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Molding the future of advanced practice nursing
Molding the Future of Advanced Practice Nursing * Linda R. Cronenwett, PhD,RN, FAAN
A plea for consistency in the regulation and education of nurses for advanced practice.
Few
questions in nursing have generated as much passion as the question of the future of advanced practice nursing. >3 The focus of the debate has been the issue of whether to merge clinical nurse specialist (CNS) and nurse practitioner (NP) roles, assuming that if separate roles exist, separate educational programs and professional certifications are required. In contrast, in this article I argue that all segments of our profession need to work together toward a common goal, a future in which the legal and professional regulation and education of nurses at the graduate level are aligned so that one educational product, the advanced practice nurse, is prepared to fill a variety of roles in the health care system. Soehren and Schumann 3 recently presented a summary of the arguments for and against the merger of NP and C N S roles. A r g u m e n t s in favor of merger were as follows: • Many similarities already exist in roles. • Practice settings for both are expanding and overlapping. * Adapted from a paper presented at the American Association of Colleges
of Nursing's Master's Education Conference, San Antonio, Texas, December 1994. NuRs OUTLOOK 1995;43:112-8. Copyright © 1995 by Mosby-Year Book, Inc. 0029-6554•95•53.00 + 0 3511165249
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• Unity and an increase in numbers would give more power to advanced practitioners. • Many similarities already exist in educational preparation. • Increased cost-effectiveness for colleges and universities would result if graduate programs were combined. • Graduates with both credentials would be more marketable. Arguments against merger: • Scope of practice remains different, as typically NPs are generalists in managing illness and promoting health and CNSs are acute care subspecialists. • Legal entanglements exist with trying to include CNSs in existing advanced practice legislation. • Titling concerns exist regarding name recognition and legal issues. • Graduate programs would need to be longer, adversely affecting enrollments. Page and Arena z added to the list of arguments against role merger the following issues: practitioners will experience too much role strain, role blurring, and role confusion if the roles are merged, and the profession will be jeopardized because nurses in merged roles might find it difficult to keep nursing, rather than medicine, as their primary focus.
With these arguments in mind, and returning to them at the end, in this article I summarize recent initiatives in practice patterns and the regulation of nursing practice and analyze the effect of these changes on the question of how the profession should mold the future for advanced practice nursing. CHANGES
IN P R A C T I C E
Clinical Nurse Specialist During the period from the 1960s to the 1980s, considerable emphasis was placed on identifying nursing as a scientific discipline and practice profession separate and distinct from medicine. Students in master's programs were more exposed to metatheories about the profession than to theories that would guide practice. 4 They learned more about the conduct of
Graduates of master's programs often came to clinical agencies with no discernible expansion of practice skills. research than about how to use research in practice. Time that might have been spent in the curriculum to master a body of knowledge for specialty practice was often spent on the fine points of concept analysis, clinical decision making, or role theory. Although physical assessrnent skills were taught, too little time was allotted for students to apply, with faculty supervision, these and other clinical management skills to patient populations. Graduates of master's programs often
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tions of the CNS. Under the current system, the NNPs are doing much of the on-the-spot staff development work with the neonatal intensive care unit nurses, while the CNS (who also has NNP certification but does not use those skills in her practice) performs the rest of the CNS role. The NNPs have little time away from clinical practice. Because they are employed by the physician practice, they are expected to teach medical students and residents but receive less support for teaching nursing students
The meaning of community health nursing as a specialty in the current environment is also becoming less clear. and nursing staff. Overall, the NNPs are bothered by their lack of colleagueship with other advanced practice nurses and with nursing in general. In contrast, CNSs are well integrated in communication and colleagueship networks in our department of nursing. They, are fully supported to be preceptors for nursing students. Their problem is that requests at the unit, division, department, and regional level for leadership of professional practice projects, research use projects, and teaching overwhelm them. Their time for patient care, even the consultation aspect of patient care, is limited, and they are constantly subjected to criticism for not being available on the nursing units. The CNSs and NPs report mirrorimage complaints: not enough clinical time for CNSs, not enough nonclinical time for NPs. Both groups of nurses, however, can envision advanced practice nursing roles that would improve the quality of patient care, the quality of their contributions to basic nursing practice, the quality of their teaching and scholarship, and the quality of their job satisfaction. A major barrier to testing new advanced practice nursing models, 114
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however, is the lack of preparation of all CNSs and NPs for the full scope of advanced practice. PROFESSIONAL REGULATORY INITIATIVES
During my tenure on the American Nurses Association's (ANA) Congress of Nursing Practice, from 1990 through 1994, the most difficult issues involved questions of how advanced practice should be defined, reimbursed, and regulated. Working definitions of advanced practice were developed and adopted, and the ANA consistently took the position that, in speaking for advanced practice, it was speaking about CNSs, NPs, nurse-midwives, and nurse-anesthetists. A number of professional regulatory initiatives occurred during this period.
