Introduction

The driving forces of health care cost containment and nursing's responsibility for helping to attain cost containment has escalated previously raised questions regarding advanced nursing practice. Namely, should the advanced practice nursing roles of the Clinical Nurse Specialist (CNS) and Nurse Practitioner (NP) merge as one? Or, should one of these advanced nursing practice roles predominate?

It is my position that the CNS and NP are both important; yet they are distinct and should remain so. Both roles are needed to address patients with clinically complex problems. Patients today are discharged from hospital care early and in increasing numbers these patients are medically underserved in the community because of problems of basic health care access. In this uncertain climate of health care reform, advanced practice nurses are a part of the solution. They are not a part of the problem.

The purpose of this paper is to 1) review the history and differences of CNS and NP (medical/surgical) roles and responsibilities; 2) describe forces bearing on the health care market and their influence on the roles of the CNS and NP; and 3) clarify the necessity of both advanced practice nursing preparations and their contributions to gaps in the health care system.

History: CNS

The CNS and NP roles are different (Mezey and McGivern, 1993; Collins and Ferrario, 1995.) The CNS role in medical and surgical nursing was originally designed to assist head nurses to prepare staff for clinical quality. This occurred at a time when both head nurses and staff were usually prepared at the diploma, associate degree or in some cases, the baccalaureate levels.

Clinical specialists were prepared at the master's level and using staff development approaches brought refined specialty nursing expertise to the patient's bedside. Some problems occurred with this new role. Nursing literature at the time documented power issues (the position of nurse manager) and authority issues (the expertise of clinical specialist) (Biordi, 1996).

These issues of roles were exacerbated by the prevailing organizational arrangements that housed the clinical specialists. That is, clinical specialists were torn between reporting structures that positioned them as independent practitioners not responsible to line authority or as integrated into unit staffs responsible to line authority. In some organizations, they were positioned as a combination of both. Clinical specialists were caught in a peculiar status; although they could be independent of units, they were also held accountable for unit based quality.

Typically the CNS reported to a single nurse executive who was responsible for the unit's nurse managers and for productivity. If, however, CNS was unit-based, the clinical specialist and the head nurses were required to come to terms about their respective bases and obligations of power.

The reality was that the power of nurse manager's office had greater longevity than the power of the CNS's expertise. Expertise requires constant updating. The line authority of the manager remains stronger than dotted-line influence of the nurse specialist. If the expertise of the CNS threatened that of the nurse manager, the job tenure of the CNS was typically affected (Biordi, 1996).

Sometimes the solution ended with supervisory responsibilities being added to the CNS. This solution split the efforts and responsibilities of CNS and provided conflict on priorities. Eventually, organizations found a niche for the CNS that permitted reporting arrangements with a secure position of the clinical specialist and without threat to the units.

Today, the CNS is typically focused on quality of care issues. But questions of CNS importance have been overshadowed by cost savings in some hospitals. Questions have included: Is it necessary that highly prepared advanced practice CNS provide services? Can lesser prepared personnel do "the work"? What difference does the CNS make? CNS efforts have been redirected toward issues of quality along with cost containment. Earlier the CNS, shaped the individual provider's nursing care; today the focus is on indirect nursing and broader hospital based care. The CNS now assesses and manages organizational system flaws, examines populations for utilization review, develops critical care paths, and provides case management (Page and Arena, 1994).

History: NP

The Nurse Practitioner role as it was originally developed focused on one-to-one direct primary health care services with ambulatory patients outside of the hospital setting. The NP was designed and educated to increase access to health care services, to educate patients, to more effectively use qualified nursing preparation to meet national health needs and to promote community based continuity of care. The NP provided important access in areas of physician shortages in primary health care. More recently the NP has been incorporated into hospital care sometimes seen as substitution for acute care house staff roles.

