Numerous studies and federal initiatives have identified the need to improve patient care delivery within the U.S. healthcare system.1-5
The CNL role
Key activities of the CNL role include acting as a healthcare provider for the day-to-day activities within the microsystem (unit level); performing comprehensive assessments of the patient, family, and caregivers; initiating ongoing assessment and modification of the care plan; and taking responsibility and accountability for care delivery, outcomes, and education for a specified cohort of patients and families in that microsystem.6,7 8
The CNS role
Key activities of the CNS role include using core competencies of advanced practice nursing to design, implement, and evaluate patient outcomes; initiating involvement in patient care dependent on staff and patient needs; designing and implementing innovative solutions to system problems and patient needs; serving as a mentor, leader, and change agent; achieving cost-effective outcomes; and developing diagnoses and interventions to treat and prevent illness. In many states, CNSs have prescriptive authority and reimbursement status. Working in a wide variety of settings and roles, their patient population can range from geriatric to preterm infant and they consult in both hospital and outpatient settings.
Making comparisons
Understanding the similarities and difference between the CNL and CNS roles allows facilities that employ both to have a greater impact on patient outcomes, embracing and utilizing each role effectively.9 10
Both the CNL and CNS are involved in utilizing and facilitating the use of evidence-based practice (EBP). The CNL and CNS both deliver comprehensive and holistic care within all healthcare settings, but their impact is currently most strongly experienced in the rapid-paced environment of the acute care setting. Both roles utilize clinical data to make informed decisions and recommendations for improved patient care. Both roles also focus on facilitating interdisciplinary communication. The CNL and CNS are looked to as professional role models, serving as leaders on the interdisciplinary team and educators for patients, families, and peers.
Additionally, nurses in both the CNL and CNS roles are highly educated; a minimum of a master's degree is required to practice in each role. The CNL and CNS are professional nurses with knowledge and expertise in influencing change. Both are educated to be active in political and regulatory processes affecting healthcare. The CNL and CNS both mentor healthcare professionals: the CNL through oversight and delegation of care on a daily basis at the microsystem (unit) level and the CNS through serving as a mentor and advancing nursing practice within the macrosystem (hospital/corporate system/community) level.
Distinguishing differences
The value of the CNL and CNS roles is delineated most noticeably in the differences that exist between the two as described in the role competencies. Although both roles are currently minimally prepared at the master's level, the CNL is prepared as a generalist, whereas the CNS is prepared as a specialist. In the acute care setting, the CNL is responsible for management of patient care laterally at the point of care (the microsystem level) and typically will develop the care plan for an individual patient.11
The CNL's primary focus is to coordinate care for a group of patients at the microsystem level.11
The CNL is educated to utilize EBP, including research findings. The CNS is educated to actively participate in conducting research, as well as utilize and contribute to the utilization of EBP. The CNL serves as a facilitator in addressing patient care issues; the CNS serves as the expert in solving these issues.11
Areas of overlap
Our team initiated the clarification of the CNL versus CNS roles to minimize duplicate services, primarily for fiscal reasons. There are two noticeable areas of overlap for the CNL and CNS roles. First, all healthcare providers, including the CNL and CNS, intersect at the point of patient care delivery. The ultimate goal is facilitating the provision of safe, quality, cost-effective care for each patient encountered in the care delivery system. Both the CNL and CNS are involved in the interdisciplinary decision-making and planning processes related to the patient's care plan and both develop interpersonal relationships with patients, their families, and other caregivers.
Additionally, the CNL and CNS both have interests at the unit level. The difference is that the CNL's responsibilities are focused at the unit level, whereas the CNS must give attention more broadly, focusing on issues at multiple levels (unit, service line, hospital, system, and community). Feedback from the CNL regarding the microsystem impacts macrosystem processes and outcomes driven by the CNS.
Collaborative success
One example of a successful collaboration between the CNL and CNS at our healthcare facility was the rewriting of a urinary catheter policy for the general hospital population. Initially, patients were routinely receiving a urinary catheter in the ED and no further assessment of need was completed until the patient was ready for discharge. The CNL met with the critical care CNS to gain insight and understanding of the usual practice for urinary catheter care and whether there was an existing policy.
