughts to challenge the employers of advanced practice nurses, chief nursing officers, and their counterparts, I would challenge the lack of understanding of the role of the clinical nurse specialist (CNS) and the lack of uniformity in role summaries and job descriptions. The hiring of nurse practitioners (NPs) into CNS positions is a prime example; it demonstrates a lack of understanding of the differences in these 2 important advanced practice roles. I would put out a challenge to all who are hiring advanced practice nurses to be certain they are clear about the work they are expecting these individuals to do. In fact, it is incumbent upon both the hiring individual and the nurse who would accept a CNS position to make certain the position is not offered to or accepted by an individual who lacks CNS preparation. This is a professional responsibility, and we must be certain that CNS roles are filled by individuals who have the best preparation to be successful. So you ask the question, who does the hiring of advanced practice nurses in the United States? What is the work you, the consumer of advanced practice nursing services, are paying for? What is the degree or credential that best matches the work you are paying this nurse to accomplish?


If the work you want to be done is patient management in outpatient clinics, then a primary care NP may be the right choice. If you want specialty-focused patient management, implementation of best practice, optimization of nursing care, support for nursing staff, and improved patient outcomes, then you are looking for a CNS. The outcomes from these 2 advanced practice roles are well documented, although different. This difference occurs due to the differences in educational requirements and credentials. The roles are not the same, nor should the work or the educational requirements be the same. If you are looking for an advanced generalist, with limited or no articulated outcomes in relation to the healthcare delivery system, then perhaps a clinical nurse leader (CNL) is the correct role. Recognizing I have a bias, I would of course suggest that any role focused on at safety and quality outcomes with a staff and innovative programmatic interface would be best filled by a properly prepared CNS.


Why do I bring this up? In looking at the future of nursing care delivery, we need to turn our attention forward. We know of areas across the country where positions have been posted, but the requirements are so unclear that a CNS, NP, or CNL could apply. I would challenge that thinking right to its core. Again, the focus needs to be on the work itself. When the work requires an NP, then an NP should be hired. If the work requires a CNS, then a CNS should be hired. When a mismatch exists, there is a dangerous disconnect between the role and the educational preparation. As a CNS, I am an expert in critical care nursing of adults. I do not do invasive procedures, nor write prescriptions, nor independently change the plan of care for the patient in the intensive care unit. I do have leverage and authority for all protocols and all equipment that interface with our patients. This is the work of a CNS: evidence-based practice with an eye for cost-effective implementation. This may mean a new protocol or more education. It may also mean evaluating and choosing a new piece of technology. A CNS is trained to do a thoughtful cost-benefit analysis of any new program or technology. When we decide to purchase new technology, the CNS deciphers the differences, builds an educational program to bridge the operational gaps, and establishes a new standard of care. This work is very different than managing patients in primary care.


It is inappropriate to ask NPs to perform as a CNS when they have not been prepared for this role. Similarly, some programs that offer dual preparation are lacking in CNS clinical and practicum experiences with an experienced CNS preceptor. Individuals prepared as NPs working in a role designed for a CNS struggle with the systems-analysis aspect of our role. Advancing the practice of nursing, a key component of the work of the CNS cannot be done without a systems focus. This type of disconnect is unfair to both the nurse and to the public, and is a setup for failure. As I understand the preparation, a CNL is also not prepared to do this work. It may be possible that a CNS could have oversight responsibilities for several CNLs doing local or unit-based work only, if the proper support structures, work flow, and reporting relationships are in place.


I am a recognized expert in critical care nursing. I cannot, and do not, accept responsibility for the entire plan of care. I do accept responsibility for the expertise of the nursing care that we deliver. Yes, we have multidisciplinary team goals, and yes, I do contribute to the overall plan. However, I am a collaborator and teacher, not the sole planner.


