Introduction

Health care reform in the last five years has led to the increasing visibility of advanced practice nurses: clinical nurse specialists (CNSs), nurse anesthetists, nurse practitioners (NPs), and nurse midwives. In psychiatric mental health (PMH) nursing the concept of the psychiatric nurse practitioner is a new one, spawned by several factors. The downsizing of hospitals has led to the elimination of CNS positions. At the same time, owing to the political acumen of organized nurse practitioners, federal funding for graduate programs preparing NPs has increased. Graduate programs across the country seeing enrollments drop in CNS programs and rapidly increase in NP programs have officially converted their CNS programs to NP programs, altering the curriculum to add courses in assessment, health management, and pharmacology.

At the same time the need for primary health care in America has become all too evident. The vulnerable mentally ill in public hospitals, shelters, inner cities, poor rural areas and on the streets lack primary health care. For these reasons PMH graduate students are being prepared to deliver primary health care including assessment, management, and pharmacological treatment as well as health maintenance and preventive care to psychiatric patients.

The development of the PMH nurse practitioner has led to controversy over whether NPs should replace CNSs who would be phased out, whether CNSs should stay and NPs go, leaving primary care to "generic" primary care providers, whether both should stay, or whether the roles should be combined into a new category called PMH advanced practice nurse. Table I shows the advantages and disadvantages of three of these alternatives, and I will elaborate on each.

The CNS Alone

The first CNSs were PMH nurses, educated at Rutgers University in a program started by Hildegard Peplau in 1954. (Fenton & Brykczynski, 1993). Dr. Peplau reasoned that there were so many psychiatric patients receiving little or no psychiatric care in large public mental hospitals as well as the community, that psychiatric clinical nurse specialists could make a decided impact. For the next 20 years she graduated PMH CNSs who went on to organize the field into a large cadre of nurse psychotherapists. These nurses in turn developed subspecialties, directed many graduate programs and continuing education programs and developed leadership positions around the country.

What does Dr. Peplau think about the nurse practitioner movement today? "It will do to us what we have accused others in the past of doing to us" (Peplau, 1994). She goes on to say, "The concept of 'the nurse is a nurse is a nurse' that has kept us down as a profession is now entering the realm of advanced practice nursing, and will water down specialization to its least common denominator." (Peplau, 1994).

As the concept of PMH nurse practitioner has evolved and graduate programs are designed to prepare them, many PMH clinical nurse specialists have been opposed to the idea. (Lego, 1995). They reason that primary care could be provided by physicians and the growing body of generic nurse practitioners. Using the analogy of medicine, psychiatrists are not being trained to give physical examinations and perform the many duties involved in primary care, as well as keep up with their specialty. Some CNSs see the new PMH-NP as a kind of "generalist/specialist" who would be required to know all there is about primary care and all there is about specialization, and wonder if one person could do all this well.

Because CNSs in PMH have worked so hard to have high educational standards leading to ANCC certification, most managed care organizations and insurance companies recognize CNSs as providers, though this varies from state to state. In addition, in many states, such as my own, Pennsylvania, CNSs operate independently, and need not have a formal collaboration with a physician. This is changing as states develop advanced practice regulations, and in some states CNSs must have a formal collaborative relationship with physicians. This is new to CNSs. NPs on the other hand, have historically been tied to medicine and in most states must be either "supervised" by or "collaborate" with physicians.

Because PMH CNSs value independence so much and have relied on internal regulation by the profession (ANCC), they have been reluctant to give this up and rely on external regulation by the state governments.

These battles have been lost. It's clear that each state will have an advanced practice act of some kind and there will be variation based on geographic location. Rural states like Maine, Oregon, and Alabama have regulations that allow for independent practice. Advanced practice nurses in states with lots of medical schools and lots of physicians will have to work more closely with physicians.

It's also clear that nurse practitioners are here to stay and that by working together with them and other advanced practice nurses politically we can all end up with more favorable regulations. This does not mean the role of CNS must be eliminated. In Pennsylvania all four groups of advanced practice nurses are working together.

The Nurse Practitioner Alone

Though nurse practitioners have not articulated a wish to eliminate the CNS role, the elimination of positions in hospitals and of CNS graduate programs could produce this result. It's clear that the concept of the PMH-NP is market-driven both by the availability of graduate training funds, and the need in the health care industry (insurance companies and hospitals) for less expensive health care providers. This market-driven approach is short-sighted and destructive to any profession. Menand writes, "True professions are self-regulating: they control the nature of their services and they do so by the lights of what is proper for the professions rather than what market conditions demand." (Menand, 1995, p 17).

