The purpose of this article is to advance the debate about whether the NP or the CNS alone should be the predominant advanced practice role in psychiatric-mental health nursing, or whether a blended advanced practice role is more appropriate for meeting the needs of services in the 21st century. We argue that a blended role is most appropriate in moving the psychiatric-mental health nursing specialty forward. The blended advanced practice role retains the excellence of our psychosocial tradition and incorporates the biological perspective of the future.
Key Words: Advanced Nursing Practice, Clinical Nurse Specs, Education, Nursing, Masters NP's, Nursing Role, Psychiatric Nursing
Introduction
Health care reform has captured the public's attention regarding the who, what, when, where, and how of advanced practice nursing. The titles, nurse practitioner (NP), clinical nurse specialist (CNS), nurse anesthetist (CRNA), and nurse midwife (CNM), have gained more name recognition than ever before. However, understanding the distinctions between these advanced practice categories and their related roles and responsibilities is much more of a challenge, particularly in relation to NPs and CNSs.
At the national and state levels, concern about the quality of health care and cost containment has resulted in increased pressure to define what CNSs and NPs do and to differentiate the contributions they make in client and family outcomes and cost of care. Within the nursing profession itself, documenting the nature of each of these advanced practice roles and demonstrating the differences CNSs and NPs make in the delivery of client care is an oftentimes heated debate. Locating the debate within a specialty such as advanced practice psychiatric-mental health nursing adds more fuel to the fire by trying to determine which advanced practice role should be the predominant one, the CNS or the NP.
The purpose of this article is to advance the debate about whether the NP or the CNS alone should be the predominant advanced practice role in psychiatric-mental health nursing, or whether a blended advanced practice role is more appropriate for meeting the challenges of delivering psychiatric-mental health nursing services in the 21st century.
Historical Context
Fifty years ago, the National Mental Health Act of 1946 authorized the establishment of the National Institutes of Mental Health and provided federal training funds to undergraduate nursing programs to integrate mental health concepts throughout the curriculum. This Act also established graduate programs in psychiatric nursing, making psychiatric nursing the first nursing specialty that required a Master's Degree. These nurses had graduated from advanced psychiatric nursing programs and were referred to as masters level nurses (Chamberlain, 1983). They were so busy "doing the work" and carving out ground breaking roles, that a formal titling ceremony never occurred.
The early psychiatric nursing graduate programs were located in the population centers on the East Coast. As programs proliferated in different parts of the country, regional needs began dictating curriculum and roles for graduates. Once again graduates were busy "doing" and the designation of an "official" global reference for advanced practice psychiatric nursing did not occur.
The CNS Role
Despite lack of an "official" title, these masters level psychiatric nurses were busy blazing trails in public health settings, psychiatrist's offices, their own solo and group private practices, public and private sector acute and long-term inpatient units, schools, and the workplace. In addition to providing individual, group, and family therapy, these nurses also carved out indirect practice roles as consultants, educators, researchers, and administrators. For the past 50 years, masters level psychiatric nurses have been found with equal frequency in outpatient and inpatient settings. As other nursing specialties evolved at the graduate level, the term clinical nurse specialist (CNS) emerged in the late 1950s. The CNS role was conceptualized as a way to provide expert specialty patient care, consult, teach, conduct research, and act as a staff role model in the CNS's area of specialty (Naylor & Brooten, 1993).
More recently, prescriptive authority became a potential or actual dimension of the CNS role. Prescriptive authority and related supervision and collaboration requirements for CNSs vary from state to state according to Nurse Practice Act statutes and rules and regulations. At this time, the majority of the 48 states that grant prescriptive authority to CNSs do so only for those CNSs who are nationally certified by ANA as specialists (CS) in psychiatric-mental health nursing. This enables advanced practice psychiatric nurses to move beyond the historical role of monitoring psychiatric medications prescribed by other mental health clinicians to providing primary psychopharmacological care (Talley & Caverly, 1994).