Role issue conflict arising in nursing circles about the NP historically has been related to the NP's ostensible abandonment of nursing to become junior physicians. The struggle continues today (Roberts, 1996). The real issue is, why does the occurrence of nurse diagnosing patients or nurse prescribing medicine change the nursing role? The issue seems false since the NP performing these functions operates with in a legal nursing framework.

Presently, NP practice varies widely by both locale and by nursing discipline. Today the NP specializes in acute care, primary health care, or specialties such as family, community, women's health, or pediatrics including neonatal intensive care. Additionally, the NP provides care in areas of medical sub-specialties.

The nursing care that the NP delivers, requires accurate and timely problem identification. This responsibility includes differential diagnosis, determination of plans including diagnostic, therapeutic and educational plans. The NP works with various amounts of interdisciplinary collaboration and teamwork. The NP role involves consultation with other health providers including physicians. (NONPF, 1995)

Differences Between the CNS and NP

Three years ago, a separatist movement occurred distinguishing the NP as a unique role in advanced practice nursing. A debate raged within the profession about whether the separatism of the NP role from the CNS was justified. The newer paradigm of the CNS and NP as separate disciplines has become more clear; the reasons for divergence have become more evident, and thus the debate has lessened, at least in some areas.

Yet the debate continues because the distinct identities of the two roles have been obviated by their empirical respective functions and role demands in advanced nursing practice. Even the continuum of distinctions are variable by locale or by state. One need only observe the roles of the NP in the coastal states as compared to the NP in, Ohio or Illinois, to realize the degree to which the role is practiced differently. It is unnecessary for nursing to be caught up in "one must predominate" debates for these two roles. More effort to recognize the demonstrated strengths of the NP and CNS would be the wiser stance.

In my twenty year experience as an adult nurse practitioner and teacher, I have found that the most demanding and distinctive feature of the NP role differentiating it from the CNS role is the direct accountability for accurate and timely diagnosis and management for patient health care outcomes over a continuum of years. This diagnosis and management requires broad based knowledge of common acute and chronic health problems along with knowledge of risk and primary, secondary and tertiary prevention. The NP must insure appropriate care for the problems with management methods adapted sensitively to the individual patients, their families and to the community at large. Accountability for the NP includes that s/he understand the standards and scope of practice (Task Force on Standards for Primary Health Care Nurse Practitioners, 1987). The scope of practice may vary by agency scope of delivery along with the legal parameters which vary by state licensure, rules and regulations (Pearson, 1996). Most importantly the NP must recognize her/his own clinical competencies.

Influences of Market and Economic Forces

Nursing is in a curious position. On the one hand, health care market forces are downsizing hospitals, eliminating registered nurse positions while procuring larger numbers of unlicensed assistive personnel (Huston, 1996). At the same time, patient acuity with the obvious need for sophisticated nursing judgement is very high. Patients are being discharged at earlier points in their recovery; the most notable being new mothers who are discharged 24 hours after their deliveries.

In such a climate, it seems obvious that there is a need for greater patient to registered nurse ratios i.e. advanced practice nurses. But economic forces of health care cost containment appear to dominate. Time will show what cost savings occur for the long term and what the overall effect is on patient outcomes (Huston, 1996). In the meantime, the NP provides direct and reimbursable care to patients. This provision of direct, reimbursable care has brought this NP role into conflict with physicians organizations who are dominant gatekeepers of the health care environment. Physicians have attempted to curtail the growth and scope of practice of the NP.

Despite physician incursion, market forces of cost containment have also driven the demand for advanced practice nurses, particularly the NP role. It is also important to recall that the NP has demonstrated sound clinical care in numerous studies for over twenty five years in primary health care settings (Brown and Grimes, 1996). In response, graduate level NP programs have grown and enrollments are up. (Berlin, 1995)

Types of NP Role

The Primary Care NP is in demand as more adult patients are moved out of the acute care facilities into their communities at early stages of their recoveries. The primary care NP addresses the need of adults, the numbers of this NP type is expected to increase as their generalized knowledge base is sought by the increasingly aging adult population. Similarly, the Family NP addresses the needs of the entire families and are in high demand because they are on the first line of entry into the health care system.