Development of the American Board of Nursing Specialties Beginning in 1988, with the support of the Josiah Macy, Jr. Foundation, national nursing leaders worked together to create a unified approach to standards for professional certification programs, zl By 1990 eight organizations, collectively representing about 65% of the total number of certified nurses, became charter members of the American Board of Nursing Specialties. Certification boards approved by this body have a plan that provides for: • A specialty nursing practice certification requiring a minimum of a baccalaureate degree in nursing and a specified educational program in the area of practice to be implemented for new certificates by the year 2000. • An advanced specialty nursing practice certification requiring a graduate degree in nursing or the appropriate equivalent, including content in the specified area of specialty practice. 21 One other organization has since joined. Additional organizations that are not members because they do not require the baccalaureate for basic specialty practice certification have agreed to the
master's requirement for certification in advanced practice. This initiative helped the profession increase consistency in the meaning of advanced practice by requiring the master's degree for professional certification; however, the board continues to approve programs that certify nurses as either CNSs or NPs. This practice resuits in significant problems for new acute care NPs, whose content of specialty knowledge is similar to that tested in CNS credentialing examinations, yet who need NP certification (with examinations still oriented to primary care) to practice in many states. One advanced practice credentialing examination for each area of specialty would eliminate this problem.
The ANA's Revision of Nursing: A Social Policy Statement During the debates over definitions of advanced practice, the profession was working with a 1980 social policy document in which the term advanced practice was not even used. = Instead, one chapter dealt with specialization in nursing practice. Nurses who were not specialists were called generalists. Politically, as well as in the real world of practice, there were problems in
The CNSs and NPs report mirror-image complaints: not enough clinical time for CNSs, not enough nonclinical time for NPs. claiming that nurses without graduate degrees were generalists. Few nurses in the country maintained a practice that could be described as generalist, in the common understanding of the term. In fact, the credentialing bodies of the ANA and nursing specialty organizations were certifying nurses at the generalist level for the specialty practice knowledge they had acquired through continuing education and experience. If
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came to clinical agencies with no discernible expansion of practice skills. CNSs were, however, nurses who had been socialized to be professional leaders and critical thinkers; motivated to learn and to teach others, they contrib-
CNSs were nurses socialized to be professional leaders and critical thinkers; motivated to learn and to teach others, they contributed immensely to the improvement of basic nursing practice throughout the country. uted immensely to the improvement of basic nursing practice throughout the country. Health agencies used CNSs to provide nursing staff development and continuing education and to lead practice committees that developed, monitored, and evaluated standards of patient care. Most practice initiatives, both interdisciplinary and within the discipline, were led by these nurses. CNSs, in comparison to NPs, spent significantly less time in direct practice and more time in research, education, consultation, and administration. 5 Now, market-driven reforms have forced reductions in health care costs. CNS positions have been lost as institutions struggle to survive financially during times of inadequate funding for the uninsured, dramatic decreases in hospital patient-days, and competition for managed care contracts with bids that do not support the numbers of nurses in their workforces. In response to this job insecurity, CNSs have sought positions in private practice with physicians or as coordinators or case managers of patient care or have returned to school to acquire acute care nurse practitioner knowledge and skills. 68 NURSING OUTLOOK
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Nurse Practitioner In contrast to the evolution of CNS practice and education, the NP movement developed initially outside of the mainstream of nursing education. 9 Special roles for nurses, such as nurse anesthetist, nurse-midwife, and nurse practitioner, were born out of societal need during periods of physician shortage. The roles involved collaboration and considerable overlap in function with physicians. Many nursing leaders were initially unwilling to accept such programs into their schools; however, federal grants for NP education provided positive motivation, and eventually preparation for the NP role was one option for master's education in nursing. Nurse anesthetists, nurse-midwives, and NPs have, by and large, a clearly defined base of practice knowledge and skills. What some of these nurses have lacked historically is graduate-level preparation, with its attendant integration of theoretical, research and practice-based knowledge, accompanied by preparation and socialization for leadership of the profession. Nevertheless, the practice skills of nurse anesthetists, nurse-midwives, and NPs have been consistently evaluated as making a costeffective contribution to health care3 ° Opportunities to practice have been affected primarily by state practice environments, n rather than health care budgets.
