The purpose of this paper is to contribute to the debate on whether or not the roles of the clinical nurse specialist (CNS) and nurse practitioner (NP) should be blended. In this paper I argue that the two roles should not be blended in masters degree programs for two reasons. First, societal needs for the advancement of nursing practice through the generation and utilization of nursing science and the provision of expert nursing care for highly complex problems have never been greater. Secondly, the two roles should not be blended because the competencies required for the two roles are more different than alike; hence the development of important competencies for one or both roles is lost in time-limited masters programs. Each of these reasons are discussed below.
Key Words: Advanced Nursing Practice, Clinical Nurse Specs, Education/Nursing/Masters, Health Services Needs & Demand, Nurse Practitioners, Nursing Role
Societal Needs for CNS Competencies and Outcomes
My argument begins with society's needs for both the advancement of nursing practice to maintain or improve quality while decreasing cost and the provision of expert nursing care to address complex problems. Health care reform, despite the failure of Clinton's 1993 federal reform package, has created changes that are particularly salient for clinical nurse specialists. Clinical nurse specialists, unlike NPs, focus on nursing's distinctive contribution to society through the provision and advancement of research-based nursing care. Although there are many changes that necessitate application of CNS competencies, none is perhaps more compelling than the move to a capitated payment system that is requiring both cost reduction and decreased demand.
The capitated payment system forces providers to look for ways to both reduce costs and decrease the demand for high cost medical services. Such reductions can occur when the illness or problem that a person experiences can be treated in a less costly environment, can be effectively self-managed, or is not caused by disease (Fries, et al.1993; Vikery & Lynch, 1995).
Methods to reduce costs to date have primarily included: (a) reduction in hospital stay days with more acutely ill patients cared for in transitional settings or in the home, (b) increase in types and number of same day surgeries, (c) lower RN to patient ratios accompanied by the increased use of unlicensed personnel, (d) systematic evaluation of programs and products to increase efficiencies and maintain or enhance quality while reducing costs, (e) use of less costly providers of medical care including nurse practitioners and physician assistants, and (f) mergers of health care institutions and provider groups to reduce both administrative costs and costs of material goods. Many of these changes beg for the competencies of clinical nurse specialists as a clinical outcomes manager, change agent, educator/coach/consultant, and program/product evaluator. Clinical nurse specialists are needed to co-ordinate care differently as patients and caregivers are helped to transition across settings after short hospital stays or same day surgeries, to develop and evaluate innovative delivery models to assure safe and effective care while using unlicensed personnel to assist in care delivery, to coach and mentor RN staff in the application of theory and research-based care that is designed to achieve desired outcomes while holding costs down, and to decrease cost through cost-benefit analysis of programs and products.
In addition to the ongoing efforts to reduce costs, the remaining four years of this millennium will be characterized by an accelerated and dramatic emphasis on reducing demand for unnecessary medical services.
Accurate diagnosis and effective treatment of symptoms and functional problems that are caused by factors other than disease requires an exquisite knowledge of nursing science and related sciences.
This shift in emphasis will create incredible needs for competencies of clinical nurse specialists through; (a) greater emphasis on prevention which requires an understanding of the dynamics of behavior change, (b) increased emphasis on self-care consumerism and self-care management of illnesses that are amenable to self-treatment, an emphasis requiring an understanding of the dynamics of self-care and self-care decision making, and (c) new efforts in the early diagnosis and treatment of illness experiences (in the presence or absence of disease) that are caused by factors other than disease and that require non-medical/non-pharmaceutical interventions to prevent or achieve a cure (Fries, et al. 1993; Sobel, 1995). Accurate diagnosis and effective treatment of symptoms and functional problems that are caused by factors other than disease requires an exquisite knowledge of nursing science and related sciences.
Experientially, contemporary nurses are quick to recognize what Florence Nightingale (1969/1860) recognized, namely, that contrary to the medical perspective, illness and disease are not one in the same. How many times have you seen patients who overstay the designated length of stay in the hospital or need to be readmitted not because of the disease per se or because a critical pathway wasn't followed, but rather because of symptoms and/or functional problems that could have been prevented or effectively treated with proper nursing care? How many times have you known or cared for someone who was experiencing illness but yet had no discernable disease; and likewise how many people do you know who have a disease but experience wellness in that they are comfortable and able to function at perceived capability levels?