The Community NP adds knowledge that includes that of population (community) assessment, diagnosis, program development, planning and evaluation. All of these NPs offer access to health care in less costly ways. And, importantly, they provide access to health care including risk reduction, early detection and prevention to underserved populations.

The Acute Care NP has been advanced as a specialty for in patient hospital settings. Expectations have developed that indicate that the "acute care" NP must have skills more customarily defined as medical skills. These skills include suturing, chest tube insertion and removal, arterial line insertion, etc. (Clochesy, 1994). The expectations for such skills are consistent with job and organizational designs that would have the acute care NP substitute for house staff (Clochesy, 1994).

Models for the acute care NP skills are drawn from the Neonatal NP who has similar high degrees of technical preparation. The skills demanded of the acute care NP contrasts with the diagnosis and management of patients typical of the primary care NP. At issue for acute care NP is their cost to the system. Typically, salaries are higher for the acute care NP than for other nurses in the hospital system, a fact that impacts a nursing budget. If, however, as is frequently the case, the acute care NP is hired through a medical departmental budget, s/he must cover their costs by revenues. In either case, the acute care NP has not yet been well costed out with those figures provided in the literature.

The CNS, as an advanced practice hospital based nurse, is now in variable demand. In some hospital organizations, the CNS role has been "downsized". In other hospital organizations, the CNS has found new niches. The stated rationale for downsizing these highly skilled nurses is that staff nurses and head nurses are increasingly better prepared so that the CNS's specialized expertise is "no longer" needed. The impact of using unlicensed assistive personnel with their reduced knowledge has not yet been factored into the hospital issues of patient care quality (Huston, 1996). Consequently, the numbers of applicants to CNS graduate nursing programs has declined to the point that some graduate programs offer only the NP clinical preparation.

The CNS role in hospital niches has branched out into responsibility for aggregate care including patient "populations." The CNS is being asked to case manage, review utilization patterns, identify and correct systems problems and establish large scale organizational quality control. The CNS has not always been systematically prepared for these roles. The CNS may not have background knowledge of the driving forces of health economics and the underlying health policy features, epidemiology, and a population orientation with an understanding of the associated resources or gaps in community resources

The hospital organization's goal for quality rests on a reduction of patient length of stay particularly when the length of stay is not reimbursable. A crucial point in the success of the CNS responsibilities is whether this role has the power of authority to alter or change the system problems that affect length of stay.

Legal Forces

Legal forces have substantially affected the scope of practice and eligibilty for third party reimbursement for advanced practice. This is particularly true for the NP. Direct reimbursement detaches the NP from physician or agency control of billing practices and increases the patient's access to an alternative care provider. The NP has been and is well accepted and in demand by patients. Because the NP provides care at less cost, s/he is in demand by agencies seeking to lower costs, and by physicians seeking to enlarge their billable services. At the same time, these characteristics of market demand and supply have alienated those health care providers who wish to maintain the status quo.

Prescriptive rights for relatively straightforward medications for common acute and chronic problems have been legally permitted for the NP in some states, usually where the physician numbers are sparse (Pearson, 1996). Where these prescriptive rights have been curtailed, the NP is bound to physicians, who "supervise" their practice and the prescriptive management of patients. The NP continues to fight for reasonable prescriptive rights. Once s/he has legal recognition for this scope of practice, s/he has full accountability for the risks and outcomes of their prescriptions and practice. The practice of the NP with prescriptive rights stands on the NP license only.

Admission privileges, credentialling practices, oversight committees, and control of health care work places are now the next challenges faced by advanced practice nurses, particularly the NP. As agencies and patients seek alternatives to the model of physician fee-for-service, the debate revolves around how agencies will open their work places to the advanced practice nurses.

