Read as Frank delaRama talks about his career as a Clinical Nurse Specialist. Find him at www.pamf.org/cancercare and on the Twitter feed in the sidebar of this interview.
What do you do for a living?
I am a Clinical Nurse Specialist, specializing in Oncology and Genomics.
How would you describe what you do?
A clinical nurse specialist is a type of advanced practice nurse that usually specializes in certain areas. My focus is mainly on cancer genetic counseling, helping patients and families learn about risk based upon personal and family history, plus facilitating any genetic tests that may be available to help guide their care. My other main focus is on prostate cancer as an oncology nurse navigator, guiding newly diagnosed patients through the process of diagnosis, treatment, and into survivorship care.
As a CNS, I am also asked to use my expertise in various projects where I work, including research studies ongoing, program planning for cancer programs in general, and even writing a blog on cancer for my organization.
What does your work entail?
The overall goal is optimal health care for my patients & families. As clinical nurse specialists, our spheres of influence fall into five groups: clinical excellence, leadership, consultation, research, and education. I use these to guide my work responsibilities.
Fostering clinical excellence is inherent already as an oncology nurse, but as an advanced practice nurse, I try to keep updated on the latest developments in cancer genetics and prostate cancer, to best serve the people that I most commonly work with, including patients, families, as well as physicians, other nurses, and health care providers. Given my work in these areas, I am often asked to help define guidelines and protocols, ensuring quality care for our system at large.
My leadership responsibilities include supervising nursing staff at the oncology clinic, but also leading committees, such as our Cancer Patient Advisory Council, where we have gathered a group of cancer survivors, as well as some key clinic staff, to provide input on any developing cancer programs. We meet at least quarterly, and continue to work on various projects throughout the year by e-mail/teleconferencing.
We commonly think of CNS’s as staff educators, and I do include this in my current role, including in-services for the nurses/physicians, in the traditional sense. I also think patient education is important, and using online outlets, I can potentially reach a broad, wide audience. Initially, I was giving input on our own website updates, to provide accurate information and get patients to the right people at the clinic. Writing a blog is another outlet where I can educate on issues in cancer, and often provides more of a dialogue than a lecture.
The current research projects in which I have a CNS role at my facility revolve around oncology nurse navigation. The list of outcomes measures we are examining is large, and includes clinical outcomes (e.g. post-treatment symptoms over time), patient satisfaction, and various psychosocial aspects (anxiety, decisional conflict). My main day-to-day responsibility in research is recruiting patients, and ensuring that the follow-up surveys (outcomes measures) are completed per protocol. For the studies that are finished recruiting, the CNS role then focuses upon data analysis and publication.
The consultations that I provide to patients and their families mainly focus upon shared decision making (cancer genetics and prostate cancer are my two areas of consultative expertise). During these individual meetings, which can range from 30 to 90 minutes, I first gather a personal and family cancer history, and then spend a good amount of time educating them on the clinical aspects of the issue at hand. The bulk of our discussion then moves to outlining all the possible choices, and the pros/cons of each. My goal for the patient is to make the best decision, given all the information available. Clinical aspects are important, but we also consider the “non-clinical,” such as qualify of life, psychosocial aspects, family dynamics, and ethics.
What’s a typical work week like?
The consultations provide the skeleton of my schedule, and I have at least 3-4 hour long slots open per day, which can be filled with patients who need help with either cancer genetic counseling or prostate cancer navigation. Patients are referred by their physicians to see me.
During the time that I am not in consultation, I try to address all the ongoing projects, which can include particular patient cases (e.g. tracking genetic test results, communicating results to patients & referring physicians), and also the broad projects in education and research.
Given all the various responsibilities and the ebb and flow of patient referrals, there is no “typical work week,” but it always seems to be busy….which is a good thing.
Since I work at an outpatient clinic, I have regular weekday business hours. Some of my CNS colleagues do have responsibilities for several shifts of nurses/patients (includes evenings, nights & weekends), so their role can be a bit more complex.
How did you get started?
