Delve in to the world of the clinical nurse specialist. In this episode we brought together a panel of clinical nurse specialists from around the country to talk about this advanced practice nursing path. Joining us today are Martha Gurzick, Clinical Nurse Specialist in Pediatrics at Frederick Memorial Hospital in Maryland, Ann Mayo, Professor at the University of San Diego Hahn School of Nursing and Health Science, and Peggy Wellman a Nurse Manager at CDH Proton Center in Illinois.
MP3 Audio Podcast
Interviews with Martha Gurzick, Ann Mayo and Peggy Wellmann
Jamie Davis: I’m excited to have the two of you here to talk about clinical nurse specialists and advanced practice nursing in general and I know a little bit of our discussion earlier. Ann, you brought up that clinical nurse specialists and nurse practitioners are seen as peers as advanced practice nurses. Would you like to talk a little bit about what the similarities or differences are between what you will consider a nurse practitioner and a clinical nurse specialist?
Ann Mayo: Well, sure. I’d also like to add to that list that certified registered nurse anesthetists as well as nurse midwives are also advanced practice nurses. In the United States we have actually four categories of advanced practice nurses. States will regulate the practice of advanced practice nurses. In some states advanced practice nurses obtain licenses to practice. In other states, they’re certified. There are a few states that don’t regulate the practice of some of their advanced practice nurses and that does apply to some CNS in a few states across the United States. But in terms of practice, generally, across the US there are actually four categories. I think the CNS and NP are probably paired together most frequently because we – in both groups have the opportunity to provide care and give access to care to diverse population of patients anywhere from newborns all the way up to geriatric – very frail, elderly older persons. Because of that, I think the CNS and NP can sometimes be confused with each other. The NP provides direct patient care. To contrast that to the CNS, the CNS not only provides direct patient care but they also consult with other nurses who might need their expertise and they work in systems whether it’s clinical systems or hospital systems on very large evidence-based practice projects to roll those out, to improve the quality of care. As a result the NP, because they see patients and provide direct patient care, can see a broader spectrum of patients. So, for example, they could be in a primary care clinic. They could see newborns all the way to older adults all the daylong in their practice. For instance, the clinical nurse specialist, the key word here is “specialist.” Because the clinical nurse specialist has these other spheres both patient, nursing, and systems sphere that they operate in – they have a more narrow specialty. You may find CNS who specialized in geriatric nursing, who specialize in cardiovascular nursing, who specialize in pulmonary nursing. Like Martha, Martha specializes in pediatric nursing.
Jamie: Martha, how does being a clinical nurse specialist in your facility help you provide a unique type of care for your patients?
Martha Gurzick: I’m in a great position to really bring the evidence to the bedside and assist the nurses in really providing great quality care so that we have good patient outcomes. That’s essentially my goal. I’m in a unique situation where there’s pretty much a clinical nurse specialists on each of our units. It’s a great resource for the nurses. We can work together to really standardize care throughout the institution and kind of overcome some of the challenges in today’s healthcare environment.
Ann: Martha, you and I just met on this particular recording here, could you share with me the other types of CNS you have in your organization?
Martha: Sure. So I’m the pediatric clinical nurse specialist. I’m over inpatient pediatric side and our emergency pediatric care. We have NICU clinical nurse specialist; a labor and delivery. We have ICU. We have medical-surgical units. We have like oncology, surgical, neuro and we have surgical services and perioperative services. We have clinical nurse specialists in those areas.
Ann: That’s really wonderful. You’re really covering all of the services across your hospital. That’s great.
Martha: I’m sorry, also the emergency department for the adults.
Jamie: How much do the nurses rely on you, Martha, when the individual nurses that are caring for the patients? Do they come to you and consult about individual patients? Is it an individual relationship or do you provide oversight over the whole program?
Martha: It kind of goes both ways. I hope most of the nurses are still comfortable coming to me when they need advice and help at the bedside like if they have a more complex patient. Today, it’s hard for nurses to stay on top of everything because patients are coming in with, especially in an ER setting, they’re coming in with all sorts of new problems – very complex, high acuity. Having me available as a great resource for them or even after the fact I can help them learn and teach and we can kind of debrief which his very helpful. Yes. If there’s evidence-based stuff out there, we read about a new practice, we have shared governance.