So I pose this call to employers of nurses. What is the work or the outcomes you are expecting from the individual that you hire? What can you afford to pay? What is the social responsibility of professional individuals to not accept positions for which they have not been appropriately prepared? Employers have a responsibility in these challenging times to only hire into advanced practice positions appropriately prepared advanced practice nurses. As another word of caution, the American Association of Colleges of Nursing acknowledges that a CNL is not an advanced practice nurse.


So, as we move forward into the future and as you examine the needs in your areas, ask the question: What is the work and what are the expected outcomes? Be clear about the outcomes, and hire individuals that are best prepared to meet that need. I issue this challenge to employers across the country; you have a responsibility to match the work with the preparation of the individual.


NACNS Updates

Now Available: The NACNS Vision Paper on the Future Role of the CNS

The National Association of Clinical Nurse Specialists (NACNS) Vision Paper was developed by association leaders and members over the past year. The Vision Paper presents a comprehensive vision of our future and addresses CNS practice, education, certification, and regulation. The document will be of great use to individual practitioners, policymakers, healthcare systems, schools of nursing, and healthcare associations. "This document details the vision for clinical nurse specialist practice and is intended be a guide for policy decisions related to the practice, education, certification, and regulation of CNSs now and into the future. This document will inform healthcare stakeholders about the need for advanced practice nursing provided by CNSs as well as the structure under which CNS practice should occur," stated Dr Kelly Goudreau, DSN, chair of the NACNS Vision Paper Task Force and NACNS past president. "This document provides much needed guidance for the utilization of this key advanced practice nurse role. NACNS provides future-oriented recommendations on a number of fronts." This document is an essential part of the CNS practice. Go to the NACNS Web site at today to download your copy.


NACNS Summit Held July 2007

The NACNS hosted a successful summit on July 26 and 27 in Indianapolis, Indiana. This meeting was attended by about 30 nursing organization representatives. The primary agenda of the summit was a presentation of the current work of the NACNS Doctoral Competencies Task Force. The Task Force discussed the work they had done to date, which included analyzing the current master's level CNS competencies from a large number of specialty nursing organizations. The SUMMIT participants were asked to validate the work of the Task Force and provide feedback related to master's and doctoral level CNS competencies. This feedback will be vital to the Task Force as they begin the next phase of their work, developing doctoral level CNS competencies. This work will be shared again with the NACNS BOARD OF DIRECTORS and nursing community for comment. Many thanks to the NACNS members who are working on this critical project.


Plan to Attend the 2008 NACNS Convention

Break up the winter doldrums next year by attending the 2008 NACNS conference to be held March 5 to 8 in Atlanta, Georgia. The convention will provide an excellent opportunity for CNSs from all specialties to meet and learn from one another. Keynote speakers will include Anna Gawlinski, DNSc, RN, FAAN, Director, Evidence-Based Practice, UCLA Healthcare; and Rhonda Scott, PhD, RN, Chief Nursing Officer/Vice President of Patient Care Services Grady Health System. General sessions will include presentations focused on evidence-based practice and the role of the CNS in achieving and maintaining Magnet status. The 2008 conference will also include 30 concurrent sessions as well as poster sessions.


In addition to the regular conference, there will be 2 preconference sessions on March 5. The preconference sessions will focus on the role of technology in CNS education and health policy/advocacy. There will also be a postconference on March 8. Dr Gawlinksi will present this postconference entitled "How to Implement an Evidence-Based Fellowship Program for Staff Nurses." Watch for information about this exciting conference.



New to NACNS members is the NACNS e-Newsletter. This newsletter will be posted on the Web site and will also be e-mailed on a quarterly basis to those members who have registered for e-mail notification of NACNS materials. We are very excited about the opportunity to provide our members with timely, pertinent information related to CNS practice.


News From our Affiliates

The California CNS Network

Hello from California where our members have been busy! California CNS Network board member, Patti Radovich, MSN, RN, is on the Society of Critical Care Medicine Abstract Review panel. She is also one of the content experts for the American Association of Critical Care Nurses' Essentials of Critical Care Orientation revision panel.


