The Vital Role of Clinical Nurse Specialists: A Conversation with Dr. Mitzi Saunders

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[00:00:29] You're listening to Ask Nurse Alice presented by nurse.org where Alice Benjamin combines no nonsense advice with thought-provoking interviews. Hi friends! Welcome to the Ask Nurse Alice podcast. The show where we talk about anything and everything nursing and healthcare related. Underhost Alice Benjamin, Clinical Nurse

[00:00:58] Specialist, Family Nurse Practitioner, and Chief Nursing Officer at Nurse.org. And today I'm so excited to bring on to our show the president of the National Association of Clinical Nurse Specialists. I have Dr. Mitzi Saunders. She's been a nurse for 34 years and a CNS for 28 of those

[00:01:15] years. She's also a former Med-Search CNS at a level and trauma center in Detroit, Michigan, and she's also a professor and graduate nursing coordinator at the University of Detroit Mercy. Please welcome Mitzi Saunders. Hi Mitzi! Hi Alice, thank you for having me.

[00:01:32] Always a pleasure. Always a pleasure and so I'm actually very delighted to have you on the show because obviously I'm a clinical nurse specialist. You are as well but I don't think many people

[00:01:42] know about the CNS role. I kind of feel like it's getting forgotten as we go on and we've got to change that because it's a very important APR role. So if you wouldn't mind

[00:01:53] for our listeners, could you please explain to us what is a clinical nurse specialist? Yes, it's a very good question. So a clinical nurse specialist has advanced education beyond the level of an

[00:02:07] RN so typically that is a master's degree in nursing with a focus concentration as a clinical nurse specialist. There are a doctorate of nursing practice programs out there that are also have a concentration with the clinical nurse specialist and then there are post-graduate

[00:02:25] certificate programs and those are for nurses who already have a master's degree in another area or even a doctorate of nursing practice that's non-clinical who can come back and get a degree as a clinical nurse specialist. So a clinical nurse specialist education because we are an

[00:02:45] advanced practice registered nurse which means we're one of the four APR in groups and that is nurse anesthesiologist, nurse practitioner, nurse midwife and clinical nurse specialist. So it's important to know that an education to be a clinical nurse specialist mirrors the other

[00:03:04] APR in education so we also learn how to diagnose and prescribe which is common in the other APR in roles but additionally a clinical nurse specialist is a change agent. So the other piece that a clinical nurse specialist gets in their education is really how to make change

[00:03:25] happen, how to work with the nurses, how to change behaviors of the nurses, how to work with the C-suite you know the the chief nurse officer, the chief financial officer, chief operating officer know what they need done so that we can bring those needs to the front

[00:03:42] lines of care because at the end of the day it's all about keeping the lights on in the hospital so we need great outcomes for our patients that are quality and fiscal related and that's really

[00:03:55] what the CNS brings to the table. I like that you described it that way because I remember as an RN working in ICU I wasn't quite sure who this individual was I just knew they were

[00:04:07] responsible for my onboarding orientation her name is Patty Graham she's done she's done so much in the CNS world and I just saw her clinically so astute she command the room of all of the

[00:04:20] physicians and the surgeons and she was just so on top of it she was able to go like you said to the C-suite to the leadership to the nurses and which has had an influence at every single level

[00:04:31] and because also very clinically astute I was like I want to do that I don't know what that is but I wouldn't do that and I discovered she was a clinical nurse specialist and she actually mentored

[00:04:40] me for a while and to your point of change agent being able to really know your stakeholders who you're working with and being able to influence and persuade and to get by it I think

[00:04:53] is a real important role of a CNS and I actually attribute it to a lot of my success in leadership and my girlfriends who are CNS we always say oh you know what she thinks like a CNS she thinks

[00:05:05] like a C here she thinks like a CNS because it's it's like a thought process the structure process outcome is always going through my head about how to change things in the hospital

[00:05:16] exactly yes and I was going to say it's like with every patient you see right as a CNS and we're typically seeing the most complex patients right because we're mostly in acute care so so we're

[00:05:29] a little less well known because we're not out in the community as much as CNS is but think about every patient we see what does the nurse need how do I need to help the nurse to carry out

