S Rose, A All, D Gresham
S Rose, A All, D Gresham. Role Preservation of the Clinical Nurse Specialist and the Nurse Practitioner. The Internet Journal of Advanced Nursing Practice. 2002 Volume 5 Number 2.
The following manuscript explores the historical development, as well as current and future roles of advanced practice nursing with specific emphasis on the clinical nurse specialist and the nurse practitioner. The term advanced practice nursing is based on the definition provided by the American Nurses Association (ANA). A statement originating from the National Association of Clinical Nurse Specialist provides the spheres of influence framework used in the critical analysis of the competencies, as well as implications for practice, role development, and scopes of practice for the clinical nurse specialist. Nurse practitioner education and development is based on the curriculum guidelines and program standards as developed by the National Organization of Nurse Practitioners.
Advanced Nursing Practice and Issues of a New Millieum
Historically advanced practice roles have lacked clarity. 1,2 Confusion regarding the educational preparation, titles, roles, and functions hampered understanding for quite some time.3 Harrell and McCullock 4 identified that words such as “specialist” or “advanced” were used to describe nursing roles without respect to educational or experiential backgrounds created confusion in the discussion of advanced practice nursing. Some institutions were using individuals with less than graduate level education in advanced practice roles, while others with graduate degrees lacked certification (American Association of Colleges of Nursing. 5 The educational background of the advanced practice nurse (APN) varied from state to state. These issues proved to be confusing for institutional management, nursing personnel, health care team members, as well as clients.
Great strides have been made by the nursing profession to alleviate confusion, provide continuity and insure quality educational preparation for the advanced practice nurse. The American Academy of Nurse Practitioners has developed a number of statements that addressed standards of practice, curriculum and roles. 6,7,8 The American Nurses Association (ANA) 9 developed the
Educational and technological advances have produced undeniably positive patient outcomes. Life expectancy has increased, death due to disease has been delayed and surgical interventions have been refined. These very positive advances have been tempered by overall increases in chronic disease and the increasing demand for health care services. The associated demand for services has resulted in an inability to meet the needs and desires of all individuals equitably. Changes have occurred industry wide. Nursing's response began in 1989 when the ANA 13 began work on
The medical community is being forced to refocus on primary care with the increasing numbers of managed care delivery systems. Callahan 15 addressed the need for physicians to adjust medical goals as they related to patient care. Callahan 15 suggested that priorities should be: disease prevention, relief from pain and suffering, care for those that cannot be cured, avoidance of premature death, and pursuit of a peaceful death when death is unavoidable. Interestingly these same priorities have been well documented and long-standing within nursing literature. 13, 16,17,18,19,20
Advanced Practice Nursing
Nursing has long provided the backbone for our health care delivery system. Recent trends of an aging nursing population, decreases in bachelor degree program enrollment, and increasing patient acuity heighten the need for the leadership and skills provided by the APN. 21 It is through the advanced practice roles that nursing can provide its greatest impact in the areas of cost containment, performance improvement, access to care, and client satisfaction.
Educational Preparation of the APN
Prior to the 1980's educational options for advanced practice roles were more or less limited to certification programs, with the exception of the CNS. CNS programs were the first nursing specialty to require graduate level preparation, and thus served as a model for excellence in advanced practice nursing education. 22 Through the 1980s the progression toward graduate level studies was added to the certified nurse midwife (CNM), certified registered nurse anesthetists (CRNA) and the nurse practioner (NP) programs. 22 In 1996 the AACN 10 identified APNs as individuals licensed as a registered nurse with graduate level education and certification.
