- Email: [email protected]
The Clinical Nurse Specialist Role
LETTERS
TO
THE
EDITOR
Error correction, clinical nurse specialists, fragmented research ERROR IN ANTIBIOTIC RECOMMENDATIONS
Y
ou have published a serious error in the January 2007 AORN Journal (“Improving compliance with prophylactic antibiotic guidelines,” vol 85). The table on page 177 indicates that 100 mg cefazolin administered subconjunctivally is the recommended antibiotic prophylaxis for all ophthalmic procedures. This is incorrect. Please refer to the Treatment Guidelines from the Medical Letter from April 20041 and December 2006.2 What you should have published is “there is no consensus supporting a particular choice, route, or duration of antimicrobial prophylaxis.”1(p31),2(p87) The incorrect antibiotic recommendation that you have published may be misinterpreted as the standard of care for ophthalmic surgical procedures and could be misused by lawyers in malpractice cases, hospital or ambulatory surgery center surgical review committees, or credentialing organizations like Medicare or the Accreditation Association for Ambulatory Health Care. STEPHEN P. KELLEY MD OPHTHALMIC SURGERY BROWNWOOD, TEX
References
1. Antibiotic prophylaxis for surgery. Treat Guidel Med Lett. 2004;2:27-32. 2. Antibiotic prophylaxis for surgery. Treat Guidel Med Lett. 2006;4:83-88.
Editor’s response. Thank you for bringing this to our attention. The Journal regrets the error.
THE CLINICAL NURSE SPECIALIST ROLE
I
was disappointed with the article “Perioperative clinical nurse specialist role delineation: a systematic review” (December 2006, vol 84). I am
© AORN, Inc, 2007
presently a clinical nurse specialist (CNS) in the perioperative setting and know this role from a very personal perspective. I would agree that the role has not been delineated as clearly as I would like and that many people both inside and outside of the perioperative setting do not understand the CNS role. There are some misconceptions that have been portrayed in the article, however, that provide substantiation and validation to incorrect information in the national forum provided by this publication. There are several areas of inaccurate information to which I take exception. My first and greatest concern is the statement made in the article that CNSs and nurse practitioners (NPs) have similar roles. I am not an NP, but I understand that most NPs define their role as medical diagnosing, prescribing medication, and providing direct patient care. The NP role is clearly needed in order to increase access to the health care system for patients in need, and at times, I feel the role is performed better by an NP than by a physician. A CNS, however, is very different than an NP. My role as a master’sdegree prepared CNS is to be the clinical expert who practices nursing in a specialty area identified in terms of a population, setting, disease, type of care, or type of problem.1 I find the suggestion of merging the NP and CNS roles to be an affront to both roles. They are different, both are much needed, and both provide strength to the provision of patient care. The authors state that the major benefit of merging the two roles would be an increased validation of the CNS role, but in the same paragraph, they state that the NP works in the medical realm and the CNS works
The AORN Journal welcomes letters for its “Letters to the Editor” column. Letters must refer to Journal articles or columns published within the preceding six months. All letters are subject to editing before publication. Authors of articles or columns referenced in the letter to the editor may be given the opportunity to respond. Letters that are included in the “Letters” column must contain the reader’s name, credentials if applicable (eg, RN, BSN, CNOR), position or title, employer, and employer’s address.