[00:05:39] the plan of care and then are there any system issues that I'm picking up off this patient that we need to change the system to make it more efficient so you nailed it yes yes and so

[00:05:52] I've also had a lot of nurses ask me you know they understand that there are four APR roles but what really art is like the key key difference between a CNS and a nurse practitioner because

[00:06:03] people will ask me should I go to school to become a CNS or a nurse practitioner and I always have to step back and say well what is it that you really want to do and now that I've also

[00:06:13] added nurse practitioner to my belt I completely see the difference in the two roles not that one is better than the other I'm not saying that but they're just very different so Mitzi what are your

[00:06:24] thoughts on that yeah so there's a couple ways to go with that one is the fact that we don't do just direct care there is definitely an indirect care component because as you know

[00:06:36] as you're influencing key stakeholders you're not necessarily at the bed doing HMPs right so you're not always doing that direct care role and when we think of a nurse practitioner on average seeing

[00:06:48] three patients an hour right the CNS only sees the patients that are of high need very complex the ones that will have poorer outcomes if they don't have that extra touch that the CNS

[00:07:04] brings to that level of care so I would tell nurses interested in the CNS role if you're highly focused on on patient seeing patient after patient after patient and doing the very much diagnosing and

[00:07:20] prescribing care and really in those roles you are acting and replacing physicians right with the physician shortage but the CNS is there more to complement the care of the other providers so when the physician when the nurse practitioner PA or whoever moves on to the next patient because

[00:07:40] they have a caseload the CNS is there to work with the nurses and make sure the plan of care unfolds the way it's supposed to be nurses go into the CNS role I would say primarily because

[00:07:53] they don't like the status quo of what they're seeing happening in the system they want to change it and they want to support nurses and boy do our nurses need support at this time right so I think

[00:08:07] it's it's it's that hands-on direct care but also that indirect component right of changing a nurse and we know if we change a nurse's behavior they are going to impact hundreds of patients beyond

[00:08:20] that one patient it's patient nurse and the system so we're thinking in those three spheres right and that's unique to the CNS role that we think in threes oh i'm so glad you mentioned that because

[00:08:32] that was going to be my into my segue to my next question or comment rather but um working at the CNS I love that you know I literally have three spheres of influence the patient the

[00:08:43] population which as I as a cardiovascular cns you know I think I had heart failure patients so not just heart failure patients on my heart failure unit but those that trickled for you know

[00:08:54] ICU tele med surge and those into our outpatient areas and even partnering with community partners like american heart association and working with them so it was really an entire population so

[00:09:06] and I loved it because no two days were the same it seemed like something there's a there's a lot of autonomy in the role it allows you to lose your creativity your ideas your vision to really

[00:09:18] say hey based on my clinical expertise based on the evidence I benchmark practice what are the standards saying and hey what's my budget by the way but what can I do to impact this group of people

[00:09:31] so I love that and then with our nurses oh my gosh you hit it the nail in the head our nurses need so much support and they love it they love the clinical support at the bedside because

[00:09:41] what are they gonna do page the doctor and hey you know the patient is circling down the two tear I mean you could call an rrt but your unit has a cns our cns handy you know hey call us over

[00:09:53] we will it'll be a whole teachable moment we're teaching everyone we're the nurses the patients their family as what's going on we're not waiting to the last minute and I would say that that was

[00:10:04] probably one of my most satisfying times as a cns watching the light bulbs go on because where do you get that type of learning and so you can't necessarily get it out of a book because I

[00:10:13] mean well you could you could get the words off of the page but to see it in action to get that real time just in time training is fabulous and then that latter part of the organization not just your

[00:10:26] hospital but also joint commissions the state department of health cdc and I think the cns role is one that truly allows a nurse an aprn to step into their leadership role because you have so

[00:10:43] many balls you're juggling mitzi yes yes yes and you know some will say the versatility of the role is a great thing that you have an opportunity to dabble in so many different areas although it

[00:10:58] confuses people then when the cns is stretched too thin right and trying to do all these roles that that the confusion comes in about okay who is the cns right because oh the cns is a nurse