I started my career in nursing as a Registered Nurse, after getting my Bachelor’s Degree in Nursing. After a brief stint in medical-surgical hospital nursing, I became a nurse in Radiation Oncology. Once I decided to pursue my graduate degree to become a Clinical Nurse Specialist, I was able to work part time (although not much!). When I did graduate, I had the luxury of writing my own CNS job description to create the role at the same facility where I was a radiation oncology nurse. It was a smooth transition into the role, and I think the relationships that I already had with all the physicians, nurses, and staff, allowed me to build a successful practice here.
What do you like about what you do?
Interacting with patients and families individually is the most rewarding (and sometimes challenging) part of my job. Not only am I able to spend quality time educating them on issues which many of them have never dealt with before, but also helping them along the pathway, whether it is just for genetic testing, or if they may have cancer themselves. My overall goal is to make the journey as effortless as possible for my patients and their families.
Also, during these visits, patients and families often open up, so we may be exploring all the emotions, fears, and feelings they are having around cancer. When I am able to provide some reassurance or insight, based upon perhaps several other families that I have met in the past with a similar situation, that “aha” moment for my patient in the room is such as great feeling.
What do you dislike?
Because I deal with cancer every day, end-of-life issues can be a concern. Talking about death and dying is never fun, but speaking frankly is important. Patients and families really do benefit from straight talk, and focus upon things within their control, while identifying and accepting the things outside of their control.
How do you make money/or how are you compensated?
I am a salaried employee at my clinic, so all of my main responsibilities and projects fall under this umbrella. If I am asked to speak at conferences or other educational events, or perhaps consult, outside of my clinics, I do often receive a one-time honorarium.
How much do people in your field make?
In California, the average Clinical Nurse Specialist salary is about $100-120K per year. This can be higher based upon the area of specialty, plus any administrative responsibilities that are added. When I first started, I was a registered nurse at the same facility, and I was already supervising several nurses, so the salary negotiations ended up in a higher than average salary. Being in oncology and genomics, as well as in the Silicon Valley, probably played a major part in making my salary in the top 5% of the bell curve.
For speaking engagements and/or consultations outside of my clinic, honorariums can range from $300 to $1500 per event. I usually only have a handful of these per year.
How much money did/do you make starting out?
Compared with my hourly salary as a registered nurse, the CNS/APN salary was at least a 15-20% increase right away, then steadily continued to increase over time.
What education, schooling, or skills are needed to do this?
To be a Clinical Nurse Specialist, a Master’s degree is required. Experience as a registered nurse is preferable, but not always required to get into a graduate program.
What is most challenging about what you do?
Acting as a change agent is the most challenging, because it usually involves influencing many different key players, which can include physicians, other APN’s/CNS’s, nursing staff, administration, and sometime even our patient population in general.
What is most rewarding?
Hearing back from patients after the fact, and continuing to keep in touch with him. They are very thankful for the time spent with them. Although I actually only spent 1-2 hours with them, I was helping them make a potentially life-changing decision, and they never forget that.
What advice would you offer someone considering this career?
“Spinning plates” is a good analogy for my job. I am busy in so many different things within my expertise. It never seems to be slow. There’s always something that needs improving. In healthcare, the motivation is clear: optimal health care and making it go smoothly for patients & families. Nurses who want to specialize in a certain area, with a taste for program planning, should consider becoming a Clinical Nurse Specialist.
How much time off do you get/take?
My schedule is very flexible, but I don’t have anyone that can back up all my responsibilities. I try to take at least one 1-2 week vacation (disconnected!) per year, plus various long weekends (e.g. mental health days!) scattered throughout.
What is a common misconception people have about what you do?
CNS’s are not just about staff education. There are so many things that we are asked to do in the healthcare setting. Given my specialty, I do have the opportunity to see patients; it is not a purely administrative role in my case.
What are your goals/dreams for the future?
I would like to see my main two programs (oncology nurse navigator and cancer genetic counseling) expand to include multiple providers (CNS’s?) so we can provide services to a broad spectrum of people in need of these services. My focus today is only on one cancer (prostate) and a handful of genetic tests/cancer syndromes. In the near future, a program could address multiple cancers and syndromes. Oncology, especially in genomics, is growing very rapidly.