The need for a unique focus on symptoms and functional problems has been well documented. There have been various estimates that anywhere from 30% - 75% of visits to physicians' offices are for illness experiences that do not require medical care (Barsky, 1981, Barsky, 1988; Gortmaker, Eckenrode & Gore, 1982; Sobel, 1995). Similar to what Florence Nightingale(1969/1860) observed, some of the more common causes of these illnesses experiences are stress emotions, worry, inadequate nutrition, inadequate hydration, ineffective breathing patterns, poor hygiene, immobility, improper body mechanics/positioning, and other non-salubrious behaviors. There are many symptoms such as nausea, fatigue, pain, dizziness, confusion, and nervousness that can be caused by, or exacerbated by, these "non-disease based" factors. Likewise there are many functional or functional-related problems that can be caused or exacerbated by non-disease based factors, such as deconditioning, falling, and skin breakdown.
Not coincidently, a principal aim of nursing science is to develop explanatory and prescriptive theories about problematic human experiences, such as symptoms and functional problems including problems with self-care decision making and self-care behaviors, that are caused by factors other than disease and for which nursing care is required. These theories help us understand, anticipate, and alter both phenomena, events, and situations that affect how people feel and their functional ability.
Unlike a principal focus of NP practice, which is the diagnosis and treatment of disease ... , CNSs have as their principal focus nursing's unique scientific and practical contributions in the management of symptoms and functional problems to meet distinctively different societal needs at the individual, group, community, and health care institution levels.
Somatic discomfort and functional ability problems caused by factors other than disease represent nursing's unique focus and thus nursing's unique contribution to meeting society's "health" care needs.
Clinical nurse specialists are masters in the application of nursing and related sciences to practice. Unlike a principal focus of NP practice, which is the diagnosis and treatment of disease (Fenton & Brykczynski, 1993), CNSs have as their principal focus nursing's unique scientific and practical contributions in the management of symptoms and functional problems to meet distinctively different societal needs at the individual, group, community, and health care institution levels. As masters in the application of nursing science to practice, CNSs often identify important research questions that contribute to the continued evolution of nursing science.
Focusing on society's need for the provision of expert nursing care and advancement of nursing practice is not about territoriality or being a "purist", it is about the raison de tre of why nursing exists within our society as a distinct discipline with separate licensing. A "discipline" has been defined as "a unique perspective, a distinct way of viewing all phenomena, which ultimately defines the limits and nature of its inquiry" (Donaldson & Crowley, 1978, p. 113). Each discipline is characterized by a unique lens through which experiences of human beings are viewed. These differences serve important scientific and practical purposes in meeting society's needs (Meleis, 1985). If each discipline does not offer something unique to society, there would be no reason for unique curricular components in educational programs or separate licensure. Furthermore, interdisciplinary or multidisciplinary efforts would be nonsensical because everyone would bring the same thing to the table.
Unrealistic Expectations That Masters Programs in Nursing Can Blend the Roles of CNS and NP
Meeting society's needs for the provision of low-cost, easily accessible primary care necessitates that NP's have competencies in the diagnosis and treatment of disease. When one discipline takes on role responsibilities of another discipline, such as is the case with NPs assuming role responsibilities that fall within the medical domain, it necessitates that the NP student spend sufficient supervised time to become competent in diagnosing disease and initiating medical treatments. This is not to say that NPs do not use nursing knowledge. However, the need to master the content of another discipline necessarily limits the time that can be allocated to mastering the application of nursing science and the acquisition of skills to advance practice. This limitation has important implications for the nature of masters degree curriculums that prepare NPs or that attempt to blend both roles in one program of study (Brykczynski, 1985; Price, et al.1992).
To prepare CNSs with salable skills for today's and tomorrow's market, masters degree programs must prepare graduates with a broad range of competencies.
Today, the CNS role can be conceptualized as being implemented in three different but interrelated domains, each with correspondingly different spheres of influence.
The competencies needed for CNS practice today are greatly expanded from those needed in the 1960s and 1970s. Although discussion of the evolutionary history of the CNS is beyond the scope of this paper, and has been addressed elsewhere (American Nurses Association, 1980; Montemuro, 1987; Peplau, 1965; Sills, 1983), it is important to note that during the 1980s there was an important evolutionary leap in the CNS role (Wolf, 1990). This leap expanded the domains of CNS practice into two additional domains, it expanded the CNS role from providing expert nursing care to a "case load" of patients with complex nursing care needs to working with staff nurses and corporate management to enhance or improve patient outcomes cost-effectively so ass to benefit a large number of patients. Today, the CNS role can be conceptualized as being implemented in three different but interrelated domains, each with correspondingly different spheres of influence.
