Introduction

Primary care has experienced a renaissance in this country in the 1990's. Despite intense challenges and competition, primary care nurse practitioners (NPs) in family and child nursing are not only surviving but thriving. This paper will highlight the critical role of primary care NPs and argue against the predominence of one generic advanced practice nursing role. Specifically, it is time to abandon discussions about the blended clinical nurse specialist (CNS)/NP role as the flagship of advanced practice. Instead, I offer an alternative metaphor for discussion: a rainbow of advanced practice nursing specialties. Primary care NPs in family and child nursing, such as PNPs and FNPs, while sharing a place in the advanced practice rainbow, are colors distinct from the traditionally defined CNS and other nurse specialist roles. Therefore, rather than continuing an outdated discussion of blending CNS and NP roles or introducing a model of a generic APN, our health care system would be better served by:

• creating and supporting a variety of new advanced practice roles based on needs of today's health care system.
• promoting legislative action to strengthen currently successful advanced practice roles such as the primary care NP.
• developing incentives and strategies to create a "rainbow coalition" to enhance collaboration among all the advanced practice nursing specialties.

The Evolution of Advanced Practice Nursing

Change is inevitable. Typewriters have been replaced by computers. The answering machine has evolved into voice-mail. Like many aspects of American society, health care delivery is changing, influenced by political and economic pressures, new technologies, and shifting social attitudes and values (Hickey, 1996). Consequently, the practice of nurse practitioners, like those of all health care professions, has evolved from that of the NPs who pioneered the primary care role.

These rapid changes in society and the health care system over the past decade have sparked dialogue about how best to conceptualize and label the advanced practice domains of NPs and CNSs (Elder & Bullough, 1990). Initially, debate focused on similarities and differences between these two roles. In the late 1980's and early 1990's, discussion of blending CNS/NP roles escalated. Surveys were conducted and findings highlighted the broad conceptual domains shared by CNSs and NPs (Forbes, et al, 1990). This debate has sparked considerable controversy among a group of primary care NPs who suggest that the notion of blending ignores the reality of their day-to-day practice in a primary care clinic (Hanson & Martin, 1990). It is reasonable, however, to expect that advanced nursing practice roles will continue to evolve as a result of societal and environmental influences as well as from our internal professional growth as nursing comes of age.

Creating a New Metaphor

Over the past decade, the term Advanced Practice Nursing has crept into acceptance as a way to communicate with groups outside of nursing about the collective contributions of these specially prepared nurses.

The 1993 landmark paper by Safriet and the 1995 national debate over health care reform also increased the acceptance of the umbrella term advanced practice nurse (APN). Initially this group included nurse practitioners, clinical nurse specialists, certified nurse midwives (CNMs) and certified registered nurse anesthetists (CRNAs). Recently evolving roles like the acute care nurse practitioner (ACNP), case manager, and specialty NP or CNS (i.e. pediatric oncology) are joining the collective and creating their place within the advanced practice family.

It is time, therefore, to create a metaphor for advanced practice nursing, such as the rainbow, which acknowledges the similarities among the advanced practice roles while specifying the strengths, contributions, and individuality of each role. Our similarities appear easier to understand, especially at the broadest conceptual level. All advanced practice roles share the foundation of a nursing perspective in the care of individuals and families. Regardless of their specialties, APNs build their practices on the health needs of the whole person in the context of their families and environment and address their specific health responses and concerns in a mutually participative way. They also share common goals. For example, Barnsteiner, Deatrick, Grey, Hayman, and O'Sullivan (1993) describe the following goals of pediatric nurses in advanced practice. The goals appear relevant to all advanced practice specialties.

• Improved access to care.
• Increased interdisciplinary and intradisciplinary collaboration with the healthcare system between providers delivering primary and specialized care for children and their families .
• An expanded knowledge base for clinical decision making, including health assessment, clinical judgment, health and social policy, scholarly inquiry and leadership activities.
• The provision of services in new arenas.
• Increased professional autonomy and eligibility for reimbursement by various payment mechanisms.