The NP Role
In 1965, twenty years after the first graduate program for psychiatric nursing, the first nurse practitioner program developed to provide access to children who lacked basic primary care services. Conceived of and born in an era of physician shortage, the use of nurse practitioners quickly expanded to encompass primary care services to adults and the elderly where there was a shortage of primary care physicians (Mezey & McGivern, 1993). Inasmuch as NPs were originally intended to be physician extenders, the delivery of primary care services necessitated the inclusion of prescriptive authority. The scope of prescriptive authority and related supervision or collaboration requirements have varied from state to state, according to state Nurse Practice Act statutes and rules and regulations.
The original academic preparation of NPs occurred in certificate programs that did not require either a bachelor's or master's degree. Frenzy in academic circles occurred regarding what this frequently non-collegiate educated nurse should be eligible to perform. However, by 1989, 85 percent of all federally funded NP programs were at the master's level (Mezey & McGivern, 1993). Currently, the majority of national certification programs require a master's degree as an eligibility criterion for taking NP certification exams.
The Debate
Now that both CNSs and NPs are regarded as having advanced practice titles and roles, one related debate focuses on whether to merge CNS and NP roles using the title of advanced practice nurse (Cronenwett, 1995; Page & Arena, 1994; Soehren & Schumann, 1994). Another debate has been ongoing about which role best meets the physical and mental health care needs of patients and their families (Elder & Bullough, 1990; Lego, 1995; Caverly, 1995). Both debates are relevant to the future of advanced practice psychiatric-mental health nursing.
To Merge or Not To Merge: The Eternal Question
The recent literature (Soehren & Schumann, 1994; Cronenwett, 1995) has highlighted a number of arguments in favor of the merger of CNS and NP roles including:
- Practice settings for both are expanding and overlapping.
- Many similarities already exist in roles.
- Unity and an increase in critical mass would give more power to advanced practice nurses.
- Many similarities already exist in educational preparation.
- Cost-effectiveness for colleges and universities would result if graduate tracks were combined.
- One educational product, the advanced practice nurse, would be prepared to fill a variety of roles in the health care system.
Equally persuasive arguments against merger of the CNS and NP :
- The scope of practice remains different, NPs are typically primary care providers who manage illness and promote health whereas CNSs are acute care subspecialists.
- Titling concerns exist regarding name recognition and legal issues
- Role strain, role blurring, and role confusion will increase as evidence of NP involvement in acute care settings expand, and CNS involvement in primary and ambulatory care settings increase.
- Advanced practice nursing may be jeopardized because nurses in merged roles might find it difficult to keep nursing as their primary focus.
Will the Most Effective Advanced Practice Psychiatric-Mental Health Nurse Please Stand Up
For the advanced practice psychiatric-mental health nursing specialty, the pros and cons of choosing the CNS or NP role or committing to a blended advanced practice role raises several compelling issues and questions for the specialty. Each question is discussed below to highlight the imprudence of retaining the roles as separate entities.
One, the meaning of the title clinical nurse specialist in psychiatric-mental health nursing is not well understood by legislators, health administrators, insurers, or the consumer public. Nurse practitioners have achieved a high level of name recognition. The public understands what primary care is and associates NPs as providers of primary care in outpatient settings. In contrast, CNSs in general, including those specializing in psychiatric-mental health nursing, do not have a high level of name recognition. This may, in part, be explained by the fact that the specialty of psychiatry has historically been poorly understood and viewed as threatening. It may also be explained by the fact that many psychiatric CNSs have identified themselves as psychoanalysts, psychotherapists, family therapists or with other such labels that obscure their professional nursing identity. Whether this phenomenon occurs because CNSs are trying to "pass" as members of a more elite mental health discipline or just lack marketing savvy, opportunities for consumer education about and marketing of psychiatric CNSs and the value of the mental health services they provide are lost. We ask the question, do some psychiatric CNSs want to become psychiatric NPs to enhance their name recognition and acceptability as health care providers?