The first domain of practice is characterized by a focus on the patient or client as the customer. When practicing in this domain, the CNS is focused on the provision of expert, theory-based and research-based care of patients/clients. Competencies at the first level of practice, which are also a requisite for the other levels, include but are not limited to expertise in: (a) functional health assessment (eating, elimination, ADLS, hydration, sleep/rest, mobility/activity, balance, self-care, stress management, somatic discomfort, skin integrity, risk behaviors); (b) differential diagnosis of symptoms (e.g., nausea, fatigue, pain, incontinence, sleep disruption, deconditioning) and functional problems (e.g., activity intolerance, difficulty swallowing, body mechanics, decisional-conflict) that require nursing interventions; (c) implementation of nursing therapeutics (e.g., pain modulation strategies, pyschoeducational counseling, neuro-muscular facilitation, health behavior change strategies); (d) consultation; (e) interdisciplinary collaboration; (f) critiquing theory and research for potential use in practice; and (g) designing, implementing, and evaluating innovations in practice. The CNS, unlike the NP and, regardless of population focus,is not focused on the diagnosis and pharmacological treatment of disease but instead is focused on the diagnosis of symptoms and functional problems that require nursing therapeutics. This is not to say that NPs do not do any nursing care or that CNSs are never concerned about disease or the need for adjustments in pharmacological interventions. It is to say, however, that the distinctive focus of the two roles, even at the first level of practice, requires a different set of competencies for each role. The first level of competencies briefly described above will become increasingly important in a capitated pay system where providers in all settings cannot afford to ignore or to mistreat non-disease based illness experiences with medical therapeutics.
The second domain of CNS practice falls under the rubric of "clinical outcomes manager" and represents a broader sphere of influence than the first level of practice. At the second level of practice the CNS's work is still purposed toward the cost-effective improvement of patient outcomes, yet the primary clients are staff nurses and other care providers. The CNS practicing within the second domain must have a "system" perspective with additional competencies in: (a) identification of "population" needs and "population" focused intervention strategies; (b) coaching and mentoring of staff; (c) diagnosing system problems/problem tracking/problem solving; (d) innovation, development and evaluation of nursing interventions; (e) interdisciplinary team leadership; (f) cost-benefit analysis; and (g) product and program evaluation. In addition to these competencies, CNSs practicing at the second level will commonly be involved in "re-design" efforts and thus need an appreciation for issues important to human resource utilization (skill mixes) in the delivery of a clinical service. The competencies of a clinical outcomes manager are essential to the successful implementation of clinical practice models that will maintain or improve quality while reducing costs.
The third domain of CNS practice is characterized by an even broader sphere of influence and often encompasses an entire institutional or network focus. When practicing within the third domain, the CNS is the farthest removed from direct patient care. However, the CNS's work at this level is still targeting quality of care and cost. Competencies in this domain include: (a) use of effective system-wide change strategies, (b) development and refinement of institutional-wide patient-care policies, and (c) development of practice models that facilitate transition of patient populations and providers across settings.
The CNS and NP roles are constructed to meet distinctly different societal needs and market demands. Therefore the competencies required to effectively carry out each role are more different than alike. Given that the set of competencies required for each role are different, it is unrealistic to think that the two roles can be blended in a time-limited masters program. Furthermore, it is questionable that, unless a CNS has a very circumscribed practice focus, it would be possible to effectively blend the full scope of both roles via post masters study. It is difficult to imagine that one person could continuously master two different areas of science while concurrently developing expertise in the application of both. Because societal needs for both the CNS and NP are distinctly different, and therefore the competencies required to effectively carry out each role are more different than alike, it is unrealistic to think that the two roles can be blended in a time-limited masters program.
The author wishes to acknowledge the helpful feedback on the early draft of the article from Sue Davidson, Associate Professor, University of Oregon Health Sciences Center, and Jan Bingle, Director of Advanced Practice Programs, Community Hospitals of Indianapolis.
Letters about this article
Meeting Societal Needs for CNS Competencies
by Pamela A. Assid (March 24, 1997)
Chairperson, Department of Nursing of Adults
Indiana University School of Nursing
6563 Calais Circle.
Indianapolis, IN 46220
Email Address: firstname.lastname@example.org
Dr. Brenda Lyon is an Associate Professor and Chairperson of the Department of Nursing of Adults at Indiana University School of Nursing. She is Director of the IUSON Office of Nursing Practice and a Clinical Nurse Specialist in private practice focused on the diagnosis and treatment of stress-related illness. She is an Adjunct Clinical Nurse Specialist with Community Hospitals, Indianapolis, and Vice-President of the National Association of Clinical Nurse Specialists.
Article published June 1996
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