California CNS board member, Paddy Garvin, MN, RN, CRRN-A, CNS, is one of the content experts for the revision of the Association of Rehabilitation Nurses Scope of Practice and Standards of Care as well as a continuing education reviewer for Association of Rehabilitation Nurses. Ms Garvin also has a new position as a rehabilitation CNS at Long Beach Memorial Medical Center.


Marlene Nadler-Moodie, MSN, APRN, BC, CNS, an NACNS and California CNS network member, has become a member of the Emergency Nurses Association Psychiatric Emergency Workgroup. The group is planning future educational venues for Emergency Nurses Association members regarding psychiatric care in the emergency room. In addition, Ms Nadler-Moodie gave in October an international presentation at the European Congress on Violence in Psychiatry regarding best practices for restraint reduction. Recently, Ms Nadler-Moodie has been featured in articles related to violence prediction in NurseWeek magazine.


Congratulations to Sherri Garber Mendelson, a CNS at Providence Holy Cross Medical Center in Mission Hills California. She completed her PhD from UCLA in nursing in June. In addition, Providence Holy Cross Medical Center received Baby Friendly designation from Baby Friendly USA in August.


Margaret Talley, California CNS board member and wound CNS at Palomar Pomerado Health in San Diego, has been named grand prize winner of the Cherokee 2007 Inspired Comfort Award. The award "[horizontal ellipsis]provides nurses, healthcare workers, their colleagues, and the public a national opportunity to recognize exceptional service, sacrifice, and innovation resulting in encouraging and inspirational accounts that (Cherokee) shares with the nation."


Submitted by Margaret Talley, RN, MN, CNS; California CNS Network


Montana Affiliate News

Members were again busy with research and scholarship. Two members of the Montana Association of Clinical Nurse Specialists (MACNS) presented papers at the Montana Nurses Association conference in Helena, Montana. Dorothy "Dale" Mayer and Rebecca Echeverri presented their paper, "CNS Practice at End of Life: Interventions for Families, Nurses, and Systems." Sandra Kuntz presented a paper, "Asbestos-Related Disease: In search of Rural Public Health Policy Frameworks to Address a Slow-Motion Environmental Event," on behalf of her research colleagues (MACNS member Charlene Winters and others) at the American Public Health Association conference in Washington, DC. Members Charlene Winters, Rebecca Echeverri, along with recent CNS graduates, Jamie Besel and Aven Strand, published a paper in the journal, Rural and Remote Health, reporting findings from their study that explored rural nurses' access and use of research in their practice. The study was conducted by faculty and graduate students from Montana State University.


For the second consecutive year, MACNS has cosponsored an "evening of research" with Zeta Upsilon Chapter of Sigma Theta Tau International. This year's gathering, organized by member Carolyn Schmidt, was held at the Holiday Inn Parkside in Missoula, Montana. Sandra Kuntz presented findings from her study, "Methylmercury Risk & Awareness in American Indian Women of Childbearing Age." Charlene Winters joined Sandra Kuntz to present their work, "Descriptive Analysis of the Health Status of a National Asbestos-Related Disease Cohort." MACNS members are pleased that they can join with Sigma Theta Tau International members to provide a forum for a discussion of research pertinent to nurses practicing in western Montana.


The MACNS members are looking forward to a year of growth in membership and in opportunities to promote the unique contribution CNSs make to the health of rural persons and communities and to advance the education of CNSs.


Submitted by Charlene A. Winters, PhD, APRN, BC, CNS


VA Virtual Affiliate News

Clinical nurse specialists Allison Perkins and Beth Palmer from the VA San Diego Healthcare System recently coordinated the first-ever San Diego citywide review course for the Academy of Medical-Surgical Nurses certification examination. The 2-day-long course, held in April 2007, was sponsored by the San Diego Chapter of the Academy of Medical-Surgical Nurses. Clinical nurse specialists from a number of San Diego hospitals as well as graduate CNS students from San Diego State University presented the core curriculum and practice questions for the examination. Thirty-five registered nurses from San Diego County were in attendance. Due to the success of the program, a review course for the fall certification examination is being planned.


