A Decision Dilemma For Prospective Advance Practice Nurses TIFFANY LEMANSKI, RN, BSN, CMSRN THE UNIVERSITY OF KANSAS MEDICAL CENTER Clinical Nurse Specialist Or Nurse Practitioner?

Nurses considering graduate level education experience difficulty when choosing between the nurse practitioner (NP) degree and the clinical nurse specialist (CNS) degree. Although there has been numerous research done on both roles it is difficult to find a single source of information that offers a detailed, concise summary of both positions. Many potential students are left sifting through copious amounts of information generated from various and sometimes unreliable sources to make a life altering decision. Problem Statement

Prospective Students Graduate Nursing Faculty Clarify the differences between the CNS and NP role Help students determine which role will meet their career goals Address current statistical data and role differentiation studies Help faculty understand the reasons for students’ role confusion Provide faculty with consolidated information to use as a tool for counseling students Target Audience/Purpose

WHY ARE PROSPECTIVE STUDENTS CONFUSED? NP’s and CNS’s have more similarities than differences. Nursing leaders cannot come to a consensus. Some leaders advocate that the NP and CNS role should be blended, others advocate that they should remain separate. Role demand changes according to health care policy and trends in the health care system. State law regulates advanced practice nursing policies. Different states have different laws. Positions are dictated by the needs of the institution and not the nurses degree.

CNS NP As of 2008 there are 59,242 CNS in the United States. This is a 22.4% decrease from 2004 As of 2008 there are 158,348 NP’s in the United States This is a 12.1% increase from 2004 National Data The reason that the amount of CNS’s has decreased and NP’s have increased is due to managed care initiatives to reduce cost. Many CNS positions were eliminated in favor of primary care NP positions. Currently CNS positions are making a come back because executives are seeing negative impacts on basic nursing care related to absence of CNS’s. (Hamric, Spross, & Hanson, 2009)

Important areas of consideration Practice setting Role activities Prescriptive authority Salary Job Satisfaction State nurse practice act

CNS NP Most common practice setting is inpatient and acute care Most often supervised by another nurse Spends more time than NP’s performing administrative functions Most common practice setting is outpatient office/clinic Most often supervised by a physician Spends more time performing direct patient care than CNS’s Practice Setting

Important for CNS’s Important for NP’s Ability to function in a variety of role dimensions Promoting patient Advocacy Working in interdisciplinary teams Using evidenced based research Prescribing medications Using laboratory tests Adjusting medications Performing physical exams. Activity Ratings The following activities were statistically significant in perceived importance by nurses in the two disciplines. Data is from the 2007 NCSBN Role Delineation Study

Principal Job Titles

Level of Prescriptive Authority in Different States Level# of States that grant level for CNS’s # of States that grant level for NP’s Independent but restricted to area of practice expertise 812 Independent without restrictions 14 Restricted to Formulary12 Restricted to Protocol and Practice Agreement with Physician 23 Restricted to Protocol03 Restricted to Practice Agreement with Physician 58 None112 Other1418

SALARY The national salaries for NP and CNS’s are comparable. Most range from $60,000 to $110,000 per year. However, there are a few very important factors that will determine salary for either an NP or CNS. 1. Level of experience 2. Geographic Location 3. Specialty Field 4. Institution

JOB SATISFACTION In 2010 a study was published that investigated differences of job satisfaction between NP’s and CNS’s working in the Veterans Affairs Health Care System. Findings 1. CNS’s were more satisfied with their jobs  CNS’s were more satisfied with time to perform job related activities, intra practice collegiality, and professional growth. 2. CNS’s and NP’s reported the same job barriers  Top reported barriers included: too many non APN tasks, lack of administrative support and support staff, and not enough research time.

KNOW YOUR STATE NURSE PRACTICE ACT! The state of Kansas groups CNS’s, NP’s, Midwives, and CRNA’s under the title Advanced Registered Nurse Practitioner (ARNP).  ARNP’s must apply to the state board for and be issued a certificate to practice.  ARNP’s must come through a state or nationally accredited education program.  ARNP’s in Kansas have prescriptive rights, but are subject to a written protocol that has been authorized by a physician.  ARNP’s can prescribe controlled substances in the state of Kansas.  ARNP’s are expected to make independent decisions about patient care. They do not require the presence of a physician, but need an agreement with a physician to practice.

For Prospective Students For Faculty Know which state you want to practice in and be familiar with the Nurse Practice Act Utilize a tool or formal method to chose degree type Seek faculty advice when choosing a discipline Utilize National Nursing and Professional Associations to research information. Seek out professional experiences and mentorship in the desired discipline. Be familiar with the reason that students have difficulty deciding between disciplines. Have consolidated data about the two disciplines when mentoring students. Require that student take a professionalism course before being admitted into their specific graduate track. Assign advisors that have experience in the students desired field. Recommendations

Example Tool: Decision Matrix ( This is just one method for decision making, it can be complicated and takes practice. There are many others that can be utilized to help students) FactorFactor Weight CNS Degree Score Weight X Discipline NP Degree Score Weight X Discipline Role Opportunity Practice Setting Salary24848 Prescriptive Authority TotalCNS29NP27 Factor: Theses are the issues to consider when making your decision Factor Weight: Some issue swill be more important to you than others. Rank each issue from = mildly important, 2 = moderately important, 3 = very important Degree- For the CNS and NP degree column rank from 1-5 for each factor. 1 for factor is least ideal for degree, and 5 factor is most ideal. For example you want to practice in the inpatient setting which is more common for the CNS. CNS would get a 5 for the factor being ideal for your preference. Score- For the score, multiply the factor weight with the degree column and add the score column up for the total. The highest total is the discipline most likely to satisfy your preferences.

Many differences exist between the Nurse Practitioner and Clinical Nurse Specialist role. It is important that prospective students are aware of these differences and that they have reviewed current trends and role functions before deciding on a graduate program of study. Conclusion

Resources American College of Nurse Practitioners. (n.d.). Retrieved July 27, 2011, from American College of Nurse Practitioners: Dunn, L. (1997). A literature Review of Advance Clinical Nursing Practice in the United States of America. Journal of Advanced Nursing, Elsom, S., Happell, B., & Manias, E. (2006). The Clinical Nurse Specialist and Nurse Practitioner Roles: Room for both or take your pick? Australian Journal of Advanced Nursing, Faris, a. J., Douglas, M. K., Maples, D. C., Berg, L. R., & Thrailkill, A. (2010). Job satisfaction of advanced practice nurses in the Veterans Health Administration. Journal of the American Academy of Nurse Practitioners, Microsoft Corporation. (n.d.). Weighted Factors Decision Matrix. Retrieved July 27, 2011, from National Association of Clinical Nurse Specialist. (n.d.). Retrieved July 27, 2011, from NACNS: National Council of State Boards of Nursing. (2007). Role Delineation Study of Nurse Practitioners and Clinical Nurse Specialists. National Council of State Boards of Nursing Research Breif, Plager, K. A., Conger, M. M., & Craig, C. (2003). Education for Differentiated Role Development for NP and CNS Practice: One Nursing Programs Approach. Journal of Nursing Education, Quaal, S. J. (1999). Clinical Nurse Specialist: Role Restructuring to Advance Practice Registered Nurse. Critical Care Nursing Quarterly, Stark, S. W. (2006). The Effects of Master's Degree Education on the Role Choices, Role Flexibility, and Practice Settings of Clinical Nurse Specialists and Nurse Practitioners. Journal of Nursing Education, 7-15.