Blurring of Practice Roles in Primary, Tertiary, and Community Care Historically, NP practice has been associated with primary care. Fenton and Brykczynski12documented that NP practice tended to be more focused on health, whereas CNS practice focused more on episodes of illness. As Mundinger 13 said recently, "It seems that nurse practitioners care for patients while they're standing up, and CNSs care for patients when they're lying down." These distinctions, however, are breaking down as reduced physician housestaff and the increase in primary care versus specialist residency programs create new opportunities for nurse practitioners in h0spitals) 4"16Evi-
dence of NP effectiveness in the acute care setting is beginning to appear, 16'17 matching findings of NP effectiveness in primary care. 18All of a sudden there are a variety of NPs whose practices are not oriented to the delivery of primary care. The meaning of community health nursing as a specialty in the current environment is also becoming less clear. With or without governmental health care reform, the market is embarking on experiments with capitated payments for populations of patients. The care of communities may become the province of vertically and horizontally integrated health care delivery systems) 9 As a resuit, graduates of all nursing master's programs need to gain a longitudinal perspective on the care of clients that includes population-based concepts of health promotion and disease prevention relevant to their areas of specialization. 2° Conversely, most communitybased nurses need advanced practice skills for at least one area of specialty in the care of patients (e.g., in school health or occupational health). Thus the way we define specialties and roles may be becoming obsolete.
All of a sudden there are a variety of NPs whose practices are not oriented to the delivery of primary care. The State of Practice in One Academic Health Center Recently the director of the neonatal nurse practitioner (NNP) service at my institution suggested substituting an advanced practice nursing service for the current system, which divides work into CNS and NP roles. She envisions a group-type practice in which most of the advanced practice nurses would be on the clinical service each month, but each would rotate "off-clinical" some percentage of the time, during which time he or she would perform the funcCronenwett
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specialization occurred in both generalist and specialist practice, what was the distinguishing feature of specialist practice? Another complicating factor was the profession's and public's increasing use of the term advanced practice. Was advanced practice just a new term for the 1980 statement's description of specialist practice, or did it have a different meaning? The lack of clarity regarding these issues was preventing the A N A from using Nursing: A Social Policy Statement zz with policymaking bodies, so the arduous process of revision began. The first draft of a new social policy statement, released to organized nursing in June 1994, was debated in numerous meetings within and among organizations. A second draft was distributed in December 1994, z3 and the document was completed in March 1995, with the input of hundreds of nurses throughout the country. It has been submitted to the A N A Congress of Nursing Practice and Board of Directors for final review. In the professional debates on drafts of what will be the 1995 social policy statement, there was support for using the terms basic and advanced practice to describe clinical nursing practice instead of the terms generalist and specialist practice. Respondents agreed that nurses in both basic and advanced practice could (1) focus on an area of specialty and (2) demonstrate competence along a continuum from novice to expert. Furthermore, individual nurses and nursing organizations, with few exceptions, supported using the term advanced practice to describe nurses who have acquired the knowledge base and practice experiences to prepare them for specialization, expansion of practice skills, and advancement.
Specialization is concentrating or delimiting one's focus to part of the whole field of nursing. Expansion refers to the acquisition of new practice knowledge and skills, including the knowledge and skills that legitimize role autonomy within areas of practice that overlap the traditional boundaries of medical practice. Advancement involves both specialization and expansion and is characterized by the integration of a broad range of NURSING OUTLOOK
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theoretical, research-based, and practical knowledge that occurs as a part of graduate education in nursing, z3 This vision of advanced practice is grounded in the present. NPs, CNSs, nurse-midwives, and nurse anesthetists all possess at least two of these three characteristics of advanced practice. Many in each group would qualify as advanced practice nurses if the definition that represents the vision for the future were applied strictly today. By describing advanced practice in terms of the characteristics of specialization, expansion, and advancement, rather than roles, a future with evolving or totally new roles may be accommodated. If this social policy statement is adopted and used to guide the development of educational programs and professional certification procedures, advanced practice nurses will be prepared for a variety of roles in health care systems.