Credentialing of the APN
Currently all APN candidates must provide evidence of completion of an accredited educational program and must hold a current RN license.23 CNSs and NPs are credentialed through the American Nurses Credentialing Center, an arm of the ANA. Re-certification activities are a component of all of the APN roles.10, 24, 25
Characteristics common to the entire APN population include leadership, flexibility, responsiveness to change, and knowledge base development.26 The AACN 10 defined those attributes that must be cultivated within the graduate education programs of all APNs. Included skills were: critical thinking, decision-making, planning, critical and accurate assessment, ability to create appropriate interventions, and evaluation of client responses. The ability to analyze, synthesize and utilize the knowledge accrued through education and client assessment is crucial to the success of the APN. All APNs must posses the ability to assess, diagnosis, prescribe therapy, and maintain accountability. Lastly, the skill of effective communication is an invaluable tool and prerequisite for all APNs. 12
In summary, the roles of the APN have transitioned into a very viable alternative for health care delivery. The nursing profession initially identified problems within the care delivery system and have since developed and refined workable alternatives focusing on the improvement of care delivery. Physicians have noted the ability of APNs to provide primary care. Acceptance and acknowledgement of APN practice by this group of providers is critical. Without acceptance by the medical profession advanced practice nurses would lack the critical link of collaboration. Mudinger, et al. 27 wrote of a study comparing clients treated by NPs versus those treated by physicians. Results revealed no significant difference in health status, health services utilization, or satisfaction among the patient populations.
Clinical Nurse Specialist Practice
The practice settings of the first clinical nurse specialists were most typically linked with a hospital facility. Over the years there has been considerable expansion in terms of practice settings for this group of nurses. In addition to the hospital facilities the CNS can also be found doing research, working with physicians in private practice, working as practitioners within behavioral medicine settings, providing expertise for community based organizations, expanding the role of school health providers, and working in nurse managed clinics to name a few. The basic components of the CNS role hold true regardless of the setting.
Literature has identified the roles of the CNS as practitioner, educator, consultant, researcher, leader, change agent, and case manager. 1, 3, 28 Historically the language used throughout nursing literature to describe the sub roles of the CNS failed to clearly articulate the value of the CNS. A less than clear understanding of the true role of the CNS has existed and continues to threaten its position within the traditional health care setting. During the mid 1990s literature addressed a proposal to combine the NP and CNS roles. 1, 29,30,31 In an effort to preserve the CNS role the NACNS (1998) published a statement with the goal of providing a guide for this advanced nursing role. This statement identified specialization as the hallmark of the CNS and used the terms “spheres of influence” and “competencies” to more accurately define the roles of the CNS. Spheres included the patient, client or client group, nursing personnel, and the organization or network. CNS competencies include leadership skills, professional attributes, collaborative skills and consultative skills.12 Competencies are fundamental within every sphere regardless of the practice setting. This framework allowed the roles of the CNS to be more fully articulated and easily visualized, without the ambiguity that once hindered clear understanding of the value of the CNS. 12
CNS Spheres Of Influence
Opportunities for the CNS have been varied and multiple in nature. Whereas the NP position was developed in response to a specific need, the CNS role encompassed a much broader field of influence. CNS skills allow for a multitude of potential employment opportunities. 28 NACNS 12 noted that the CNS possessed competencies in both clinical theory-based nursing practice and research based-nursing practice within a specialty area.