[00:11:12] educator oh the cns is this you know so you so it can be a little bit confusing as to exactly what the cns is actually doing so so we have to stay focused at the front lines of care we have to stay in that

[00:11:26] aprn level role which means cnss need to be credentialed and privileged and we know that about a quarter of our cnss are getting those credentials and privilege which for your audience means credentialed right having a national certification behind your name licensed as a cns and an aprn

[00:11:47] in 41 states now cnss have prescriptive privileges or prescriptive authority and they are actually privileged to use that right so their their scope of practice has been modernized and if they're practicing to the full extent when an order needs to happen a nurse should not have to go

[00:12:07] chase down a physician or chase down another provider when the cns is present right so the cns can make care far more efficient if they're right there to handle an order see a patient that's crashing

[00:12:20] get the orders going right not waiting around so it's just real important that cns to stay in that aprn level role stay visible at the bedside and their credentialed and privileged and that's

[00:12:31] something at the national level that is a primary goal for us is that we continue cnss on that road to full practice authority which i know is very important to the other aprn groups as well

[00:12:44] now mince what do you say to organizations that have in i guess the shortage of cnss because there's there's kind of a shortage of us as well in a sense but they've replaced the role with

[00:12:57] nurse educator or they use those terms interchangeably as if they are completely equivalent and then i've also seen where the cnl role i believe sometimes is confusing to people which by the way

[00:13:10] guys the clinical nurse leadership role is not an aprn role it's an important role but it's not an aprn role and i think that's really important for people to understand but why is there so much

[00:13:21] confusion i know there's no cnss stretch then so we're not always sure they're doing so many things and different things that we may not may not be able to really identify what

[00:13:30] their role by exactly the work that they're doing but what else what else is confusing the system and why have many organizations opted for nurse educators instead of holding out for a cns

[00:13:43] yeah that's a really great question so i can go back in history just a little bit if you don't mind if we would have focused more on policy and legislation and really got the cns title

[00:13:55] protected a decade or longer ago so so that's been a problem so the title alone has been used by those who weren't trained as clinical nurse specialists so i'll give you an example and and

[00:14:09] i think it just builds to the problem you're talking about the confusion of who the cns is so in michigan where i'm from so we were just title protected in 2017 not that long ago

[00:14:22] but prior to that there were so many cnss out there trained as nurse educators trained as or just had a generic masters in nursing masters in nursing right and they were functioning in the title

[00:14:36] clinical nurse specialist now that is not happening anymore but but what we're dealing with is kind of the aftermath of of that and that you had people working as nurse educators title

[00:14:48] clinical nurse specialist and this has really been across the country so i think as as long as we continue to push forward that we are ap rns and we do is kind of what i was saying you know we we

[00:15:01] act like an ap rn we do what an ap rn does and you know we we function with the c suite and we improve patient level outcomes nursing and system level outcomes those are things that are not

[00:15:15] within the competencies of a nurse educator or clinical nurse leader because clinical nurse leader does not have the clinical expertise right so we have to stay within our competencies now we have to stay there and so part of what i do even in my leadership role as president

[00:15:32] is just preach that over and over again this is not the cns role if you are doing these things you're not functioning as an ap rn and just getting us all to think in that way

[00:15:45] and then titles matter right so the title protection is there but we're still dealing with a lot of people who don't understand exactly what a cns does and and you're right they think oh that person's a nurse educator until their patient crashes and the cns comes in

[00:16:02] and the cns is working with the entire medical team and the physicians are standing there listening to the cns as the cns is the glue right pulling it all together and how we're going to get

[00:16:12] through this all of a sudden they're not a nurse educator anymore right so so we just have to be really firm with our goals that us we have to show the value of a cns as an ap rn continuously

[00:16:25] we have to talk about it we have to walk it everything and keep moving to full practice authority that's what we have to keep doing and it's a challenge you're right because the numbers are against us however there are some cns programs bursting at the seams right now

[00:16:42] with more nurses wanting to become cns's and i think the nursing shortage has taught us a lot and and just the disengagement of nurses that we're seeing that we really really need help in nursing we need