Two, because of rapid and radical changes occurring in health care delivery, the "eliteness" associated with specialty health care has been pushed aside by the demand for "who can do it safely, quickly, and economically" by both the public and third party payers. As health care delivery shifts to a capitated, community-based primary care system, NPs appear to be an answer to that demand! As a result of convincing outcome data, excellent marketing strategies, and assertive lobbying efforts, the consumer public and insurance companies associate nurse practitioners as providers of generalized medical services equivalent to or substitutable for the majority of those provided by primary care physicians. It therefore makes sense that managed care companies and public and private sector insurers are seeking to employ and reimburse NPs more readily than CNSs with whom they are unfamiliar or who, in the absence of a cohesive package of cost-effectiveness and quality CNS outcome data, they regard as providers of expensive specialty care. We ask the question, do educators and psychiatric CNSs believe that the NP title will provide a more marketable product?
Three, identity confusion is further enhanced by regulatory issues associated with the plethora of advanced practice titles promulgated by State Boards of Nursing which are used to codify advanced practice categories as well as determine which advanced practice categories are granted prescriptive authority and the ability to write orders for treatments for acute and chronic illness. Each state Nurse Practice Act is different in what it codifies. For example, in Washington, Oregon, Montana, Florida, and Iowa all advanced practice nurses, irrespective of advanced practice category, are licensed as Advanced Registered Nurse Practitioners (ARNP) and have prescriptive authority.. In contrast, in Georgia, Connecticut and Utah, CNSs and NPs who meet the requirements for prescriptive authority are licensed as Advanced Practice Registered Nurses (APRN). In Alaska and Wisconsin, the license is APN or APN-P (advanced practice nurse and advanced practice nurse with prescriptive authority). In New York, NPs are the only advanced practice category codified in the Nurse Practice Act, thereby granting them prescriptive authority. Psychiatric CNSs who want to obtain prescriptive authority and meet the state credentialing requirements (e.g. 45 hour pharmacology course) are certified by the State Education Department as Psychiatric Nurse Practitioners and are no longer considered CNSs. We ask the question, is there a fundamental difference in the practice of advanced practice psychiatric nurses who are ARNPs, APRNs, ANPs, NPs, or CNSs?
Four, just because CNS education in the past did not generally prepare these advanced practice nurses for the clinical management of acute and chronic illness or prescriptive authority, does not mean that it cannot and should not do so today and for tomorrow. It should be noted, however, that psychiatric CNSs have always been educated to manage acute and chronic mental illness. Moreover, with the knowledge explosion in biological psychiatry, the traditional psychosocial emphasis has shifted to a more holistic biopsychosocial perspective with a renewed understanding and valuing of psychopharmacology as a dimension of the comprehensive treatment regimen. As the biological underpinnings of psychiatric illnesses are being unraveled, it is critical that advanced practice psychiatric nurses choose to collaborate as a major player with the major mental health disciplines. Our future is destined to include state-of-the-art biological knowledge and neurobiologically based interventions (Talley & Brooke, 1992). We ask the question, does one have to be a psychiatric NP versus a psychiatric CNS to prescribe? Is the greater availability of prescriptive authority for NPs the only reason to choose the psychiatric NP versus the psychiatric CNS title and role?
Five, a final area of role confusion pertains to determining the essential practice differences between the psychiatric-mental health advanced practice registered nurse who is titled and credentialed by virtue of education, certification, or nature of clinical practice as a psychiatric CNS or psychiatric NP. According to the document Essentials of Master's Education for Advanced Practice (AACN, 1995), there is a basic common educational core in master's education for advanced practice nursing consisting of research, theory, health policy, ethics, professional role development, and social issues. Moreover, there is an advanced practice nursing core curriculum; all students take courses to develop competence in advanced physical assessment, physiology/pathophysiology, and advanced pharmacology. Beyond that are the clinical concentration courses. All advanced practice nurses must be competent in physical assessment and prepared for prescriptive authority, whether or not they can or choose to enact it. We ask the question, what would differentiate a psychiatric NP clinical concentration from a psychiatric CNS clinical concentration? Would a psychiatric NP provide primary care as well as specialty mental health and mental illness care? These are largely unanswered questions.
