Historical Perspectives

In 1943, Frances Reiter espoused the concept of the "nurse-clinician" which embodied three aspects of clinical practice: "(1) clinical competence in the dimensions of depth of understanding, range of function, and breadth of services; (2) clinical expertise for coordination of and responsibility for continuity of care; and (3) professional maturity in collaboration with the medical profession." (Sparacino, 1990, p.4). During that same decade the National League of Nursing Education recommended that universities develop a curriculum at the master's level, to educate advanced clinical nurses, primarily in the psychiatric discipline. There was a shift from preparing a nurse in the functional role to developing knowledge, expertise, and competency in all clinical nursing areas. (McGivern, 1993; Sparacino, 1990). In predominantly hospital settings, the CNS offered expert patient care and consultation, role models for less experienced staff and facilitated clinical research.

In 1965, the first nurse practitioner (NP) program was developed by Loretta Ford and Henry Silver, based on a model for health promotion and disease prevention in the pediatric population. According to Ford, societal needs, nursing's potential, and the primary care physician shortage provided the opportunity for this new nursing niche. (McGivern, 1993). This role has grown from a three month formal preparation beyond the basic nursing education program ("Division defines ", 1994; Gaedeke & Blount, 1995) to master's level NP preparation in family health, pediatrics, gerontology, adult health, women's health, neonatal care, obstetric/gynecologic care, acute care, and psychiatric/mental health. (Snyder & Yen, 1995).

Thus, the CNS and NP roles were originally created with different goals in mind. The CNS is skilled in consultation, professional and patient education, advanced specialty clinical expertise, analyzing health care systems, and research to improve patient outcomes and the professional practice of nursing (Gaedeke & Blount, 1995; Page & Arena, 1994).

This places the CNS in the unique position to link research and nursing practice within a specified discipline. (Gawlinski, 1995).

The NP provides direct, holistic, comprehensive care to the patient while maintaining a family focus. Practice knowledge base spans nursing and medical diagnoses. Because NPs functions include assessment and treatment within the stipulated scope of practice, they have the greatest impact by delivering direct patient care as a primary provider. (Page & Arena, 1994; Snyder & Yen, 1995). Studies have shown that NPs provide care as good as or better than physicians, while being more cost-effective. (Ramsay, MacKenzie & Fish, 1982; Safreit, 1992; Snyder & Yen, 1995).

Current Controversy

Although the original intent of the CNS and NP roles were different, the title Advanced Practice Nurse has been put forth to encompass both roles. In 1992, the National Council of State Boards of Nursing and the American Nurses' Association promoted the designation of the APN. Overall their recommendation--and the view of this author--was to merge the roles so that NP + CNS = APN. The overriding concept is that the blending of the preparation and practice modalities of the NP and the CNS into APN would create the following benefits:

• Generate initiative and control in the practice of nursing
• Simplify the concept of nurses in the advanced practice role for consumers and for practice sites
  • Enhance productivity in the acute care setting, especially important in the era of health care reform and the consolidation of depleting resources
  • Enable practitioners to follow patients through various care settings
• Engender greater political visibility. (Clancy & Maguire, 1995; Faller, Dowell, & Jackson, 1995; Giacalone, Mullaney, DeJoseph & Cosmo, 1995; Ingersoll, 1995; King, 1995; Rudisill, 1995; Snyder & Yen, 1995).

Much has been written about the merger of these two distinct nursing roles. The role of nurse practitioner has been traditionally functional. The role of clinical nurse specialist has been predominantly consultative, research generating, and more oriented to nursing practice. The blending of roles is a viable alternative as we mold and shape health care delivery systems of the future, and promulgate nursing's position in the dynamic shifts currently occurring.

In parent-child nursing there are several different types of roles that could be subsumed under the APN model. Certified nurse midwives offer prenatal care to mothers whose pregnancies are uncomplicated. OB/Gyn and Women's Health Nurse Practitioners offer well-woman care across the reproductive continuum. Neonatal Nurse Practitioners frequently work in newborn nurseries or in the neonatal intensive care unit. The inpatient obstetric clinical nurse specialist works with the high risk antenatal patient, directing care of nurses and ancillary personnel and often functions as a case manager between insurer, primary medical care provider, hospital and community.

Future Implications

Traditional roles of parent-child NPs and CNSs are already beginning to blur and it is thus time to merge the roles under one APN model. The critical question is "what will be necessary to create the new parent-child APN of the future?" Several dimensions need to be taken into account during such a transition:

Those who currently practice as NPs need enhanced educational preparation in systems management, consultation, and research, as well as a minimum of master's preparation in the specialty. Those currently in the CNS role need to perfect assessment skills and primary care management techniques.