Patient/Client sphere of influence
Within the sphere of the patient or client, the CNS functioned as both a direct and indirect care provider and educator. As a care provider, the CNS is involved in a type of client assessment that went well beyond the bedside and included aspects of culture, family dynamics, long-term needs, and life styles. For those clients attempting to cope with chronic and life threatening diseases the CNS was prepared to manage symptoms and assist with necessary life style changes. 32 The traditional CNS role may be seen in a variety of settings. Some CNSs have operated within community-based organizations. From this vantage point CNS roles have demonstrated knowledge of community resources, sharp problem solving skills, an ability to prioritize and coordinate care, and strong collaboration within the community of providers. 32 The hospital based CNS role described by Larsen, Neverett, and Larsen 33 has served to identify problems, facilitate interdisciplinary planning, promote development of improved care for patient populations, develop patient education material, promote staff education, and monitor outcomes. Opportunities to further the CNS's mission of providing preventive care at the community level flourish in a variety of practice settings. An example of this influence is the CNS in a school nurse role. 34 The expansion of the school nurse role created by the CNS is congruent with the description nursing has advocated in the changing complexion of the health care delivery system. 13
Nursing personnel sphere of influence
Activities that influence the sphere of nursing personnel are and were most heavily impacted by positions occupied by a hospital based CNS. In a study to explore the roles, skills, and activities of the CNS, Scott 2 identified activities that impact nursing personnel as: (1) staff education, (2) graduate nursing student education, (3) coordination of nursing orientations, (4) evaluation of staff RN competencies, and (5) providing certification review courses. CNS consultant activities are listed as those of a change agent and leader with regard to the development and implementation of policies, protocols, procedures, and critical pathways. This consultant role also encompassed activities of collaboration with nursing administration in the identification of clinical issues, development of interventions for those issues, and facilitation of staff support programs. 2
CNSs have also impacted the nursing personnel sphere through research activities such as the dissemination of research findings and the development of research-based protocols. These types of research activities would effect staff nurses as evidence–based practice protocols are incorporated into the workplace. CNS activities in this sphere have also included consulting with individual staff nurses who are conducting research and participating on nursing research committees. 2
Organization/ Network sphere influence
An example of the organization or network as a beneficiary of the CNS role is described in an article highlighting the activities of a CNS employed within a community based AIDS program. 32 Within that setting the CNS served as an educator to the non health related multidisciplinary team members on subjects such as (1) universal precautions, (2) confidentiality issues, and (3) care of a choking victim. Recognition of the needs of the organization and the requisite teaching of the staff fell to the expertise of the CNS. The CNS is an individual that has been prepared to think inclusively and can thereby enable a detail-driven program that provides both safe and effective care to the target population. This scenario also called for the CNS to serve in a role of mediator and collaborator as the program positioned itself to market its services to various managed care organizations.
Nurse Practitioner Practice
The NP role has recognized a tremendous evolution from its beginnings in the 1960s. Initially developed to meet the needs of underserved populations, the nurse practitioner is now practicing throughout the continuum of health care in multiple settings and with various client populations. 22 NP employment opportunities have expanded in both the outpatient setting as well as the specialty areas within the hospitals. Practice settings commonly were within the rural community but are now utilized in various rural, suburban, and urban communities.
Hanna 35 identified the core competencies of the NP to include coaching and guidance, consultation, research, clinical and professional leadership, collaboration, and ethical decision-making skill. These competencies have been incorporated into the basic nursing process regardless of the practice setting. Primary care NPs have typically worked within the outpatient setting and the ability to coach and provide guidance has represented the essence of health promotion and disease prevention through the education of clients and client groups. While a majority of the work of the primary care NP is associated with diagnosis and management of minor illnesses and stable chronic disease, the ability to recognize and consult with medical counterparts when appropriate is paramount in maintaining optimal patient care and satisfaction. Research skills are needed by these NPs in order to identify appropriate practice innovations as well as the development of practice guidelines. 35 The coordination of patient care, establishment of care priorities, and the insurance of continuity of care are enhanced by the NPs' leadership skills. Collaboration with the patient, the medical counterpart, and other health care providers is promoted by a belief in an inclusive type of patient care Lastly, the acceptance of accountability for the care one has provided is based in the strength of ones ethical decision-making skills There are numerous decisions made on a day-to-day basis that may enter the whelm of ethical decision-making: assisting patients and families in end of life issues, managing resources, and reproductive issues to name only a few. 35
Role Differentiation between the NP and CNS
The clinical nurse specialist role was historically seen as one that focused on an explicit patient population, the provision of expert nursing care for that patient population, implementation of staff development programs, and facilitation of system changes. Nurse practitioners, however, were recognized as primary care providers for a broad base of clientele in an outpatient setting. 36 Numerous changes have occurred within health care settings over the past two decades that have fostered both the development of NP practices and threatened the existence of the traditional role of the CNS. These changes have caused an inappropriate distribution of physician specialties thus resulting in a lack of primary care providers and some acute care providers, thus opening the door for an increased numbers of NPs both in inpatient and outpatient settings. 37 During this same time period hospitals were looking for ways to cut costs, and CNSs were asked to take on increased managerial tasks, thereby decreasing the effectiveness of the CNS role or eliminating the CNS role all together. Since that time the National Association of Clinical Nurse Specialists 12 has grown and provided critical support for the CNS role. Documentation of financial outcome measures has increased the understanding of the CNS's value to the financial managers of hospitals and other facilities. The ability of the CNS to develop population based programs to augment, refine and monitor chronic disease care gives facilities a bargaining chip when seeking new contracts with various third party payers.