New Directions
In light of the above arguments and questions raised, we argue for a blended role. In this light, we agree with the consensus reflected in Nursings Social Policy Statement (ANA, 1995) and the Statement on Psychiatric-Mental Health Clinical Nursing Practice and Standards of Psychiatric-Mental Health Clinical Nursing Practice (ANA, 1994) about the designation of advance practice registered nurse (APRN) as the umbrella title for advanced practice nurses regardless of the advanced practice psychiatric nursing specialty. However, as we all know, psychiatric-mental health advanced practice registered nurses are currently being educated or credentialed as both CNSs and NPs. As indicated above, the titling possibilities seem limitless. Yet, the only national certification exams for psychiatric APRNs are the CNS exams in adult psychiatric-mental health nursing or child and adolescent psychiatric-mental health nursing either of which confers the credential, certified specialist (CS) (AACN, 1995). Psychiatric NP credentialing is only accomplished on the state level. Of course, the irony is that the psychiatric-mental health CNS certification credential must be obtained before the psychiatric-mental health NP designation can be conferred.
We believe that master's prepared psychiatric-mental health CNSs have always provided and will continue to provide the full spectrum of mental health services, that Haber and Billings (1995) define as primary mental health care, including: mental health promotion, mental illness prevention, treatment of acute mental health problems, and health maintenance; that is, management of serious and persistent mental disorders using rehabilitative interventions.
We believe that master's prepared psychiatric-mental health CNSs have always provided and will continue to provide the full spectrum of mental health services ... defined as primary mental health care, including: mental health promotion, mental illness prevention, treatment of acute mental health problems, and health maintenance.
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A holistic philosophy that operationalizes the biopsychosocial nature of psychiatric-mental health nursing care, including choices about prescriptive authority, moves the specialty forward as the twenty first century approaches. It retains the excellence of our psychosocial tradition and incorporates the biological perspective of the future, combining the best of the art and science of advanced practice psychiatric-mental health nursing.
We also believe that the practice parameters for advanced practice psychiatric-mental health nurses, whether CNS or NP, are also consistent with those for primary care nurse practitioners. Nurses with either advanced practice title are capable of diagnosing, determining treatment interventions, monitoring responses, and using complementary care providers for consultation or referral when necessary. Advanced practice psychiatric nursing expertise is based on knowledge of psychiatric and physical assessment, history taking, observation, differential diagnosis, psychotherapeutic and psychopharmacologic interventions, and evaluation of treatment outcomes (Talley & Caverly, 1994). Given the fact that the current health care system does not provide adequate primary care to clients with mental health disorders, advanced practice psychiatric nurses, with their history of holistic practice and client advocacy, are well positioned to assess basic primary care health problems and help clients access appropriate primary care resources (Haber & Billings, 1995).
Given the nature and trajectory of severe and persistent neurobiological disorders, concern has been expressed that the lifetime care needs of this client population, which numbers over 53 million, may bankrupt the health care budget. Recognizing that undiagnosed as well as under diagnosed physical health problems that have not been appropriately treated contribute to the mental health problems of this client population, Talley and Caverly (1994) propose a set of primary mental health care services that are within the role of advanced practice psychiatric nursing. Among the services proposed are: maintenance of a medical health care record in the mental health treatment record, provision of selected lifetime health screening and health education services in mental health settings (eg. blood pressure and cholesterol screenings, weight checks, education about nutrition, exercise, mammography, family planning, and Pap smears, and AIDs prevention) and evaluation of health care risks and problems secondary to psychiatric illnesses or psychopharmacological interventions (eg. diabetes insipidus, agranulocytosis, tardive dyskinesia, or hypothyroidism), and monitoring before drug treatment, during treatment, and at drug discontinuation of the laboratory and medical procedures needed to ensure safe psychopharmacological interventions. Advanced practice psychiatric-mental health nursing practice of the future must integrate this level of primary care into mental health care to provide a more holistic model of care for clients whose ability to attend to their own physical and mental health needs are compromised (Talley & Caverly, 1994). Given the previously described description of the AACN (1995) graduate curriculum of the future, we believe this role can be enacted by an NP or CNS specializing in psychiatric-mental health nursing.