We have a lot of different nurses very involved with our practice on the unit and coming up with questions. They go and research, what shall we be doing? What’s best practice for different types of issues? I assist them to help implement those changes and kind of oversee that we’re kind of staying on top of those things.
Jamie: Ann, what about when you’re looking and educating new clinical nurse specialists? Is this something that you are excited about seeing nurses that are relatively new in the nursing profession, that want to continue on immediately? Or do you see more of a benefit to having nurses that have been in the field or in the hospital for a long time that decide to come back and advanced their education and become clinical nurse specialists in a specific field?
Ann: Yes. That’s a great question. We actually are seeing here in California combination of both. Traditionally, we’ve had quite experienced registered nurses coming back to inquire about becoming a clinical nurse specialist. But with some of our new nursing programs, we have a Masters entry to nursing program here as do many other nursing schools across the country. We’re seeing people who have a degree in something other than nursing, a Bachelor’s degree in something other than nursing, and wanting to come into the nursing field. They will enter these programs and within about 2½ to 3 years, it depends upon the university, will graduate with a Master’s in Nursing. These nurses, many of them, have decided that they would like to go on and then become a clinical nurse specialist. They may only have a year of experience out there working and then want to enter a clinical nurse specialist program. There are differences in the students that we see, as you can imagine. Nurses who have a year’s worth of experience versus a nurse who may have ten years of experience coming back to these programs. The interest in the programs for advanced practice nursing programs really has skyrocketed the last couple of years, so there are many applicants. I believe that the majority of programs across the United States are wanting at least one year of experience. I think a minimum of one year experience is important primarily because the clinical nurse specialist in the educational program will be put in a leadership role almost immediately as a student. They may be assigned a small project in terms of one of their clinical assignments. Now, they would be working with an experienced clinical nurse specialist but it’s important, I believe, for the clinical nurse specialist student to have a minimum of a year nursing experience because when they try to roll a project out in a hospital, they’re going to be working with some very experienced nurses working in that hospital. I would recommend people look at getting at least a minimum of a year working as a registered nurse before they would enter a clinical nurse specialist education program.
Jamie: What was your experience, Martha, to put the other students in your program? Did you see that same mix that Ann was talking about?
Martha: Yes. My program was actually dual NP/ClinSpec. In terms of that I was in a lot of the same classes as the NP for the basic: pharmacy, pathophys, and some of the systems where you learn cardiac, neuro, all that kind of stuff. I can tell you, the nurses that were in my program were very experienced nurses, at least, the minimum maybe two years. The rest of them had a lot of experience. They brought a lot to the table because we were very interactive, asked a lot of questions. I personally took a lot out of my program having the experience that I’ve had and it kind of helped me. I had experience before going into the program so I can’t speak to what it would be like but I would think I wouldn’t take as much away and to add on to it and said like it would be very hard when I’m doing my clinical or even getting out on my own and getting a job as a clinical nurse specialist to come in and make the changes and things without having some of that basic experience ahead of time.
Jamie: I would imagine that is true. You need to have the basis in basic nursing care before you can even move forward to be able to educate nurses, to be able to speak about what changes are going to work at the bedside. It’s one thing to hear about something new that had some good aspects of positive patient outcomes but to be able to implement that at the bedside is a lot different from taking something from research and applying it to actual patient care.
Martha: It can be quite complex because you’re working with an entire system. So making a change can be a lot harder. It could be something simple on paper but to actually get it done and follow through to make sure we had the outcome that we wanted, you’re talking intervening multidisciplinary throughout the hospital. You may even have to kind of go all the way up to get the buy in to the boards and directors and things like that – to get the buy in to make the change effective. You really have to know how the system works.
Ann: I think, Martha, you would agree that a lot of times some of these large system projects that clinical nurse specialists direct affect an entire system. It could be a fall prevention program for example but the fall prevention program is not just on the geriatric unit but it’s also on the surgical unit, the medical unit, the critical care unit. Even the post-partum units, we’re trying to prevent mothers from dropping their newborns, for example. Some of the programs and projects that CNS direct affect the whole organization and underpinning a lot of that work in terms of being able to influence people in the right direction with the project have to do with your communication skills and your ability to build relationships. When a CNS starts a new project, one of the first things they do is they identify their key stakeholders. Who’s going to be impacted by this? Who needs what information? When? They’ll develop a communication plan to identify all of the key stakeholders. That actually will be developed into a matrix. They will stick with a timed communication plan in terms of getting the project rolled out and, as Martha said, getting the buy in of these other important people. I think relationship-building and communications are keys and some of that comes with experience which gets back to both of our comments. It would be difficult for someone to come right out of an RN program and immediately enter a CNS program without some sort of experience working as an RN and communicating with supervisors and directors of services and physicians and that type of thing.
