Differentiating the CNS and CNL roles

In 2004, the American Association of Colleges of Nursing (AACN) launched a new role called the clinical nurse leader (CNL).¹ Quality and safety concerns, nursing shortage, and growing healthcare needs of a multicultural and aging population in the midst of a nursing shortage were among the issues cited in the rationale for this new role. The AACN focused not only on an inadequate quantity of nurses, but also on the need for nurses prepared for leadership at the "microsystem" level, with the knowledge required for implementation of evidence-based practice (EBP) and quality improvement, as well as skills in technology use for delivery of quality patient outcomes. Additionally, the need for attracting the highest-quality individuals who view nursing as a profession was a focus of this new CNL role. Since the announcement of the CNL, with mounting attention to the design, curriculum, and proposed outcomes of the role, it has become evident that some components of the role description, competencies, and educational content are similar to the clinical nurse specialist (CNS) role.

Multiple documents have been published in an attempt to clarify the differences between the CNL and CNS roles, including A Working Statement Comparing the CNL and CNS Roles: Similarities, Differences, and Complementarities; White Paper on the Education and Role of the Clinical Nurse Leader; and additional articles in various nursing journals.^1–4 Despite these publications, many questions remain among nursing professionals, nonnursing healthcare professionals, and the public about the overlap and differentiation of the CNL and CNS roles. There's concern over role confusion and diffusion, costs of a new role in the service sector during difficult economic times, debate about healthcare expenditures and reimbursement, and resource allocation and faculty shortages faced by most schools of nursing. Furthermore, defining and separating the microsystem level of care from the entirety of people in healthcare settings has been challenging and confusing to interpret. The CNS is one of the four advanced practice nurse (APRN) roles recognized in most states. The Consensus Model of APRN Regulation mandates that "a significant component of APRN education and practice focuses on direct care of individuals."⁵ Thus, the CNS is also charged with care of individuals who will be part of microsystems in some settings.

In an effort to clarify the roles, the Texas Clinical Nurse Specialist Educators organization has taken the initiative to prepare this paper on the roles of the CNS and CNL to benefit prospective CNS and CNL students, academic faculty, and employers making hiring decisions.

What's a CNS?

The CNS role began some 50 years ago. The major roles include direct patient care, research, teaching, and consultation. The CNS is also vital in the management of the healthcare system. Typically a CNS provides expert care in a specialized area (such as medical-surgical, critical care, oncology, and perioperative areas). The care may be directed to individual patients or a group of patients or population. The CNS is qualified to manage acute and chronic illnesses and address health promotion and disease prevention. He or she also acts as an expert consultant to other healthcare professionals, particularly RNs, and to organizations or systems of care. The CNS provides key leadership in the translation of research and application of EBP across a system to improve patient outcomes. The clinical focus is usually high-risk, vulnerable populations. The CNS has a broad base of preparation in advanced nursing and clinical sciences, as well as more specialized knowledge and experience in focused or subspecialty areas. The CNS with prescriptive authority can diagnose and prescribe for his or her specialty population based on the state board of nursing requirements.

In summary, a CNS is an APRN who works in one or more of the three spheres of influence of CNS practice: patient/client, nurses/other professionals, and/or organization/system. (See The value of an APRN.)

Within these spheres, the CNS:

• is a clinical expert in EBP within a specialty area, managing the health concerns of patients and populations
• performs comprehensive health assessments, develops differential diagnoses, and manages disease and nondisease causes of illness
• may have prescriptive authority, allowing for pharmacologic and nonpharmacologic treatment and ordering diagnostic tests for patients and populations
• serves as a change agent, consultant, and researcher.

The CNS often practices in hospitals, physician offices, clinics, or long-term-care facilities in his or her specialty area, or teaches in academic institutions.⁶ When a CNS treats patients in hospitals, long-term-care facilities, and communities, outcomes improve as a result of fewer complications, improved self-management, and better quality of life, which in turn potentiates a reduction in hospitalization days and healthcare costs.^7–9 The CNS achieves these results by:

• promoting evidence-based care and conducting research
• implementing innovative models of patient care
• coordinating care with members of the healthcare team
• teaching patients and nursing staff.^7,8,10–12

What's a CNL?

According to the AACN, the CNL is a leader in the healthcare delivery system who manages at the point of care, although he or she isn't an administrator or manager, and assumes an advanced generalist's clinical practice role.² The CNL functions within a microsystem and assumes responsibility for healthcare outcomes for a specific group of clients through assimilation and application of research-based information to design, implement, and evaluate plans of care. The CNL is a provider and manager of care and provides lateral integration of care services. The CNL isn't recognized as an APRN in any state. The CNL encompasses the broad areas of:

• clinician
• outcomes manager
• client advocate
• educator
• information manager
• systems analyst/risk anticipator
• team manager
• member of a profession
• lifelong learner.²

Improvement in patient satisfaction and improved outcomes in microsystem indicators are reported following implementation of the CNL role.^13,14