While the rainbow metaphor encourages us to remember that all colors together create a powerful whole, we must acknowledge the distinctiveness of each color despite their common foundations. It is paramount to balance the broad conceptual level of shared knowledge with in-depth specialty information during preparation for advanced practice roles. For example, Gillis (1996) contrasts CNS and NP curricula for APN preparation and proposes an educational approach divided into three core areas:

• graduate-level core (e.g. research, leadership).
• advanced practice core (e.g. health assessment, pharmacology)
• specialty content.

The key issue for primary care NPs is ensuring the appropriate balance between specialty content in primary care and shared advanced practice content. The practice of primary care requires an extensive and in-depth body of knowledge for basic competence in practice. It is critical therefore, to utilize Gillis (1996) proposed educational paradigm to move us away from a generic education for all of advanced practice. The generic APN role has been promoted under the guise of assuring ultimate flexibility in a time of rapid change. While flexibility is certainly key for all professionals in today's world, a sufficiently solid base of primary care skills is even more critical for primary care NPs to compete with other primary care providers such as physician's assistants and physicians. If we modify our course to allow ultimate flexibility, we will not have the foundational skills to participate in the race.

Reflection and debate to formulate a creative direction for evolving advanced practice specialties in family and child nursing is clearly appropriate in this time of rapid change. This reflection however, needs to address our strengths as well as formulate visions of the future. The primary care NP is currently one of the strongest assets in the advanced practice family. Therefore, moving toward blending the primary care NP role with the CNS role has serious untoward consequences. While blended roles clearly have a place in the rainbow of advanced practice nursing, assuming that this is the predominant direction for the future reflects serious limitations. This assumption:

• ignores current realities of the larger context of health care.
• inaccurately delineates the NP role.
• restricts our creativity in developing new advanced practice roles.
• creates serious, negative consequences for the collective of advanced practice nurses with established credibility.

Limitation #1: Ignoring Current Realities of the Health Care Context

Due to the complexity and rapid change of today's health care environment, there is no pre-eminent plan for the evolution of advanced practice. It is to our advantage to assume an open and entrepreneurial stance toward the development of new roles. A decade ago, the blending of CNS and NP roles was proposed by some as a visionary goal for advanced practice education. Now in 1996 this idea seems even more shortsighted, ignores current realities in health care reform, and overlooks the longer rhythms of change and evolution. Blending roles undermines the building of a strong foundation of primary care NPs exquisitely prepared to function competently as primary care first line management experts. Continued insistence on a blend of CNS and NP roles fuels the fire of elitism among specialities and perpetuates the stepchild phenomenon that both CNSs and NPs have experienced at different points in time. In the past, the creative and multifaceted CNS role was heralded as the ultimate goal for nursing because it offered exciting clinical and organizational contributions and allowed nurses with advanced educations to create legitimate, autonomous mechanism to improve patients' health. In contrast, the primary care NP role was often viewed as a suspicious defection into medicine and the medical model, or at best a marginal player in the nursing community.

Today the tides have turned. The wave of enthusiasm about health care reform has cast the primary care provider as the new quarterback (Goeppinger, 1996). The current potential opportunities for primary care NPs to occupy a powerful place in the changing health care system have spotlighted their contributions on a national level.

This spotlight has cast pediatric, family and women's primary care nurse practitioners, as well as other primary care NPs, as nursing's new "fair-haired children."