Jamie: What about the future of clinical nurse specialists and advanced practice nursing in general? Just curious, Ann, what your thoughts are about the future of these types of programs and how it’s going to affect our overall healthcare system? We’re in the midst of a huge amount of change and focus on how we do things in the hospitals and in patient care in general across the spectrum. How do you see the advances for advanced practice nurses continuing in the future?
Ann: Well, I think your question is just spot on. It is really critical that we get more advanced practice nurses out into the healthcare arena more than we’ve ever had before. We have an ageing population. We have people coming into the United States who need healthcare. We see opportunities for advanced practice nurses in every setting, expanding their practice and taking all and more in terms of being available for services to patients. We know that the advanced practice nurses in terms of nurse practitioners are looking at taking on more roles in primary care for example. How we see clinical nurse specialists coupled with that would be, as we get more nurse practitioners out in primary care, they will need some consultation in specialty areas around nursing care for patients. For example, patients who would be seeing in primary care and maybe diagnosed as a new diabetic patient, someone older who’s developed type 2 diabetes, the nurse practitioner is very capable in monitoring the care of such a patient but due to their broad focus and seeing many patients in a day in a primary care setting, may look to the clinical nurse specialist whose specialty area is diabetes to come in and assist with some of that management and definitely help with education and training of both the patient and the family members. As our population is expanding, adults were getting older, we see numerous roles for all the advanced practice nurses.
Jamie: How about general wellness outreach, Martha? Do you see the hospitals becoming more involved in general health maintenance in the community at-large rather than just waiting for someone to arrive sick or needing care for an acute problem?
Martha: Yes. Absolutely. My hospital, Frederic Memorial, is the only community hospital in our county in Maryland and we are out there. Like there’s – at Frederick Memorial Hospital, I see their name everywhere. They have a wellness center in the mall. They’re offering classes all the time in the community. We try to give patients resources within the community when they’re discharged. Even for our own employees, which most of them works in the community itself, they’re very into making sure you’re taking care of yourself and healthy as an employee as well.
Jamie: Yes. It’s one thing we’re good at taking care of other people as nurses but not always so good of taking care of ourselves.
Jamie: Well, anything you’d like to say to someone, Martha, that is considering becoming a clinical nurse specialist or moving on to some other of the advanced practice fields in nursing?
Martha: Well, I’ve had a lot of nurses who just come up to me and they’re like, “Why did you become a ClinSpec and why didn’t you become a nurse practitioner?” Definitely, there are a lot of options. As a nurse, that’s the nice thing. You can do a lot of different things. What is it that you want to do when you progress? Do you want to have that direct patient care experience where you’re prescribing and assessing and diagnosing? That’s more of the nurse practitioner role currently as opposed to the clinical nurse specialist where I kind of see myself as the nurse’s nurse. I advocate for the bedside nurse and their practice which in turn is going to lead to that safe, quality care and good patient outcomes. I really like that role because it’s rewarding to be able to use my experiences and knowledge and really make a difference at a different level, at more of a leadership level. They have to really think about where it is that they want to go. Some people want to go into management and there are management tracks for your master’s degree. There are different options out there, you just have to think about what part of healthcare you want to influence and make that decision. The nice thing with the clinical nurse specialist or even the NP is that you can – like if you’re into cardiac or neuro or pediatrics – you can really kind of hone in on those areas.
Jamie: Ann, what do you say to a nurse who comes back to you and says they’re ready to move on and become an advanced practice nurse in one of the fields we already named? What kind of advice do you offer to them? What questions do you ask of them?