Hospitals reason that with nurse practitioners they can get primary care provided for much less money at all hours of the day and night. This is beneficial for hospitals and for patients, but how does it effect the profession? Many studies as well as anecdotal wisdom tell us that nurse practitioners provide better primary care than primary care physicians. But will PMH nurse practitioners? This depends on how they are educated. In some of the new graduate programs students are taught a lot about physical assessments, pharmacology, anatomy & physiology, and pathophysiology, but not much of the theory traditionally considered to be core to our specialty. For example, these programs have no organized theoretical courses in psychopathology, individual, group, or family therapy. When I've asked about these deficits, I've been told these are a part of the "management" courses or that these will be taught "at the placement." We all know what that means. On-the-job training. Some of these programs use non-psychiatric patients for a primary care practicum in the first year and psychiatric patients in the second year, thereby reasoning the graduates are "psychiatric nurse practitioners."

However, some graduate programs are building on a year at the end to learn primary care, or are adding a "post-masters" extension in primary care. These programs continue to provide courses in the "core" clinical specialization. (O'Toole, 1996)

For many CNSs across the country, the role of PMH nurse practitioner is simply not appealing. This is because they enjoy practicing psychotherapy and have no interest in performing physical tasks. Many are leaving the field, and becoming social workers, psychologists, marriage and family therapists, or counselors. If the CNS role is eliminated in PMH nursing, nurses who like to use their heads but not their hands will be lost to nursing.

The Combined Role

Those who advocate combining the roles point out that overlap already exists, that this is a fait accompli in some states, that this would save money in educational programs, that the combined nurse would be more marketable, that there is power in numbers, and that the public will be less confused by all the titles in nursing. All of this may be true, but there is more to consider.

First, can one person do all this well? Can the PMH advanced practice nurse (APN) provide primary care keeping abreast of all there is to know about assessing and treating disease, health maintenance, general pharmacology and psychopharmacology and the interactions of drugs, psychopathology, psychotherapy, theory about human development and behavior? The PMH APN will be the first health profession to claim so much territory. How could this person keep up with all the new information needed and still have time to practice? The information explosion after all is why we have specialization! It is inevitable that the care this nurse provides will be watered down.

Second, because our patients need primary care, do we simply do away with specialization? Suppose cardiologists as a group decided that since heart disease is caused in part by poor diet, lack of exercise, and smoking they should eliminate the specialization and prepare primary care cardiologists who only teach good diet, exercise, and smoke-ending techniques. Who would do the highly specific cardiac management and surgery? One might argue, but no one else can do these things except cardiologists. What PMH CNSs do can be done by others - social workers, counselors, etc. But can it? Can it be done well? PMH CNSs provide high quality care because of our knowledge of general health matters and wellness learned as undergraduates (Lego, 1993). Does this mean we should abandon our specialization? Specialization does not necessarily mean abandoning a holistic approach.

Autonomy has been maintained in professions by delegating "down" technical tasks. No one confuses a lawyer with a paralegal or a dentist with a dental hygienist. Nursing has failed to gain full respect as a profession because it has not differentiated levels but has rather maintained the "nurse is a nurse is a nurse" stance (Brannon, 94). For this reason most of the public sees no difference between the diploma nurse and doctorally prepared nurse. Combining the NP and the CNS is a further example of what some consider an "anti-intellectual," self-destructive streak in nursing. By watering down our specialty to include primary care, we reduce our professional standing, follow the market forces and reaffirm that "a nurse is a nurse is a nurse."

Futurists agree that knowledge is the tool that will be marketable in the next century, and that the more specialized one's knowledge is, the better. Drucker (1994) writes:

"In the knowledge society knowledge for the most part exists only in application. Nothing the x-ray technician needs to know can be applied to market research, for instance, or to teaching medieval history. The central work force in the knowledge society will therefore consist of highly specialized people. In fact, it is a mistake to speak of "generalists." What we will increasingly mean by that term is people who have learned how to acquire additional specialties rapidly in order to move from one kind of job to another -- for example, from market research into management, or from nursing into hospital administration. But "generalists" in the sense in which we used to talk of them are coming to be seen as dilettantes rather than educated people.

This, too, is new. Historically, workers were generalists. They did whatever had to be done - on the farm, in the household, in the craftsman's shop. This was also true of industrial workers. But knowledge workers, whether their knowledge is primitive or advanced, whether there is a little of it or a great deal, will by definition be specialized.