At the same time, in many parts of the country, CNSs have been the unfortunate victim of downsizing and cost containment due to health care reform. These cuts do not necessarily reflect the critical contributions of CNSs but instead appear financially motivated. Nevertheless, waves of nurses, concerned about future employment opportunities, are retooling or returning to graduate school to prepare themselves to be primary care NPs in anticipation of an escalating need for primary care providers. Much of this enthusiasm about PNPs, WPCNPs, FNPs, CNMs, and other specialties is well-founded. It is likely that the next decade in health care will see a continued emphasis on cost containment, coordination of services, and efficiency through greater use of primary care providers. If our individual and collective efforts and professional organizations' political action activities are successful, primary care NPs will occupy a key role in this evolving, cost-conscious health care system.

It is unlikely however, that primary care NPs will enjoy the only exciting opportunities for advanced practice. If nurses can maintain the creativity from which the CNS was conceived, we will continue to generate potential roles in which highly educated nurses can enhance the care of patients. Insistence on blending CNS and NP roles limits our vision and creativity for future possibilities and diminishes the entrepreneurial approach necessary during a rapidly evolving health care delivery system. Furthermore, while exciting opportunities for blended roles have increased, forcing the primacy of "blending" overlooks other new advanced practice roles that may not be an addition or combination of CNS or NP. These new roles often reflect portions of one or both roles with unique and important new innovations.

Limitation #2: Inaccurately Delineating the NP Role

The notion of blending has often been based on broad, sweeping generalizations and inaccurate delineation of the NP role. It is instructive to note that the label NP was initially shortened from the original title primary care nurse practitioner. PNPs and FNPs who pioneered the role, as well as most current NPs, have educational preparation and currently practice as primary care providers. Even OB-Gyn/Women's Health NPs, whose practice focuses heavily on family planning, pregnancy and STDs, are the initial and only health care providers for millions of low-income women without access to other primary care services. At first glance, OB-Gyn NPs may be considered specialists, but in reality they provide health screening and management of routine, common gynecological complaints like their generalist PNP, FNP, and Women's Primary Care NP counterparts in primary care.

Discussions often misconstrue role blending as providing CNSs with more extensive physical assessment skills or expanding their arena of care, such as for telephone and home visit follow-ups of patients with specialized needs. While this addition of comprehensive physical assessment skills is insufficient to constitute role blending, Gillis (1996) argues that these skills may be extremely useful to CNSs' response to the changing health care arena by expanding the direct care component of the CNS role.

Discussions of blending roles also overlook primary care as the core component of the NP role. Advanced health assessment is certainly the foundation for the work of NPs and all primary care providers, but it is not the only component of primary care practice and education. There are other key components to primary care practice, such as the various elements of first contact, continuity, comprehensiveness and coordination of services. For example, pediatric and family primary care NPs serve as the initial contact for children and their families and require a generalist body of knowledge to provide the initial assessment. They triage and independently manage children and/or refer them to pediatricians or other specialists for more focused in-depth assessments and management. They utilize traditional differential diagnosis to assess and treat children's most commonly occurring health complaints, such as otitis media or asthma, with pharmacologic and non-pharmacologic management of the associated symptoms.

Through frequent well child checks they vigilantly emphasize general health screening and immunizations and offer extensive health promotion and counseling about the child's growth, development and safety. The content and structure of their practice is vastly different from that of the CNS at the children's hospital who works with children undergoing cardiac surgery and coaches the staff who care for those children and families. Consequently, it is unclear whether "blended roles" reflect true blending of NP primary care practice with CNSs' tertiary care oriented, multi-faceted (researcher, teacher, administrator, clinician) specialty roles.

Often, the analysis of APN roles is conducted at such a broad conceptual level that the results paint an over-generalized picture of the similarities among the roles. For example, in their analysis of core curricula of NP and CNS programs, Forbes, et. al., (1990) chose broad conceptual categories, such as pharmacology, health promotion, nutrition, advanced role development, research, and clinical practice. As expected, most advanced practice graduate programs require content in these areas. However, detailed assessment of the specific content of broad conceptual areas, such as health promotion and nutrition, would likely paint a very different story. Beyond the basic principles, pediatric primary care providers would have unique informational needs as compared to those of pediatric oncology specialists. For example, primary care providers for children may learn about immunization schedules and approaches to introducing solid foods, while pediatric oncology specialists may focus on TPN, preventative oral hygiene and strategies for addressing anorexia. It is critical therefore, to highlight the continuing need for this specialized body of knowledge that is the essential base of the generalist primary care provider.