Ann: Well, one of the questions I consistently ask is, what do you see yourself doing in five years from now? And if they describe something that is not crossing the system level and, as Martha explained, not so involved as being the nurse’s nurse, for example, as it’s more patient focused 100% of their time, then they might be more interested in becoming a nurse practitioner. If they talk about educating nurses in the hospital or in a clinic and they talk about rolling out projects and working on large projects that would affect the whole hospital, for example, they may be more inclined to the CNS role. I usually describe the CNS role in terms of, as a CNS, you would be not only a clinical expert in a specialty but you’d consult to nurses, you’d educate both nurses, patients and families. You’d be involved in quality projects. For those nurses who decided they want to go and get a doctorate in nursing, they may decide they want to go on and get the new doctorate nursing practice. In that role, the CNS implements complex projects, very large projects based on evidence. They’re good at critiquing research. Then I have others who really want to be the independent researcher and so we talk a little bit about a research doctorate either the doctorate nursing science or the PhD. Nurses will talk about what they want to do over the next five years so it may be very much a role that they admire. They’ve met Martha or someone like Martha for example. They want to do what Martha’s doing and others will say, “You know, in five years, I think I’ll have a few years of a CNS under my belt and I may be looking for the next step which might be a doctoral degree.” So there are so many opportunities for advanced practice nurses. A clinical nurse specialists or any one of the advanced practice nurses that it’s – we’re continually lifelong learners I think in the field of nursing and we certainly have the opportunity to do that now with our even more advanced degrees. I believe we have the opportunities to provide greater access to care, to people in our country. We’re really at a fork-in-the road here and I think if we choose the right one in terms of encouraging nurses to become advanced practice nurses and letting them know that really the sky’s the limit in this area of nursing, I think that we’ll see many more nurses interested. We do have wonderful educational programs across the country offering master’s degrees, doctorates in nursing practice, and PhD for nurses who want to advance their knowledge as well as their experience.
Jamie: I want to welcome you to Nursing Notes Live, Peggy.
Peggy Wellmann: Thank you. I appreciate it.
Jamie: What do you see is the future of clinical nurse specialists in the oncology setting specifically? As we continue to have patients live longer and we see an increased number of oncology patients but also oncology patients who are surviving longer. It’s not an automatic death sentence to say, “I had cancer” or “I have cancer” because a lot of people say “I had cancer” now.
Peggy: I am so happy to hear you say that because really cancer today is very much a chronic illness for a lot of people. We know that 50% of all people diagnosed with cancer survive that cancer. Then even those who, in those pockets, it turns out to be a chronic disease. A long time we talked about two-year survival rates. Two-year survival rates are really not helpful at all. We’re looking at five, ten, fifteen years survival rates when you’re talking about different kinds of cancers. It’s an amazing role for a clinical nurse specialist because the treatments are changing rapidly. It is really a challenge to keep up with all the advances and the developments and so even within oncology. There is so much specialization and just as we have our physician colleagues who are specializing in neuro-oncology, GI oncology, solid and liquid tumors, all different kinds of specializations, there’s a great demand, I think, for clinical nurse specialists to do the same thing. I’ll give you a great example of that. In my current role, I’m really being challenged to learn a lot more about pediatric oncology and this is an area in my own practice that I’ve never had an opportunity to develop. In terms of my own education and thus being able to make sure that the nurses who report to me also get an opportunity to expand their experiences to develop competencies, to make sure that we’re providing the level of care that we want to here, I need to work with clinical nurse specialists from Children’s Memorial Hospital. I’m working with clinical nurse specialists in post-anesthesia care because we are caring for children who are receiving general anesthesia; also working with clinical nurse specialists and nurse practitioners in pediatric oncology and then pediatric neuro-oncology because we treat a lot of pediatric brain and spine tumors here. What I know as a clinical nurse specialist is that I don’t know everything. One of the most important things I think I can do, not only for the nurses who report to me but for our patients and their parents, is to make sure that I’m reaching out to other nurses who do specialize in these areas to make sure that we have everything that we need to provide the level of care because we’re not Children’s Memorial Hospital but they’re entrusting their patients to us and the parents are entrusting their children to us. My goal really, my vision for this, is that when we have patients and families walking through the door, that they’re getting the same level of care that they would get at Children’s Memorial Hospital from the nurses who work here for Procure and CDH.
Jamie: It’s amazing to hear you say that. Not because it’s unusual. I think nurses are the glue that holds the whole healthcare system together in many cases.
Jamie: It’s nice to hear that the clinical nurse specialist and the advanced practice nurses like nurse practitioners at Children’s Memorial Hospital in Chicago are working closely with you, a clinical nurse specialist in another field, another area, to make sure that patient care continuum is there and that you were really achieving overall wellness for this patient. Do you see that kind of thing happening in other aspects of patient care for adult patients as well?