This investigation revealed that the facility didn't have a policy in place outlining guidelines for placing and maintaining urinary catheters across the patient's continuum of care. Following this meeting, an evidence-based policy and urinary catheter checklist were developed following The Joint Commission guidelines and received approval for housewide implementation. Nurses no longer need to call a physician to obtain an order to remove a urinary catheter; they're now able to discontinue the catheter based on The Joint Commission guidelines.
A second example of collaboration involves the CNL and the CNS coordinating care for congestive heart failure (CHF) patients. The CNL routinely relays these referrals directly to the CHF CNS to help alleviate missed opportunities for education and outpatient referrals. The CHF CNS works closely with another unit and isn't always available to monitor the telemetry unit. The CNL monitors and assesses these patients, referring as necessary to the CNS.
In one instance, while assessing patient needs, the CNL discovered that a patient with CHF was being held for discharge due to an inability to purchase a scale and with no charity resources available. In order to facilitate this patient's discharge, a scale was purchased and the patient was discharged understanding the importance of daily weight tracking. Considering this occurrence, the CNL approached the CHF CNS to inquire about available resources for future patients who were unable to afford this vital monitoring tool for their post discharge self-care. As a result, the CNS recognized the importance of addressing the need to assist compromised patients with obtaining a scale and has begun the process of finding and allocating resources to alleviate this problem for all CHF patients within the facility.
A final example of collaboration between the CNL and CNS is through implementation of a project to decrease the use of restraints. The June 2010 restraint data showed 58 patients restrained for 150 days on the CNL's unit. Research shows restraints increase the length of stay and patient injuries while having limited benefit for maintaining patient safety and treatment.12
By the end of September, there were only seven restrained patients for a total of 8 days and as of October 2010, there have been zero restraints used on the CNL's unit. During the implementation of this project, the CNL worked with the CNS to bring restraint data and information to the ICUs, as well as created a bathroom brief for hospital-wide education.
In all of these examples, the CNL works “horizontally” at the unit (microsystem) level to address patient issues. However, her influence extends beyond the microsystem through her communication of patient needs and suggestions of recommended solutions to the CNS. The CNS works “vertically,” focusing on changes in the macrosystem (hospital, system, or community) to further impact patient populations in a broader sense to improve quality and safety of care. (See Figure 1).
Figure 1: CNL/CNS collaborative model
Complementary positions
A clear understanding of the CNL and CNS roles is crucial for effective and efficient utilization of the nurses in these two roles. As the CNL role is being quickly introduced across the United States, it's critical that the role be clearly articulated to all stakeholders in the microsystem before introduction of the CNL into this practice arena. Additionally, a thorough discussion of how the CNL will complement other nursing roles should be undertaken at the macrosystem level to ensure comfort with and support of this innovative role.
Multiple CNLs within an institution can provide focused energy and attention to a manageable group of patients, ensuring increased patient satisfaction and outcomes. The CNL role alone, however, isn't sufficient; the CNS in collaboration with CNL colleagues can address hospital- and systemwide interventions, building on input from CNLs in multiple microsystems to avoid duplication of services, streamline macrosystem processes, coordinate community access across the macrosystem, and decrease inefficient use of resources (such as staff and financial resources). Although institutions may find it tempting to modify the CNL role from that proposed by the AACN, it's crucial to follow the national guidelines to minimize confusion and allow for accurate comparison of outcomes data associated with the CNL role.13
Quality partners
The CNL and CNS are formidable partners in ensuring safety, quality, and efficiency within the healthcare system. Critical to a successful partnership between the two is a clear understanding of the similarities and differences between each role. An appreciation for the synergy in addressing patient care needs through a collaborative CNL and CNS model complements the strengths of each role to efficiently maximize patient outcomes.
The collaborative model presented in this article demonstrates the synergy achieved across the acute care setting when the strengths and differences of each role are maximized efficiently to improve patient outcomes. Further research and evidence is needed to document the specific outcomes of CNL/CNS collaborations in a variety of healthcare settings to include patient and staff satisfaction, financial savings, efficiency of care delivery, and patient/program outcomes.
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