Applied knowledge is effective only when it is specialized. Indeed, the more highly specialized, the more effective it is. This goes for technicians who service computers, x-ray machines, or the engines of fighter planes. But it applies equally to work that requires the most advanced knowledge whether research in genetics or research in astrophysics or putting on the first performance of a new opera.

Again, the shift from knowledge to knowledges offers tremendous opportunities to the individual. It makes possible a career as a knowledge worker. But it also presents a great many new problems and challenges. It demands for the first time in history that people with knowledge take responsibility for making themselves understood by people who do not have the same knowledge base." (p.68).

I have been supportive of the nurse practitioner movement since I first learned of it years ago, because I believe the health of the nation will benefit. I do not support the concept of the combined role because I don't believe one person can know all there is to know about both primary care and specialized care to provide the high level of care PMH clinical nurse specialists have tendered. I believe the move toward "generalizing" the specialist places us in a poor light when viewed by other disciplines.

The best compromise? If PMH nurse practitioners are educated to work side by side with PMH clinical nurse specialists, I would advocate for longer NP masters programs that retain the core CNS knowledge, and add on a year's preparation in primary care.

Author

Suzanne Lego RN, PhD, CS, CGP, FAAN
Private Practice, Pittsburgh, PA and Kent, OH
Editor, Perspective in Psychiatric Care: The Journal for Nurse Psychotherapists
Email Address: Lspray@telerama.lm.com

Dr. Suzanne Lego is a nurse psychotherapist in private practice in Pittsburgh, PA and Kent, OH. She is editor of Perspectives in Psychiatric Care: The Journal for Nurse Psychotherapists. She is a fellow of the American Academy of Nursing and is a certified clinical nurse specialist in adult psychiatric nursing by the American Nurses' Association. She is also a certified group therapist by the American Group Psychotherapy Association, and a founder of the International Organization of Psychodynamic Nurses. Dr. Lego has published extensively and has delivered numerous national and international presentations.

TABLE 1
A Comparison of the Nurse Practitioner, the Clinical Nurse Specialist, and the Combined Role in PMH Nursing

• Advantages
  1. Provide individual, group, and family therapy based on specific theory.
  2. Owing to ANCC certification, receive reimbursement from most insurance companies and are recognized providers by most MCOs.
  3. Practice independently without the "supervision" or regulated "collaboration" of physicians, though this is changing in some states.
• Disadvantages/Liabilities
  1. Have not been as well organized politically as NPs and have less political clout.
  2. Graduate programs are becoming more scarce than NP programs.
  3. Positions in hospitals are dwindling. CNS must practice privately in solo or group practice.

• Advantages
  1. Primary care is increasingly becoming synonymous with any health care (Haber & Billings, 1995).
  2. Underserved populations will receive better care from NPs (Lego, 1993).
  3. Legal entanglements exist when trying to include CNSs in advanced practice legislation (Cronenwett, 1995).
  4. "...as policy-makers and the public become familiar with the nurse practitioner title, CNSs will become all but invisible" (Caverly, 1995,p.65).,
• Disadvantages/Liabilities
  1. Unless programs are lengthened beyond two years, NPs have only a superficial knowledge of specialized theory in PMH nursing.
  2. Longer programs adversely affect enrollment. (Cronenwett, 1995).
  3. PMH nurses who want to practice psychotherapy alone, without doing physical exams or care will leave the field (or will not enter it) for careers in psychology, social work, or counseling.

• Advantages
  1. Many similarities already exist in roles. (Soehren & Schumann, 1994).
  2. Practice settings for both are expanding and overlapping (Soehren & Schumann, 1994).
  3. Unity and an increase in numbers would give more power to advanced practice nurses (Soehren & Schumann, 1994).
  4. Many similarities already exist in educational preparation (Soehren & Schumann, 1994).
  5. Educational institutions would save money by combining roles into one program (Soehren & Schumann, 1994).
  6. Graduates with both credentials would be more marketable (Soehren & Schumann, 1994).
  7. In many states they are already combined.
  8. The public and other disciplines would be less confused about nursing titles.
• Disadvantages/Liabilities
  1. Scope of practice is different; NPs are generalists who manage illness and promote health and CNSs are specialists (Cronenwett, 1995).
  2. Specialization is watered down, so the APN knows a little bit about a lot of things.
  3. The knowledge explosion would make it difficult for the practitioner to keep up with health and disease management, general pharmacology, psychopathology, psychopharmacology, etc.
  4. Same disadvantages as NP alone (see above).