APRIL 2007, VOL 85, NO 4 • AORN JOURNAL • 711
Letters to the Editor
APRIL 2007, VOL 85, NO 4
in the nursing realm. How can you merge two practices that work in different realms? In the results and findings, the authors stated that the perioperative CNS was shown to affect the surgical environment through activities such as advocating for patients, collaborating with surgeons, consulting for nursing staff members, precepting, assessing patients both physically and culturally, and offering clinical insight.2(p1022) They then go on to state that this versatility leads to ambiguity. It is my opinion that this versatility leads to good patient outcomes through the provision of advanced practice nursing care. The authors also state that regulatory inconsistency from state to state leads to confusion and varying roles for CNSs. Of note is the fact that state boards of nursing also have inconsistent regulations for NPs. It is my opinion that this problem would not be solved by combining the two roles, it would just be exacerbated. In that same paragraph, the authors say that several states fail to recognize a CNS as an advanced practice nurse (APN). Oregon is listed as a state that fails to recognize the CNS. I practice in Oregon, and I am recognized and title-protected because I have a separate certificate as a CNS. The Oregon State Board of Nursing,
712 • AORN JOURNAL
Nurse Practice Act, Division 54, defines a CNS as an advanced practice nurse.3 Not all of my comments about the article are negative. I agree with the authors that the current health care climate is ready for growth and that the perioperative CNS provides a needed dimension of advanced practice nursing. I also agree that CNSs need to work with the National Association of Clinical Nurse Specialists and AORN to develop clear expectations of the role of the perioperative CNS. AORN has APN competency statements that, unfortunately, blend the two roles.4 I would be a strong advocate of supporting the American Nurses Credentialing Center in the creation of a certification examination for all CNSs. In closing, I want to say that although there are problems with the role delineation of the perioperative CNS, the best way to solve the problem is not to combine the CNS role with the NP role but to define the two roles and clearly delineate the differences. A CNS provides expert nursing care as defined by and through nursing terms and not as defined by medical terms. Yes, there will be some crossover in the roles, but the differences are what define the two roles not the similarities. STEPHEN PATTEN RN, MSN, CNS, CNOR CLINICAL NURSE SPECIALIST VA MEDICAL CENTER PORTLAND PORTLAND, ORE
References 1. Statement on Clinical Nurse Specialist Practice and Education. Harrisburg, Pa: National Association of Clinical Nurse Specialists; 2004. 2. Glover DE, Newkirk LE, Cole LM, Walker TJ, Nader KC. Perioperative clinical nurse specialist role delineation: a systematic review. AORN J. 2006;84:10171030. 3. Oregon State Board of Nursing Nurse Practice Act. Division 54: Clinical Nurse Specialists. Portland, Ore: Oregon State Board of Nursing; February 15, 2001. Available at: http://www.oregon .gov/OSBN/pdfs/npa/Div54 .pdf. Accessed February 28, 2007. 4. Perioperative advanced practice nurse competency statements. In: Standards, Recommended Practices, and Guidelines. Denver, Colo: AORN, Inc; 2007: 97-124.
Authors’ response. We would like to say a few words that may help to clarify this issue. Let us begin by stating that this article was, as it is titled, a systematic review of the literature comprised of 859 articles. The information presented is the published fact and opinion of many other authors over the years and in various regions without the current authors’ personal perspective. We forced ourselves to step back and present not what we may have personally thought but what the literature holds for nursing on this topic. This article should serve as a basis for research to go forward and either support or contest the statements about the relationship between the CNS and NP roles. Evidence-based research is needed to clear the air.
TO
THE
EDITOR
Error correction, clinical nurse specialists, fragmented research ERROR IN ANTIBIOTIC RECOMMENDATIONS
Y
ou have published a serious error in the January 2007 AORN Journal (“Improving compliance with prophylactic antibiotic guidelines,” vol 85). The table on page 177 indicates that 100 mg cefazolin administered subconjunctivally is the recommended antibiotic prophylaxis for all ophthalmic procedures. This is incorrect. Please refer to the Treatment Guidelines from the Medical Letter from April 20041 and December 2006.2 What you should have published is “there is no consensus supporting a particular choice, route, or duration of antimicrobial prophylaxis.”1(p31),2(p87) The incorrect antibiotic recommendation that you have published may be misinterpreted as the standard of care for ophthalmic surgical procedures and could be misused by lawyers in malpractice cases, hospital or ambulatory surgery center surgical review committees, or credentialing organizations like Medicare or the Accreditation Association for Ambulatory Health Care. STEPHEN P. KELLEY MD OPHTHALMIC SURGERY BROWNWOOD, TEX
References
1. Antibiotic prophylaxis for surgery. Treat Guidel Med Lett. 2004;2:27-32. 2. Antibiotic prophylaxis for surgery. Treat Guidel Med Lett. 2006;4:83-88.
Editor’s response. Thank you for bringing this to our attention. The Journal regrets the error.