Limitation #3: Restricts Creative Thinking about Future Roles

Exciting new possibilities could arise from this time of health care system transition and change. Debates about blending NP and CNS diminish that expansive thinking by using an additive model of NP plus CNS. Instead, we need to think more expansively and adopt an entrepreneurial approach to refining the possibilities for advanced practice nurses. For example, it would be instructive to study current trends of specialty care and specify precisely how chronically ill individuals might benefit from APN care.

One example of this new evolution is exemplified in a new specialty role which may be labeled NP, CNS or, inaccurately, as "blended." This role is not a blending of CNS/NP and is not tertiary/acute care. Instead it occupies a role in specialty care similar to the role the NP assumes in primary care. Nurses with advanced, in-depth education and expertise in a specialty area, such as oncology or cardiology, assume major responsibility and accountability for physical assessment, differential diagnosis, and pharmacologic and non-pharmacologic management of specialty related medical problems. They are usually based in a specialist ambulatory care setting (cardiology, orthopedics, urology, oncology), and work independently yet collaboratively with physician colleagues to co-manage and coordinate panels of patients who share common problems. As a new type of advanced practice nurse without a well-identified and consistent label, they are making critical contributions to quality enhancement, continuity of care, and holism in special populations of patients.

An example of this role seems to be what Hobbie and Hollen (1993) inappropriately describe as a "blended role" where pediatric nurse practitioners in oncology (PNP/0) specialize in caring for of a formerly acutely ill population, childhood cancer survivors. They note that the role melds the responsibilities of clinician/caregiver, educator, and researcher. They assert that among specialty care providers there is a clear demarcation between the primary care provider's role and that of the PNP/O, where all routine care including minor illness is first filtered through the local primary care provider. However, they note that any concerns related to the past family medical history of cancer can be evaluated initially by the PNP/O. While this role appears to provide some exciting opportunities for filling important gaps in the health care system, it appears to contain little evidence of blending roles with the advanced practice nurse providing primary care to the children.

One example of ambiguous role categorization is Sawyers' (1993) description of a combined CNS and NP position. This role was labeled "gastrointestinal malignancies CNS" because of the fluidity of the movement in between the tertiary care and ambulatory care settings. The role provides opportunity for continuity of care during acute illness and exacerbations, and attends to the reality that most oncology patients spend the majority of their time at home, cared for by family members and managed by specialty providers on an outpatient basis.

Another example of creative additions to the advanced practice family is the acute care nurse practitioner (ACNP). Some view this role as the blending of the NP and CNS. Another possible interpretation is that the ACNP is one the new advanced practice nursing specialty described earlier that is responsible for management of a target population. The focus of the ACNP is acutely ill hospitalized patients or individuals with a specific type of life threatening illness. Richmond and Keane (1996) note that "ACNPs draw on the strengths of the primary care nurse practitioner, but focus specialized knowledge and skill on the management of select patient groups who often have acute and specialized healthcare needs. [They] "incorporate both the caring paradigm of nursing and parts of the therapeutic paradigm of medicine" (p. 316).

Another new hue in the rainbow of advanced practice is the provision of primary care to individuals with a specific disease or type of health problem. Examples of this phenomenon might be advanced practice nurse specialists who manage (or co-manage with a specialist physician) a group of chronically ill individuals while also providing primary care to the same population.

Examples could be APNs who provide ongoing primary and specialty care for diabetic children or paraplegic adults. This role would indeed require a true blending of specialist and primary care knowledge and expertise.