The Balanced Budget Act of 1997 greatly enhanced the roles of both the NP and the CNS. No longer was the NP limited to bill for services based on geographic location. NP services could be billed regardless of location. This legislation also provided for the reimbursement opportunities for the CNS. 38 This change undoubtedly increased the marketability of the CNS. Physicians in specialty practice could see the financial benefits of the CNS within the private sector as well as the hospital setting.
The increasing number of CNS providers seeking and procuring prescriptive authority also broadens the practice settings for this nursing population. Progressively more and more states are recognizing prescriptive authority for the CNS (American Psychiatric Nurses Association. 25, 39 Some nursing program have and others are considering the addition of prescriptive authority into the core curriculum for the CNS; others provide post graduate programs to meet the prescriptive authority guidelines of the state. 40
Undoubtedly there are many aspects of the CNS and NP roles that are similar; however both roles have provided a richness that nursing needs to consider preserving. Both roles have served their clients and each other well. The CNS role has been credited with creating an advanced level of nursing with an eye toward theory-based practice. 36 NP's have been credited with the movement of nursing beyond traditional roles and increasing the public's awareness of advanced practice nursing. 36 There are still a multitude of problems in the health care setting that need the attention of both the CNS and the NP. Levels of chronic disease continue to climb, patient acuity continues to rise, there are inequities in the delivery of services to individuals across the country, and in the midst of these problems there has been an increasing shortage of nurses. The burden of providing quality care to the patient populations can best be met by the efforts of both the CNS and the NP. Jointly these two groups need to focus on issues to strengthen the whole of advanced practice in order to better meet the needs of clients of both the CNS and the NP. Attention to problems such as marketing and contractual considerations, improved understanding of the regulatory and credentialing requirements, development of health policy issues in the changing environment, strengthening advanced practice in organizational structures and cultures, identifying new directions for the APN, and uniting advanced nursing practice and education will improve the level of care for all patients.
Patients now demand and need health care services beyond what has traditionally been available. Consideration must be given to the triad consisting of the patient, the payer, and the system. From the perspective of the patient, services must be accessible and affordable, but from the payer's perspective these services must be cost effective. 41 Both of these entities desire and demand high quality services and it is the job of the health care system and the APNs working within it to fulfill the health-related needs of the patients. Successful CNSs and NPs will develop, implement, and continually analyze the direct and indirect process of care used to meet various outcome measures. The price of failure is not only in dollars but in human suffering.
Even though advanced practice nurses are not a new entity in health care there continues to be a lack of knowledge among health care colleagues and consumers about what these nurses do. Health and illness today are driven by market forces and it is a massive problem that so many Americans cannot access or afford health services. 42 Both the CNS and the NP must understand marketing concepts and use marketing strategies to help solve these two issues. Those APNs who cannot go beyond their instinctual aversion to dealing with dollars will be left behind and their patients will suffer. CNSs and NPs must promote their practice and make sure it is known that this marketing is about the needs of clients and the positioning of services/ businesses in the marketplace. A challenge advanced nursing practice is to provide standards of quality upon which advanced practice nursing is defined and regulated. Skills required for political activism and advocacy need to be stressed during basic preparation and at the advanced level of education if nurses are going to be successful in making a far-reaching impact on quality of patient care. 39 Both the CNS and the NP must understand the regulatory and credentialing requirements as well as issues of advanced practice nursing in a dynamic practice environment that are critical to quality patient care. 39, 43
Health policy issues influence nearly all aspects of clinical practice for APNs. The public views health care as a “right” 44 and as a prerequisite to life, liberty and the pursuit of happiness. 45 CNSs and NPs must take the responsibility to exert influence on the legislative phase of policy development and understand health care finance to fully impact the care of clients. 46
The future impact and existence of advanced practice nurses seems to change every two to three years 47 but with the increase in managed care there are predictions that an increasing number of nurses prepared at the advanced level will be needed in all aspects of health care. APNs have and will continue to experience tension within nursing and other professions. These tensions will no doubt affect support within health care for all advanced practice roles but specifically for nurse practitioners and clinical nurse specialists. Tensions include: (1) balancing components of blended roles, (2) defending the role, (3) lack of involvement in decision making, and (4) lack of authority to make changes. 48, 49 Clinical leadership skills will be essential in redesigning and reconfiguring advanced practice nursing's role in care delivery.