Educational funding is being squeezed at both the federal level and at the employer level. Given cost and time constraints, the existing institutions of higher learning must construct curricula to meet the preparation needs of the new APN role. Those nurses currently designated as NPs and CNSs must be prepared to meet the demands for the new parent-child APN role with the most efficient use of time and money. (King & Ackerman, 1995).

Legislation governing the practice of nursing exists in every state. At least 18 states currently have either no title designation or have limited practice focus for the nurse in the CNS role. (Pearson, 1996). For those states which have defined the APN role with the designation of NP, CNS, NA, and NM, new legislative language must be enacted that supports the combined role concept. Provisions must be made to assess how the expanded APN role will affect a nurse's exposure to professional liability claims.

The method by which reimbursement will be allocated for the nurse in the combined APN role must be examined. We must assess not only what presently exists, but as payment modalities rapidly move from fee-for-service in diagnostic related groups to managed care payment by capitation, we must identify equitable reimbursement for all providers, including nurses. (Betz, 1995).

The key components of health care reform include access to an appropriate care provider, continuous quality management and cost-containment -- providing the right care by the right provider in the right place at the right price. It is imperative that APNs identify and effect outcomes. (Brooten & Naylor, 1995; Buppert, 1995; Smith, 1995). This requires measurement of cost containment, care effectiveness, and patient satisfaction.

Nurses in the advanced practice role must be educated to conduct research, a facet that is woefully inadequate in every provider classification. These nurses must be educated to systematically examine patient outcome research questions as well as service delivery questions e.g. "what works, by whom, and why".

Currently, most NPs work in collaboration with, or under the supervision of, a physician. Given the thrust toward the APN title, medical providers must be educated regarding the scope of practice that is uniquely nursing. There will be an even greater need for interdisciplinary education to further encourage the concepts of appropriate utilization of resources as well as collaborative practice. (Avery, 1995; Larson, 1995; Norsen, Opladen, & Quinn, 1995; Stone, 1995). This task will be even more arduous than merging the CNS-NP roles!

Conclusion

Norma Chaska (1990) refers to the kaleidoscope as an appropriate prototype for the nursing profession. The word is derived from the Greek terms for "beautiful", "form", and "to see". (p.645) It symbolizes diversity, individual scopes, and a holistic spectrum.

Should there be a merging of the CNS-NP roles in parent-child nursing? I think so. Yet we must carefully examine the benefits and liabilities of each role before blending them. Nurses are vital to assuring that the patient remains the focus of care. The clients we serve must be assured that the nomenclature represents a standard in education, credentialing and regulation that designates quality. ("Advanced practice nursing ", 1995). This is even more imperative when the nurse as APN will care for the client across the life span, as is the case in parent-child nursing. This care will be given primarily in the community, with only periodic episodes in the acute care setting. In effect, the tenet of wellness will necessitate the community to be our client.

In this time of evolution, we must seize the moment. We must be instrumental in shaping the change. However, we must remain vigilant that the facets of the CNS and NP roles in the kaleidoscope remain sharp and intact as we create the new vision.

Letters about this article

At the Crossroads
by Carol Scoville (March 25, 1997)

Author

Annette M. Lynch, MSN, RN

Director Professional Nurse Associates, Inc.
330 S.O.M. Center Road
Cleveland, Ohio 44143

Annette M. Lynch, R.N., M.S.N. is a Principal, Director, and Corporate Secretary of Professional Nurse Associates, Inc., a private nursing practice specializing in consultation, nursing care and education.

Annette holds degrees from the University of Detroit Mercy (B.S.N.) and Case Western Reserve University (M.S.N.), where she was educated as a clinical nurse specialist in maternity nursing. Her clinical experience includes labor and delivery, postpartum, and newborn nursing in both community and teaching hospitals. She has taught nursing students at Lakeland Community College and Ursuline College. She is an adjunct professor at the University of Akron.

Annette has published research on maternal stressors associated with the birth of a second child. Together with her colleagues in practice, she authored the Postpartum Home Care Record System and a companion Orientation Manual nationally marketed through Hollister, Inc. She was a principal author of the Ohio Nurses Association (ONA) Continuing Education Manual. She was the primary author of the chapter, "Maternal Child Nursing: Postpartum Home Care" in Home Health Nursing Practice: Concepts and Applications (2nd Edition). She writes a quarterly column, "Nurses And Politics Go Together" for The Voice(Greater Cleveland Nurses' Association), and is editor in chief of a quarterly newsletter, House Calls: Contemporary Perinatal Home Healthcare Nursing.