It is imperative to create a foundation and an environment for the continued development and evolution of new advanced specialty roles to fill unmet needs in the health care system. Some current APN roles evolved from a period of primary care NP practice and naturally or serendipitously developed over the course of time, as do most career trajectories. Many others among these new types of APNs appear to have struggled with difficult launchings of their roles. The only option for many of these APNs, because regulatory constraints, was to be educated as primary care NPs. Furthermore, until recently, there have not been graduate programs with sufficient flexibility and vision for this new approach to education. Primary care education and credentials have been perceived as the only option for entry into any autonomous advanced practice. These inappropriate educational and regulatory constraints must be addressed. APNs entering specialty or acute care oriented roles must experience a relevant, specialty-oriented educations. They must become licensed and credentialed to appropriately reflect their intended practices. Using the door of primary care education and credentials for specialty practice is fraudulent, significantly weakens our collective creativity in developing new roles, and jeopardizes our professional accountability to the public.

Limitation #4: Creating Negative Consequences for Established Specialties

Finally, the insistence on blending the traditional CNS and primary care NP has serious, negative consequences for the collective of advanced practice nurses and focuses on only part of the larger picture of the health care system. Current trends suggest that some of the categories of advanced practice nurses, such as primary care NP, CNM, and CRNA, will remain relatively intact (not merged) for the foreseeable future. Given the current direction of health care reform, exponential increase in the number of nurses entering these three traditional advanced practice roles is predicted (Goeppinger, 1996). Primary care NPs and CNMs are central to virtually every current proposal designed to increase access to primary care for our nation's citizens. It is likely that they will be called on to do what they already do very well on a considerably larger scale. Therefore, over time, their preparation for and enactment of those roles will become more sophisticated and efficient. These APNs will work closely with their other colleagues (MDs and PAs) in managed care systems in outpatient ambulatory care clinics. Primary care provided by NPs is a reasonably straightforward concept to explain to health policy makers (since primary care is a designated medical specialty). Primary care NPs and CNMs are a known commodity to many policy makers and legislators and considerable research documents their efficacy. Consequently, they are well positioned in a time where there is an openness to change.

These opportunities, however, could quickly dissolve if our tunnel vision forces all preparation for advanced practice into a blended role paradigm. Primary care NPs, who are facing escalating competition with PAs and MDs for positions as primary care providers, would meet disastrous consequences without a strong and intensive preparation in primary care. If nurses from blended role backgrounds seek traditional primary care positions, they will bring less in-depth preparation in primary care than other providers such as PAs. It may decrease their competitiveness as well as affect other professionals' view of the competence of nurses as primary care providers. While expanding the breath of knowledge and expertise of primary care providers is certainly a laudable ideal, the realties of limited time and resources in graduate education allow little opportunity for significant expansion. Instead, the objective of educating a safe, competent entry-level primary care NP who can compete with other primary care professionals for available positions needs to remain paramount as a strategy for today's and tomorrow's healthcare market.

Does that mean that blended CNS/NP roles should not exist or are not possible in graduate education? Absolutely not. Nurses at all levels need to be encouraged to approach advanced practice in entrepreneurial and expansive ways. Some will want to prepare for established roles like primary care NP, CNM or CRNA. Other nurses who have specialty backgrounds may see new and exciting possibilities for expanding their current practices and improving care to their patients in advanced practice roles. It is imperative that graduate programs offer options for new blended and specialized APN roles as well as for established roles such as primary care, nurse midwifery and nurse anesthesia. All of these are the colors in the rainbow of advanced practice. Each type of nurse will have their unique challenges in securing employment. While primary care NPs compete with PAs and MDs for positions, other APNs will likely create new positions. They will face unique challenges when interpreting their role and expertise and future employers will be unfamiliar with their potential contributions.

Future Directions

All possibilities in the advanced practice rainbow need support and cultivation. Our nation's health needs extend considerably beyond traditional primary care. For example, cancer and cardiovascular disease as the leading causes of death require intensive specialist APN care and management. Many of the nation's health care needs are met and will continue to be provided by advanced practice nurses in blended roles, newly evolving roles, and traditional CNS roles.