The past decade in health care has seen changes in the organization, delivery, and financing of health care with continued pressure on the system to be more accountable to the policy makers, consumers, and the general public. 50 The educational and practice competencies of the CNS and NP demand that these APNs provide evidence of their contributions to health care. Attention must be given to creating a value of advanced practice nursing! 51 This value must include both the concepts of quality and cost for success. Challenges will include: (1) types and numbers of services, (2) need for and difficulties with measuring continuity of care, (3) needs of individuals and populations, (4) access to and availability of care and services, (5) types of outcomes, (6) examination of processes, when outcomes cannot be measured and (7) the need to maintain a current knowledge base.
Finally and perhaps most importantly nursing education must be clearly linked with practice! A continuing challenge is to link scholarship with expert clinical practice in a rapidly changing health care environment and delivery system. Society in general continues to fall short in its efforts to provide care to all individuals. In a system dominated by health maintenance organizations NP's are increasingly well prepared to serve in the role of a primary care provider. 27, 28 NP's working as primary care providers foster nursing's agenda to provide care to all individuals, regardless of ethnicity, cultural beliefs, gender, and financial status.
The educational background of the CNS creates a base from which system analysis can take place. In an interview with Lucian Leape, a health care policy analyst and contributor to the Harvard Medical Practice Study, Buerhaus 52 described the gravity of adverse events within our nation's hospitals. Preventable adverse events in 1998 were estimated at 120,000 deaths with a financial loss of $100 billion. 52 These statistics scream for the attention of effective interventions to limit hospital based errors. The research and clinical background of the CNS makes them outstanding candidates to address these types of issues within our health care facilities. Additionally, all APNs are able to insure that nursing care is grounded in theory through research and evidence-based activities. These crucial aspects of the NP and CNS roles represent the skills that will serve to suppress those preventable adverse events within our hospitals and clinics.
Individuals who practice at the advanced level are prepared and capable of delivering care within the scope of practice as defined by the ANA. 11 Despite efforts aimed at education, the public and other health care providers continue to lack understanding of the role differentiation of advanced practice nursing. In order to insure an appropriate place in the health care system, it is critical that others within healthcare, including other nurses, understand the educational background and clinical preparation of both the CNS and the NP. Additionally, APNs must educate those in management, medicine, the insurance market, and the general public regarding the preparation and capabilities of both the NP and the CNS. Until all share a clear awareness of the roles and the values they bring to our profession as well as the public at large, there will continue to be discussion of a blending of these two distinct and rich nursing roles. Both roles were clearly and precisely developed to meet specific needs within our health care system. The needs that drove the creation of these two separate roles have only grown over time. The nursing profession strives to provide a safe and competent environment for all of our patients, and preserving the practice roles of both the CNS and the NP strengthens this mission.
It might be said that the role of the advanced practice nurse is one that is emerging with both depth and breadth. Both the nurse practitioner and the clinical nurse specialist possess the skills and knowledge that promote the application of these roles in a variety of settings, both those that currently exist and those yet to be created. Research and change agent skills allow these APNs to function at multiple and varied levels within the health care system. It is through these roles that nursing can resume its mission to provide health care to all individuals and reshape health care with an eye toward wellness and prevention as described originally in
Stacey B. Rose RN, MS, CNS 7305 N.W. 114th Terrace Oklahoma City, OK 73162 firstname.lastname@example.org