THE CLINICAL NURSE SPECIALIST ROLE
I
was disappointed with the article “Perioperative clinical nurse specialist role delineation: a systematic review” (December 2006, vol 84). I am
© AORN, Inc, 2007
presently a clinical nurse specialist (CNS) in the perioperative setting and know this role from a very personal perspective. I would agree that the role has not been delineated as clearly as I would like and that many people both inside and outside of the perioperative setting do not understand the CNS role. There are some misconceptions that have been portrayed in the article, however, that provide substantiation and validation to incorrect information in the national forum provided by this publication. There are several areas of inaccurate information to which I take exception. My first and greatest concern is the statement made in the article that CNSs and nurse practitioners (NPs) have similar roles. I am not an NP, but I understand that most NPs define their role as medical diagnosing, prescribing medication, and providing direct patient care. The NP role is clearly needed in order to increase access to the health care system for patients in need, and at times, I feel the role is performed better by an NP than by a physician. A CNS, however, is very different than an NP. My role as a master’sdegree prepared CNS is to be the clinical expert who practices nursing in a specialty area identified in terms of a population, setting, disease, type of care, or type of problem.1 I find the suggestion of merging the NP and CNS roles to be an affront to both roles. They are different, both are much needed, and both provide strength to the provision of patient care. The authors state that the major benefit of merging the two roles would be an increased validation of the CNS role, but in the same paragraph, they state that the NP works in the medical realm and the CNS works
The AORN Journal welcomes letters for its “Letters to the Editor” column. Letters must refer to Journal articles or columns published within the preceding six months. All letters are subject to editing before publication. Authors of articles or columns referenced in the letter to the editor may be given the opportunity to respond. Letters that are included in the “Letters” column must contain the reader’s name, credentials if applicable (eg, RN, BSN, CNOR), position or title, employer, and employer’s address.
APRIL 2007, VOL 85, NO 4 • AORN JOURNAL • 711
Letters to the Editor
APRIL 2007, VOL 85, NO 4
in the nursing realm. How can you merge two practices that work in different realms? In the results and findings, the authors stated that the perioperative CNS was shown to affect the surgical environment through activities such as advocating for patients, collaborating with surgeons, consulting for nursing staff members, precepting, assessing patients both physically and culturally, and offering clinical insight.2(p1022) They then go on to state that this versatility leads to ambiguity. It is my opinion that this versatility leads to good patient outcomes through the provision of advanced practice nursing care. The authors also state that regulatory inconsistency from state to state leads to confusion and varying roles for CNSs. Of note is the fact that state boards of nursing also have inconsistent regulations for NPs. It is my opinion that this problem would not be solved by combining the two roles, it would just be exacerbated. In that same paragraph, the authors say that several states fail to recognize a CNS as an advanced practice nurse (APN). Oregon is listed as a state that fails to recognize the CNS. I practice in Oregon, and I am recognized and title-protected because I have a separate certificate as a CNS. The Oregon State Board of Nursing,
712 • AORN JOURNAL
Nurse Practice Act, Division 54, defines a CNS as an advanced practice nurse.3 Not all of my comments about the article are negative. I agree with the authors that the current health care climate is ready for growth and that the perioperative CNS provides a needed dimension of advanced practice nursing. I also agree that CNSs need to work with the National Association of Clinical Nurse Specialists and AORN to develop clear expectations of the role of the perioperative CNS. AORN has APN competency statements that, unfortunately, blend the two roles.4 I would be a strong advocate of supporting the American Nurses Credentialing Center in the creation of a certification examination for all CNSs. In closing, I want to say that although there are problems with the role delineation of the perioperative CNS, the best way to solve the problem is not to combine the CNS role with the NP role but to define the two roles and clearly delineate the differences. A CNS provides expert nursing care as defined by and through nursing terms and not as defined by medical terms. Yes, there will be some crossover in the roles, but the differences are what define the two roles not the similarities. STEPHEN PATTEN RN, MSN, CNS, CNOR CLINICAL NURSE SPECIALIST VA MEDICAL CENTER PORTLAND PORTLAND, ORE
References 1. Statement on Clinical Nurse Specialist Practice and Education. Harrisburg, Pa: National Association of Clinical Nurse Specialists; 2004. 2. Glover DE, Newkirk LE, Cole LM, Walker TJ, Nader KC. Perioperative clinical nurse specialist role delineation: a systematic review. AORN J. 2006;84:10171030. 3. Oregon State Board of Nursing Nurse Practice Act. Division 54: Clinical Nurse Specialists. Portland, Ore: Oregon State Board of Nursing; February 15, 2001. Available at: http://www.oregon .gov/OSBN/pdfs/npa/Div54 .pdf. Accessed February 28, 2007. 4. Perioperative advanced practice nurse competency statements. In: Standards, Recommended Practices, and Guidelines. Denver, Colo: AORN, Inc; 2007: 97-124.
Authors’ response. We would like to say a few words that may help to clarify this issue. Let us begin by stating that this article was, as it is titled, a systematic review of the literature comprised of 859 articles. The information presented is the published fact and opinion of many other authors over the years and in various regions without the current authors’ personal perspective. We forced ourselves to step back and present not what we may have personally thought but what the literature holds for nursing on this topic. This article should serve as a basis for research to go forward and either support or contest the statements about the relationship between the CNS and NP roles. Evidence-based research is needed to clear the air.