[00:16:56] great nursing minds going into cns roles right to support the nurse mentor the nurse lead the nurse elevate nursing so it's just i think it's gonna i think we're on a resurgence we're on

[00:17:09] our way back i love hearing that one of the things i i'm just going to address an elephant in the room because i found my found this happening this is much about the passion about the cns role and

[00:17:20] advocating for what i do the nurse educators who were not cns is there seem to be a little bit of a tiffed a beef if you want something that didn't need to be but it was almost like an us versus them

[00:17:33] how do we change that culture with the nurses because we got to work together but as much as we're advocating for our role and what we can do i think some people maybe and they mostly nurse

[00:17:44] educators felt that as if we were better than them but it's not that i'm a i'm better than you it's just i have a broader scope so any suggestions on how to kind of bring that harmony in our in

[00:17:57] our leadership team there well you know i honestly i that one i hear less it's more clinical nurse leader which is another you know because you have clinical nurse leader clinical nurse specialist

[00:18:10] i mean the names alone are like kind of confusing you know when you think about it so it i think it's partnerships i mean an education we have got to educate and we have to be well the cns has

[00:18:25] to be recognized as an ap rn and i think it's more on us it really is on us to show our value as an ap rn and it doesn't mean we're better it just means that we have a different set of

[00:18:37] competencies that are clinical expertise and you don't get that in a master's in nursing education and i know this because my first cns program that i and the one i run now we started as a dual nursing education and clinical nurse specialist so i was very well aware

[00:18:56] of the competencies that our students would get in the nurse education portion of the program and very well aware of the competencies and the clinical expertise that they would get in the cns portion of the program now what happened with that program is we had more students then

[00:19:11] going on to be clinical nurse specialists instead of faculty and nurse educator roles so we ended up just changing our program into straightforward clinical nurse specialists and that's that's how we evolved and we do very well you know every year since i've done that and i've

[00:19:26] been running that since 2007 so we've had a robust cns program here in the detroit area so again it's just educating and and it's just delineating these are the competencies for this group these are the competencies for this group and making sure that both both scopes

[00:19:44] practice are being modernized and everyone is functioning at the full extent of their education and we need both we need both right we need nurse educators to make sure the cns's are competent that that they have everything they need and those competencies get checked off every year

[00:20:02] and then we need cns's at the bedside in real time role modeling in front of in front of nurses and working with nurses clinically which is not the nurse educator role right exactly and

[00:20:16] speaking of that i mean how how do cns's demonstrate their value in the healthcare system um how do you quantify that if i met the beds at the cns if i met the bedside with nurses the evaluation

[00:20:29] time was a hard time because i didn't always do a great job at quantifying the work that i did but if you asked anyone before like oh my gosh we love alz alz here she did this but you know

[00:20:39] how can i it how can we as cns is in the leadership world where everything's kind of black and white on paper numbers right it's all about the budget how do we demonstrate our value to healthcare systems

[00:20:51] so our number one strategy that at the at the national level that we want to trickle down is a focus on patient outcomes the cns has to constantly demonstrate their role in patient

[00:21:03] outcomes now how do you do that how you do that is you identify what is most of most concerned of the c suite and it was decreasing length of stay when i graduated from my cns program in 1994

[00:21:16] and guess what it is still decreasing length of stay because patient volumes are at 50 percent patients are staying too long and we're not getting patients in the beds that does not make

[00:21:29] the c suite very happy so cns's need to target the key outcomes so in their specialty population and there's been some great work out there by cns's lately they're a study i read recently

[00:21:42] of a cns team that were focused on head and neck surgery patients and the long lengths of stay that were taking place post tracheostomy or laryngectomy patients so these cns's went in they looked at the data they followed these patients from admission to discharge and saw

[00:22:01] where are the inefficiencies and how do we need to change care that's what cns's do and they ended up learning some procedures learning how to downsize trachs decanulate patients they even learned how to put a different fate a plate on the on the neck to decrease the

[00:22:18] pressure injuries that were happening and their savings were about 2.2 million with statistically significant findings so we need groups of cns is doing that everywhere and there are cns is doing that so it's just really as you say you're doing these indirect cares you're supporting the nurse