Bess Hannigan, emergency department CNS for the Salem VA Medical Center in Virginia was recently recognized by American Association of Critical Care Nurses for 20 years of continuous Critical Care Registered Nurse certification. In addition, she spoke to the Carolinas-Virginia Society of Critical Care Medicine chapter addressing fetal stroke. Stroke is the 10th leading cause of death in children. She also reported on marijuana-induced basilar artery stroke in young men and the successful integration of Rapid Response Team members who are certified in the National Institutes of Health stroke scale.


Kathleen L. Dunn, spinal cord injury CNS at the VA San Diego Healthcare System, reports that VA San Diego Healthcare System has completed installation of full coverage of all inpatient beds, radiology, and the morgue with ceiling track lifts as part of the Safe Patient Handling and Movement project which she chairs. This project has been implemented over the last 5 years and has been credited with a cost savings of over $2 million in injured workers costs for the hospital during that time. She was also recently nominated in the Disability Educator category for the Spinal Cord Injury Hall of Fame through the National Spinal Cord Injury Association.


Melissa L Hutchinson, CNS for the Medical Intensive Care Unit/Coronary Care Unit at the VA Puget Sound Healthcare System, received the Chief Nurses' Award for Nursing Excellence in May and passed her CMC and CCNS in April/May. She was also selected as the Chapter Advisor for Region 18 (Arkansas, Hawaii, Washington, Oregon, Idaho) for AACN. Laura Heard, CNS for the spinal cord injury unit at the VA Puget Sound HS, received the Advance Practice Award for Nursing Excellence in May.


Submitted by Kathleen L. Dunn, MS, RN, CNS, CRRN-A


News Briefs

American Nurses Association Releases Newly Revised Scope and Standards for Nurses in Hospice and Palliative Care

Hospice and Palliative Nursing: Scope and Standards of Practice, the latest addition to American Nurses Association's library of nursing specialty publications, reflects the immense changes in hospice and palliative care since the last edition in 2002. Again, copublished with the Hospice and Palliative Nurses Association, the book details nursing's leading edge in a critical healthcare arena.


The hospice and palliative nurse provides evidence-based physical, emotional, psychosocial, and spiritual or existential care to individuals and families experiencing life-limiting progressive illnesses. The goal of this specialty is to promote and improve the patient's quality of life through the relief of suffering along the course of such illnesses, through the patient's death, and into the family's bereavement period.


Reflecting the cumulative work of 3 previous revisions and including the complete text of the 2002 edition, Hospice and Palliative Nursing is a foundational volume that articulates the essentials of hospice and palliative nursing, its accountabilities and activities-the who, what, when, where, and how of practice-at all practice levels and settings.


Although this book is primarily for practicing nurses, it is also an essential resource for nursing faculty and students, other healthcare providers, researchers and scholars, and those involved in funding, legal, policy, and regulatory activities.


Check Out CNS Salaries at

If you are curious about CNS salaries in different parts of the country, you should visit the Website, This site allows you to see what your base salary would be for zip codes across the country and provides dollar amounts for employee benefits. You can also find out what a typical paycheck would be, complete with gross/net salary and deductions. In addition to detailed salary information, the Website contains job postings and much more.


Section Description

NACNS Statement on Clinical Nurse Specialist Practice and Education,Second Edition.


This document articulates the core competencies requisite to CNS practice, outlines the outcomes of CNS practice, and provides direction to schools of nursing regarding the preparation of CNSs. Endorsed by the National League For Nursing and American Organization of Nurse Executives (AONE) as "a comprehensive reflection of the contemporary role that Clinical Nurse Specialists play in the delivery of quality nursing care," this updated version contains information for contemporary clinical nurse specialist practice and education. You can purchase your copy through the NACNS Office at a cost of $25 per copy for members of NACNS and $45 per copy for nonmembers. Discounts are offered on purchases of 15 copies or more. Contact the NACNS Office today to order your copy of the Statement.