The recent political realities and opportunities requiring a more unified voice call forth the imperative that having advanced practice nurses work together under one rubric is not only an "idea whose time has come" but a political necessity and a key to our collective survival. In a 1990 debate about merging NP and CNS roles. Hanson & Martin argued that it is crucial to keep titling or other professional issues from impinging on the need to focus on political power:

The real name of the game in this issue is power. Power gives the clout that we need when we come before national legislators; power makes the advanced role in nursing strong and reliant. Especially from a marketing standpoint, power is essential and we must keep this clearly in our vision (p. 3).

These words are even more salient in today's volatile health care environment. Hopefully, our increasing political savvy will continue to keep our collective vision clear and our collaboration paramount in our minds.

It is equally critical, however, to keep our thinking clear and not confuse political unity and collaboration with role delineation and evolution. We must not dismantle the gains made in refining the education and implementation of advanced practice specialties. Clearly there are a number of colors in the rainbow of advanced practice nursing: NP, CNS, CNM, CRNA, and ACNP, as well as new roles with yet to be determined titles. The rationale for the rainbow is based both on professional issues and marketing opportunities. As we add new shades and colors to the rainbow of advanced practice nursing, it is imperative to refrain from undermining the practice and status of primary care nurse practitioners, nurse midwives and nurse anesthetists. These groups have been lauded by many outside of nursing for their historical contributions to health care delivery and serving the underserved.

The amount of collaboration occurring between the currently specified advanced practice groups in order to move nursing's professional and political agenda forward has significantly escalated in the past several years. There is clear value in including all our "cousins" as we talk about advanced practice. We have by necessity come together around our political agenda to free ourselves from some of the professional (legislative) constraints to practice. It is time, therefore, to eliminate this discussion of blended roles as the predominant vision for the future. Instead we must call forth our creativity to continue to bring new colors to the rainbow. At the same time, we must avoid undermining the strong, previously-established, and currently successful advanced practice roles, such as the primary care NP. The quintessential challenge is : balancing and honoring our uniqueness and individuality while recognizing our need for collaboration and mutual support in order to survive and thrive.

Letters about this article

Nurse practitioner and clinical nurse specialist: two separate roles
by Esther Ann Gilman-Kehrer (April 2, 1997)

Nurse Practitioner and Clinical Nurse Specialist are two different roles
by Phyllis Schulz, RNC, BSN (April 21, 1997)

I am a graduate nursing student in the Family Nurse Practitioner track.. .
by Lori Vanhove, RN, BA (July 13, 2001)

As a student in a Family Nurse Practitioner Program I found the article to be very educational as well as inspiring...
by Wendy Torres (June 10, 1998)

Author

Marie-Annette Brown, Ph.D., R.N., ARNP, FAAN

Profesor of Nursing
University of Washington
School of Nursing
Department of Family and Child Nursing
Box 357262
Seattle, Washington 98195.
E-mail: marieab@u.washington.edu

Marie-Annette Brown is a Professor of Nursing at the University of Washington School of Nursing in the department of Family and Child Nursing. She coordinates the FNP program and has served as the overall coordinator of the cross-departmental primary care programs. She maintains a faculty practice at the Roosevelt Women's Primary Care Clinic.

Dr. Brown conducted several research projects on the role and practice of nurse practitioners and presented papers on a variety of issues related the professional development and practice of Nps. Most recently, she published research about the experiences of new Nps during their initial year of practice. She has been actively involved in research, faculty practice and political and professional service to further the role of Nps and was named "Nurse Practitioner of the year" by the American Nurses Association. She served on the Washington State NP Executive Committee, is a past president and board member of National Organization of Nurse Practitioner Faculties and has testified at numerous state and local hearings about issues related to NP practice.