[00:22:37] you're doing all these things but cns's have to be very astute to showing their value in patient outcomes so and targeting length of stay decreasing readmissions right transitional care roles that we

[00:22:50] see cns is going into so there's so many ways but the dollar sign is very important and we focus on quality but we got to i also say you've got to focus on the dollar sign too so how does quality

[00:23:03] equate to dollar signs because at the end of the day right the light bulbs have to be kept on in the hospital so exactly one of the things that i i learned during my tenure cns is cost avoidance

[00:23:16] having to quantifying that because you don't think you know everyone thinks about the money they spend but how about the money i saved you and so i think that's something that well that's become a

[00:23:28] critical it's become a big thing now especially because everyone's kind of tightening up their budgets but now you know Alice another one is nurse retention i mean that is of and the shortages

[00:23:37] of nurses so if you as a cns can come in and change those retention rates change those nurse satisfaction scores get your nurses at a at a higher level that they're practicing at right

[00:23:50] now you know take them to next level i mean those are very important to the c-suite right now too because the cost of labor is is killing our health care systems yes those are definitely some

[00:24:02] very important things that we need to look at and that we can greatly influence um i know in the structure of where i worked it was myself and then it was the unit manager and we were

[00:24:13] kind of like husband and wife type of thing and then we reported up to the director so we're really partners you know working hand in hand with trying to change those those work conditions

[00:24:22] and oftentimes the manager is like well go ahead ala tap if you can get this happen what do you need what do you need so i was very fortunate in that sense but now mitzi we were in a pandemic it was

[00:24:32] life changing so much has changed the culture of health care has changed uh what is the future like for cns is well i think the future is very very bright and it's and you know the fact

[00:24:45] that we have 41 states now mariland just signed their laws into place in the last three months so we have title protection which is great we have prescriptive authority or prescriptive privileges

[00:24:58] in 41 states which is really awesome and we have a growth in enrollment we're seeing that we have a growth at the national level just in memberships in our national organization i think that as long

[00:25:12] as we stay focused we stay on showing our value as an ap rn stay focused on the patient outcomes the quality and fiscal related outcomes i think the future is very bright for cns but we can't

[00:25:29] quit talking about it so just being with you here today is so important and i take advantage and and we do with a leadership level at the national association to make sure we take

[00:25:40] advantage of every opportunity to talk about the cns role because you're right our numbers are lower and i would say that in graduate nursing education there's been more of a push towards nurse practitioner and filling physician shortages that i think we need to really think about the

[00:25:59] nursing shortage and what cnss can do to help the nursing shortage and bring those great minds into the cns role we're really needed yes i agree with you i mean there are lots of great minds there

[00:26:11] i've worked with several nurses um and you know they've always the question again is should i go to school to become an np or a cns again that's like the number one question that i get so just

[00:26:23] real quickly before i let you go what do you believe are the attributes or characteristics that would help a nurse to be successful in the cns role yeah well i think one of the most

[00:26:35] important ones is you're not afraid of change because you are a change agent i think if you're not happy with the status quo and you want to see nursing the profession rise to the next level

[00:26:48] and work with the nurses and be that leader who really makes a difference i think the cns role is for you and and you don't necessarily want to be solely patient focused but you want to be

[00:27:00] able to have that autonomy to go across an entire health care system talk to physician groups talk to all the stakeholders and and be a change agent and just really see change happen because of

[00:27:15] of your leadership and your coordination skills and your communication skills and what you can do to really make change happen across health care systems and i just want to say you mentioned covid medscape did some interesting surveys about career satisfaction during those covid years

[00:27:33] and it's interesting that the cns for two years in a row had the highest level of career satisfaction during the covid years now why is that because we were in our element right we like

[00:27:46] change complex care and they were making things happen but so cns is you know when we were getting thrown at you know just thrown to the wolf it was the worst time for all of us cns's were

[00:27:59] happy in their career making change i definitely can see that and i'm smiling because i was so fortunate when i kind of when i said i grew up in my nursing in san diego cns rich city like cns's