Conclusion
It is time to move past obstacles created by old terminology and embrace these changing times as an opportunity to educate the public, the consumers of mental health services, about who we are and what we do. We must rapidly mature, expand or diversify our boundaries, problem-solve, reach consensus, and come of age at a time when public recognition is critical to survival. If advanced practice psychiatric nurses are to gain an cohesive and visible identity, the dominant logic of dichotomous either/or thinking must change (Begun & White, 1995).
As advanced practice psychiatric-mental health nursing continues its quest for identity, we believe that it is time to stop wasting precious moments engaging in intra specialty conflict about whether the CNS or NP title is more appropriate or better than the other. As advanced practice psychiatric-mental health nurses develop new and innovative roles and deliver mental health care in settings as diverse as the clients themselves, the time for an identity is NOW! Whether advanced practice psychiatric nursing focuses on the care of clients with chemical dependence problems, AIDs treatment, domestic violence, or community-based programs for those with a serious and persistent neurobiological disorder, we suggest moving beyond the either/or issue of NP versus CNS. We must think of ourselves as our founders did 50 years ago, as Advanced Practice Registered Nurses (connoting that advanced practice is an expansion of basic nursing practice as a Registered Nurse) specializing in psychiatric-mental health nursing.
The American Psychiatric Nurses Association (APNA) is sponsoring the first Congress on Advanced Practice in Psychiatric Nursing in July of this year in Washington, DC. Ironically, July is the same month that this article will be posted. We anticipate that frenzied debate about titling will occur. We believe that our leaders must rally the troops to move forward in a unified fashion that will take advanced practice psychiatric-mental health nursing sensibly and cohesively into the next 50 years.
Authors
12204 W. Sundridge Drive
Ninemile Falls, WA
Mary D. Moller is licensed as an advanced registered nurse practitioner with autonomous prescriptive authority. She is administrator of the Suncrest Wellness Center, an all advanced practice nurse-managed psychiatric clinic near Spokane, Washington. Mary is also CEO of Psychiatric Rehabilitation Nurses, Inc. which is responsible for the ongoing implementation of the Three R's Program: A Wellness Approach to Psychiatric Rehabilitation. She is a member of the Advanced Practice Psychiatric Nursing Congress and the immediate past President of the Washington State Chapter of the American Psychiatric Nurses Association.
111 New England Drive
Stamford, CT 06903
Judith Haber, PhD, APRN, FAAN is a Visiting Professor in the Division of Nursing at New York University. She is a certified by ANCC as a clinical specialist in adult psychiatric-mental health nursing, licensed by the state of Connecticut as an Advanced practice registered nurse (APRN) with prescriptive privileges, and has a private practice in Stamford, CT. Dr. Haber is a past member of the executive committee of the ANA Council on Advanced Practice Nursing, is currently an elected member of the ANA Congress of Nursing Practice. She is a member of the Commission on Certification of the American Nurses Credentialing Center (ANCC), writes a column called "Politics and Policies" for the Journal of the American Psychiatric Nurses Association and is Chairperson of the Council of Connecticut Mental Health Providers, a statewide coalition of mental health provider organizations. Dr. Haber is a Fellow in the American Academy of Nursing.
Article published August 1, 1996
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