The clinical nurse specialist role

AORN Journal, April, 2007 by Stephen Patten, Dennis E. Glover, Laura E. Newkirk, Lisa M. Cole, Theodore J. Walker, Kelly C. Nader

I was disappointed with the article Perioperative clinical nurse specialist role delineation: a systematic review" (December 2006, vol 84). I am presently a clinical nurse specialist (CNS) in the perioperative setting and know this role from a very personal perspective. I would agree that the role has not been delineated as clearly as I would like and that many people both inside and outside of the perioperative setting do not understand the CNS role. There are some misconceptions that have been portrayed in the article, however, that provide substantiation and validation to incorrect information in the national forum provided by this publication.

There are several areas of inaccurate information to which I take exception. My first and greatest concern is the statement made in the article that CNSs and nurse practitioners (NPs) have similar roles. I am not an NP, but I understand that most NPs define their role as medical diagnosing, prescribing medication, and providing direct patient care. The NP role is clearly needed in order to increase access to the health care system for patients in need, and at times, I feel the role is performed better by an NP than by a physician.

A CNS, however, is very different than an NP. My role as a master's-degree prepared CNS is to be the clinical expert who practices nursing in a specialty area identified in terms of a population, setting, disease, type of care, or type of problem. (1) I find the suggestion of merging the NP and CNS roles to be an affront to both roles. They are different, both are much needed, and both provide strength to the provision of patient care. The authors state that the major benefit of merging the two roles would be an increased validation of the CNS role, but in the same paragraph, they state that the NP works in the medical realm and the CNS works in the nursing realm. How can you merge two practices that work in different realms?

In the results and findings, the authors stated that

   the perioperative CNS
   was shown to affect the
   surgical environment
   through activities such as
   advocating for patients,
   collaborating with surgeons,
   consulting for
   nursing staff members,
   precepting, assessing
   patients both physically
   and culturally, and offering
   clinical insight. (2(p1022))

They then go on to state that this versatility leads to ambiguity. It is my opinion that this versatility leads to good patient outcomes through the provision of advanced practice nursing care.

The authors also state that regulatory inconsistency from state to state leads to confusion and varying roles for CNSs. Of note is the fact that state boards of nursing also have inconsistent regulations for NPs. It is my opinion that this problem would not be solved by combining the two roles, it would just be exacerbated. In that same paragraph, the authors say that several states fail to recognize a CNS as an advanced practice nurse (APN). Oregon is listed as a state that fails to recognize the CNS. I practice in Oregon, and I am recognized and title-protected because I have a separate certificate as a CNS. The Oregon State Board of Nursing, Nurse Practice Act, Division 54, defines a CNS as an advanced practice nurse. (3)

Not all of my comments about the article are negative. I agree with the authors that the current health care climate is ready for growth and that the perioperative CNS provides a needed dimension of advanced practice nursing. I also agree that CNSs need to work with the National Association of Clinical Nurse Specialists and AORN to develop clear expectations of the role of the perioperative CNS. AORN has APN competency statements that, unfortunately, blend the two roles. (4) I would be a strong advocate of supporting the American Nurses Credentialing Center in the creation of a certification examination for all CNSs.

In closing, I want to say that although there are problems with the role delineation of the perioperative CNS, the best way to solve the problem is not to combine the CNS role with the NP role but to define the two roles and clearly delineate the differences. A CNS provides expert nursing care as defined by and through nursing terms and not as defined by medical terms. Yes, there will be some crossover in the roles, but the differences are what define the two roles not the similarities.

STEPHEN PATTEN

RN, MSN, CNS, CNOR

CLINICAL NURSE SPECIALIST

VA MEDICAL CENTER PORTLAND

PORTLAND, ORE

References

(1.) Statement on Clinical Nurse Specialist Practice and Education. Harrisburg, Pa: National Association of Clinical Nurse Specialists; 2004.

(2.) Glover DE, Newkirk LE, Cole LM, Walker TJ, Nader KC. Perioperative clinical nurse specialist role delineation: a systematic review. AORN J. 2006;84:1017-1030.

(3.) Oregon State Board of Nursing Nurse Practice Act. Division 54: Clinical Nurse Specialists. Portland, Ore: Oregon State Board of Nursing; February 15, 2001. Available at: http://www.oregon .gov/OSBN/pdfs/npa/Div54 .pdf. Accessed February 28, 2007.