[00:28:13] dominated uh the places there was always plenty of mentors and things like that so i was well supported uh worked in hospital systems that really you know were so happy and supportive of cns roles

[00:28:26] and i loved it because might someone described as your clinical deviance you get to alice you get to you kind of get to look for the holes in the swiss cheese and you know anticipate the problems

[00:28:38] and help protect the the nurses and the organization from those problems so i loved it no two days were ever the same i always had a different schedule yes they were standing

[00:28:47] meetings which i was like uh okay we go to those i guess but i got to based on whatever the the clinical issue was of the day oh i need to go meet with you know the nephro team oh i need to go down to

[00:28:59] perioperative and see what's happening with you know our cardiac patients why is this happening and it was just different and so i would add on to if you are someone who loves solving problems who likes variation who's proactive and a go-getter and likes to initiate things

[00:29:17] that's the role for and loves clinical stuff and getting down to the nitty gritty and you know helping others learn uh learn these things i would i got a chance to start so many

[00:29:26] cool projects and then pass the baton to kind of the manager and directors who'd like to sustain they're the sustainers i was the builder they were the sustainers and someone could say well

[00:29:35] that's a bad thing well i loved it because it kept me excited about nursing and passionate about nursing so if that's someone if you guys for those of you who are listening if this describes you

[00:29:45] then probably the cns role is for you so mitsi before we let you go can you please let our listeners and our viewers know uh a little bit more about nacns where they could

[00:29:56] go to become a part of it and if there's anything coming down the pipeline yes so then it's the national association of clinical nurse specialist and you can go to our website and if you're

[00:30:07] interested in becoming a cns we have a cns program directory um we are just getting ready to update it but at least if you if you were interested and there was a state that you live in you could

[00:30:18] contact a program director but we are all about the cns and if you are interested in more information on the cns um role at all we have an ask mitsi anything page so if you open our first

[00:30:34] web page you can ask any question and i will answer it for you or work with you and even troubleshoot with you to see if the cns role is good for you oh i love it thank you so much

[00:30:46] mitzvi for coming on sharing your expertise and talking more about the cns role because guys this is really important that we talk about this i know we you know we go through nursing school

[00:30:55] but we're all just so focused on graduating passing NCLEX and getting our first job and so you know but we we got to think beyond that because it's also important even if you're someone who decides not

[00:31:07] to go on for more school or to enter an api role it's still important for you to understand your profession and you know the dynamics of it in the different roles because patients are coming

[00:31:17] to you with questions um and i think we as nurses do ourselves a disservice when we don't understand fully understand uh the scope of scope or practice of some of our colleagues because we're not we're probably not optimizing um each other the or leveraging the work that's

[00:31:36] we each can do um when we don't fully understand the roles can create some confusion so thank you so much for coming on and talking about it so guys make sure to visit nacns.org there's

[00:31:47] tons of information there you can learn more about the national association clinical nurse specialist learn more about the role and find out if this is a role for you and even if it's not

[00:31:54] for you maybe for someone else or maybe later down the road you never know so but just go there tons of information and i'm sure there's lots of events educational opportunities a great resource

[00:32:04] to have and thank you so much to you missy uh for your leadership at nacns for all the great work that you're doing and educating our nurses and future dnses of tomorrow i really appreciate

[00:32:16] thank you i appreciate you too nurse alice and guys thank you so much to nurse.org who has hosted the website make sure to visit nurse.org tons of great information there guys everything from education to loans student loans finance what's going on in the world today

[00:32:34] and clik's tips you name it it's there make sure to visit nurse.org um it's a one-stop shop for all your nursing information and you guys i'm nurse alice i always love chatting

[00:32:42] with you guys i have one of the coolest shops ever i think you know getting to talk with cool people like missy and getting to talk to you guys um and if you have any questions or comments for me

[00:32:51] please feel free to email me at nurse alice at nurse.org we'll have to hear your questions comments and hey if you have an idea for your the next show please let us know i'd love

[00:32:59] to hear from you there and until next time guys please make good choices be kind to one another and live well my friends thanks for listening to ask nurse alice visit nurse.org for nursing career education and community resources