Educational Forces

A major reason that the debate occurred about a merged versus a divergent role between advance practice nurses (CNS, NP) is the consolidation of educational tracks in cost-conscious graduate programs. Higher education, like the rest of the world market, has downsized. Thus workloads, courses, and faculty resources have been impacted. Graduate faculties have tried to maximize courses to fit both the CNS and the NP role needs. But, as Page and Arena indicate (pg. 317) "while content may be the same, focus and application should remain distinct".

However, this is difficult as NP programs proliferate, and qualified NP faculty are sparse. Consequently, it is the critical reader who distinguishes the needs, roles, history, and market forces impacting on the education and products of graduate programs for CNS and NP.

A central struggle for the NP is the issue of a "lost nursing identity". The NP fears becoming more like a physician in autonomy and responsibility. This concern is mirrored by the CNS who seeks to become an NP as they see their CNS job opportunities diminishing.

I believe, this nursing identity concern is unfounded and is grounded in a belief that assumes identities are not internalized but assumed and shed easily. Roberts (1996) argues that the fear of losing one's nursing identity to a physician-like model buys into a model of nursing oppressed group behavior. Even as nurses fear the dominance of medicine, they take on the values of the dominant group (oppressor) in an attempt to be dominant themselves. In doing so they deny and devalue their own characteristics. She (Roberts, 1996) suggests that the NP is both envied for her/his autonomy and shunned for her/his dominance, as other nurses (including some NPs) fear the identification with medicine. Robert's oppression model is analytically clear and further argues that nursing group consciousness can bring about an end to unjust oppression through awareness and group action.

And yet there is another side of the oppressor argument that I would like to advance. At the psychological level, one may wish to define an "oppressor" as an evolutionary and developmental step to distinguishing oneself from that "other". Insofar as one's sense of self develops a clear definition, the need for an "other" "oppressor" wanes. Nurses must develop strong nursing identities through valuing of their own work and through education that critically evaluates nursing assumptions, actions and contributions. If nurses develop and maintain a strong sense of a nursing self, there is nothing to fear in a more autonomous NP or CNS differentiated role.

Conclusion

In this article I have argued that there is a role, an important role, for each, the CNS and the NP. It is a false dichotomy to argue that one or the other should predominate in the health care field. To argue otherwise, in my opinion, is to fall into oppressed group behavior, devaluing nursing's differences and specialties.

Both roles are needed and address different system needs. Each role has been shaped by population needs, education, market, and legal forces that have varied over time. The different preparations of the CNS and NP lead to different outcomes, purposes, and research questions.

Most importantly, the needs of the public for health care are addressed and must be met through responsive, sensitive, nursing practice. Advanced practice nurses offer much to the future: the present is not served by continuing to blur necessary role distinctions of NP and CNS advanced practice nurses.

Author

Penny L. Cukr, RN DNSc
Director, Adult Nurse Practitioner Programs
Kent State University, School of Nursing
Kent, Ohio 44224

Dr. Penny Cukr received her Nursing Diploma from Grant Hospital School of Nursing, Chicago, IL. Dr. Cukr holds a bachelor's degree in nursing from Loyola University, Chicago, IL, a master's degree in Medical-Surgical Nursing (Health Nurse Clinician) from Wayne State University, Detroit, MI and a Doctor of Nursing Science, with specialization in psychiatric nursing and primary care from Rush University, Chicago.

As an adult nurse practitioner, she was a Nursing Administrator/Practitioner at Loyola's Burke Ambulatory Medical Center, and a Practitioner/Teacher and Assistant Chair in Community Health Nursing at Rush University College of Nursing both in Chicago. In 1994, she consulted on the development and later became the Director of Adult Nurse Practitioner programs at Kent State University, Kent, Ohio, where she is located presently. She is a member of Sigma Theta Tau and the ANA.