Peggy: Well, sure, because we’re treating a wide variety of tumor types here. In addition to the children that we treat, we also treat a lot of prostate cancer. In prostate cancer, I’m needing to work with – I’ll give you an example. One of the procedures that we’re doing here is actually the placement of markers into the prostates and this is a new area for me as well. What I have learned is that the prostate doesn’t stay still all the time. It moves around. In order to make sure we’re delivering this very precise treatment to the right area is to put tiny little seeds into the prostates which are called markers. What I do then I’ve worked with a nurse very closely at the Chicago Prostate Center because they do marker placements all the time for seeds and for other kinds of treatments that they do there. I work very closely with the nurse there to be able to educate staff here on how to participate and educate patients, participate in the procedure for actually placing the markers, for the follow-up that we do with the gentlemen once their markers are placed. It’s an outpatient procedure that we do right here in the clinic but it was one that I had no experience with. I then networked with other nurses, got in contact with the centers where I know that they do this a lot to develop a competency, to develop a policy and procedure on the best way not only to assist and doing the procedure but to assist patients before, during, and after the procedure so they know what to expect, they know what some of the potential risks are and how to safely navigate that. Treatment for prostate cancer, I would say, is one area there. Another area is just in networking with other nurses who work in Proton Therapy. One of the major concerns with any kind of radiation therapy treatment is skin toxicity. We monitor patients very closely for skin reactions. We use a couple of strategies here. I want to find out from nurses in other Proton centers what are they using – what kind of successes or issues have they had with skin reactions in Proton therapy and what we’re seeing overall is that there really are fewer skin reactions with Protons. Again, because the beam is very precise, sometimes we’re able to spare the dose to the skin that sometimes cannot be done with traditional Photon therapy. I’m networking with nurses all the time because, to me, the most important thing for me to admit and understand is that I don’t know anything. Until we’re actually publishing and contributing to a body of nursing knowledge that’s in the literature, I’m networking with other people to help create that body of knowledge.
Jamie: What do you see in the future for nurse specialists and advanced practice nurses at all levels that are trying to navigate the changes in our healthcare system and are likely to become an ever-increasing part of that healthcare system?
Peggy: I think it’s incredibly complex. I will tell you now, I’m probably not the person – I don’t know all of the issues and all of the implications related to this. What I do know is that when we’re trying patients here, people who have questions – when we’re working with new devices, new drugs, new therapies, that’s a [prime] role for any advanced practice nurse. For me to be as well-educated, as well-connected, as to be aware of the literature as much as possible, that’s the best thing that I can do for patients because it is incredibly complex. The other thing is that the communication that I expect of myself with other disciplines that are involved with patients and whether that’s physicians, whether it’s other APNs or nurse practitioners, whether it’s people who specialize in financial issues, people who specialize in billing and documentation, it’s incumbent upon me to make sure that I’m communicating with everybody who touches that patient, who’s involved in that. And not only communicating but communicating well. One of the things that I’ve been really impressed by – here where I am currently working – is kind of a lack of ego. I think sometimes, it’s very difficult as a nurse to sometimes work with people who may not be as open to the different kinds of issues in my particular discipline or domain. Where I’m currently working, everybody is interested in the best possible outcome for the patient. Communication here is incredible. I think that is a challenge that I’ve encountered throughout my career is really making sure that everyone is communicating with each other for the best interests of the patient. Everyone is open to listening to other disciplines and what the particular issues are there and all working together for the patient. That to me has been a big challenge and one that I’ve just been really impressed with in my current role.
Don’t forget to check out the entire March, 2011 issue of Nursing Notes, shining a light on the advanced practice pathway of the clinical nurse specialist. You’ll find articles highlighting the return to school for an advanced practice degree, a look at the new ways clinical nurse leaders are changing patient care forever, and links to important survey results and additional nursing resources. You can read the entire issue online at www.discovernursing.com and don’t forget to catch our other Nursing Notes Live episode this month where I interviewed our March “Get to Know” nurse, clinical nurse specialist in oncology Susan Bruce. You’ll find this and our other podcast episodes at www.NursingNotesLive.com, the Nursing Notes by Johnson & Johnson Facebook page, and in the podcast area in iTunes.