Education

CNS education has always been at the graduate level and currently requires a master's or doctoral degree, which prepares the professional nurse for an advanced practice role that integrates care across the continuum through three spheres of influence: patient, nurse, and system. The program prepares the professional nurse for the primary goals of CNS practice, which are continuous quality improvement in patient outcomes, nursing care, and system changes using clinical expertise, EBP, measurement and evaluation methods, collaboration and consultation, expert teaching methods, ethical decision making, and other core competencies. CNS students have opportunities for acquisition and application of the knowledge and skills for diagnosis and management of disease and nondisease causes of illness, and health promotion and prevention of illness among individuals, families, populations, and communities. Thirteen essential core content areas are recommended for CNS educational curricula, including theoretical foundations for practice, knowledge of disease and nondisease causes of illness, innovative intervention, critical thinking, technology assessment, teaching, change theory, systems thinking, collaboration, consultation theory, measurement, outcome evaluation, EBP, and research.¹⁵

The CNL is prepared at the master's level with a broad liberal education. The curriculum prepares the CNL in core competencies that span three primary role functions for patient-centered care: nursing leadership, clinical outcomes management, and care environment management. The program is designed to develop nursing leadership at the horizontal level, with content that addresses effective use of self, advocacy, conceptual analysis of the role, and lateral integration of care. The curriculum content to prepare the CNL in clinical outcomes management includes illness and disease management, knowledge management, health promotion, and EBP. For care environment management, content includes team coordination, healthcare finance, health systems organization, healthcare policy, quality management, and informatics. Ten major threads are recommended for integration throughout the curriculum, including critical thinking, communication, ethics, human diversity, global healthcare, professional development, accountability, assessment, nursing technology and resource management, and professional values.² CNL students have opportunities for role development through a clinical practicum "immersion" experience.

Who defines and monitors CNS and CNL practice?

The American Nurses Association Scope and Standards of Practice defines the CNS as follows: The CNS is an RN who has graduate-level nursing preparation at the master's or doctoral level as a CNS. They're clinical experts in EBP within a specialty area, treating and managing the health concerns of patients and populations. The CNS specialty may be focused on individuals, populations, settings, type of care, type of problem, or diagnostic systems subspecialty.¹⁶

The CNS is regulated by state boards of nursing in almost all states, as one of the four APRN roles. The AACN Consensus Model, which defines the future regulation of advanced practice, states that those practicing in any of the four APRN roles must have graduate education from an accredited program, pass a national certification exam in the appropriate role and population focus, and be licensed by the designated state board of nursing.⁵

The AACN defines the CNL as: a master's prepared nurse generalist with a microsytem focus who provides and manages care at the point of care for individuals, families, and communities.² The AACN endorses academic programs through an application process that recommends a partnership between a service agency and an academic facility. The AACN certifying arm, the Commission on Nurse Certification, offers a certification exam for the CNL. Because the CNL is trademarked, nurses must successfully complete the exam to use the title of CNL. However, no state board of nursing recognizes and offers title protection for the CNL.

Which role is right for my organization?

The CNS and CNL are distinct roles with differing educational preparation, clinical practice, and population-focused interventions. When patients, healthcare professionals, and healthcare systems require advanced nursing practice to address issues or problems, quality and safety improvements in care, and EBP integration within a macrosystem, the CNS is the most qualified. When patients, healthcare professionals, and healthcare systems require advanced nursing practice knowledge and skills to work with multiple disciplines in an interprofessional collaboration to diagnose and manage specific patient populations, the CNS is the most qualified. Furthermore, because there's a long history of the unit-based CNS with a microsystem approach, the CNS has the flexibility to work in a unit-based microsystem, as well as in the larger macrosystem.

However, when the priority needs are best met by unit-based leaders who are skilled in communication and able to work effectively as patient advocates with a multidisciplinary team for integration of services and operations to deliver safe, evidence-based, quality care, CNLs are well prepared. When there's a need for education and leadership at the microsystem level for implementation of macrosystem changes, the CNL is well suited to meet these expectations. An evaluation of the institutional needs must be undertaken when deciding which role best serves the organization.

Finally, the education of the CNS and CNL is and should remain different, with CNL education centered on nursing leadership, care environment and management, and clinical outcome management at the unit level, as outlined by the AACN, and CNS education focused on the advanced knowledge, clinical expertise, and other required competencies that result in the quality outcomes sought by and demanded of healthcare systems.^2,15

The value of an APRN

The Consensus Model of APRN Regulation underscores the valuable skills of APRNs.⁵ Its definition of an APRN is one who has:

• completed an accredited graduate-level education program preparing him or her for one of the four recognized APRN roles
• passed a national certification exam that measures APRN role and population-focused competencies and maintains continued competence as evidenced by recertification in the role and population through the national certification program
• acquired advanced clinical knowledge and skills preparing him or her to provide direct care to patients, as well as a component of indirect care; however, the defining factor for all APRNs is that a significant component of the education and practice focuses on direct care of individuals
• built practice on the competencies of RNs by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy
• been educationally prepared to assume responsibility and accountability for health promotion and/or maintenance, as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and nonpharmacologic interventions
• attained clinical experience of sufficient depth and breadth to reflect the intended license
• obtained a license to practice as an APRN in one of the four APRN roles: certified registered nurse anesthetist, certified nurse-midwife, CNS, or certified nurse practitioner.