The focus of education should be content related to the core of specialization. National Nursing Summit Concurrent with the work on Nursing's Social Policy Statement, 23 the profession was influenced by other events. In August 1993 the Tri-Council organizations hosted a national nursing summit for representatives of all nursing organizations. Nurses and other health care leaders involved in developing President Clinton's health reform plan spoke as plainly as they could about the importance of speaking with one voice, particularly as it applied to advanced practice nursing. Barbara Safriet told us, in no uncertain terms, that nursing's future depended on an ability to reach consensus on consistent titles and consistent preparation for anyone holding such titles, z4 At the end of that meeting, representatives of 63 out of the 66 organizations agreed that master's education in nursing should be a requirement for advanced practice.
National Organization of Nurse Practitioner Faculties In 1990 the National Organization of Nurse Practitioner Faculties established a policy endorsing master's preparation for all nurse practitioners. In 1994 they received a grant from the Pew Foundation to bring together all nursing organizations to try to reach consensus on documents containing model program standards, curriculum guidelines, and graduate outcomes. These documents are vitally important, because at this critical point when opportunities to expand advanced practice nursing exist in every part of the health care sector, we must produce consistently qualified graduates. If consensus can be reached, the A N A and the Tri-Council organizations can lobby the federal government to fund only programs that meet the identified standards. If the language of the proposed social policy d o c u m e n t is adopted, z3 the terminology used in the National Organization of Nurse Practitioner Faculties' documents could be changed to refer to advanced practice, rather than NP programs, because the documents clearly describe programs that prepare nurses for the full scope of advanced practice.
American Association of Colleges of Nursing: Nursing Education's Agenda Finally, the American Association of Colleges of Nursing is currently holding a series of consensus-building conferences on issues related to CNS and NP education. The end product will be a definition of the essential core curriculum for advanced practice nursing. AACN's current document, Nursing
Education's Agenda for the 21st Century, states: Advanced nursing practice requires graduate preparation, which may focus on primary health care, case management, specialization, education, or administration across health care settings. 25 First, I hope that specialization and expansion of practice skills will, in the end, be considered essential to preparation Cronenwett
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for advanced practice, and not be an •profession's view of advanced practice for issue of student choice. Second, the title decades, many state nurses associations "advanced practice" will have meaning have urged state boards to include CNSs only if it is used consistently to refer to as advanced practice nurses. Yet the state advanced clinical practice, rather than is concerned only about nurses to whom being inclusive of other advanced roles they are considering granting privileges in the profession, such as in research, that will not be available to nurses in education, and administration. Finally, basic practice, typically prescriptive auprimary health care (as opposed to pri- thority and the ability to write orders for mary careZ6)and case m a n a g e m e n t treatments for acute and chronic illness. should not be considered foci of gradu- CNS education in the past did not preate preparation. Courses including such pare nurses for the clinical management content will certainly be offered to of acute and chronic illness or prescripgraduate students, but the focus of edu- tive authority. Therefore the state may cation should be related in content to have a legitimate interest in ensuring that the core of specialization. nurses who receive designation for these privileges have the knowledge base and LEGAL R E G U L A T O R Y certification that is relevant to the priviINITIATIVES leges being conveyed. In 1993, amid much dissent within the The ANA tried to gain the profesprofession, the National Council of sion's consensus on criteria for advanced State Boards of Nursing (NCSBN) practice with an ad hoc committee on adopted a position in support of second credentialing (a group of organizational licensure for advanced practice, z7 The A N A and its constituent member organizations have traditionally argued for one scope of nursing practice, one license for registered nurses, and minimal statutory language about advanced practice. Although many state nurses associations are not opposed to special designations for advanced practice nurses, they prefer such language in rules and regulations, as opposed to law, and they believe, along with the ANA, that the states should defer to the profession's certification mechanisms for deciding who qualifies for advanced practice nursing. representatives of all possible types of For people who support this position, advanced practice nurses) that met beit is important that the profession retain fore the NCSBN vote. But disagreement the responsibility and accountability for about the requirement for master's edudefining scope of practice, setting stan- cation remained. The NCSBN then dards of practice, and credentialing ad- chose to try to create the consistency vanced practice. Because the boundaries by endorsing their position on second of our profession are constantly chang- licensure, which included a requirement ing, it is risky to commit distinct scopes for master's preparation, z7 The debate of basic and advanced practice to statu- now moves to the states, where legislators, state boards of nursing, and repretory language. The profession, however, has not sentatives of nursing organizations will been able to achieve consensus on the decide the extent to which each state level of education, educational program adopts the NCSBN model practice act. The irony is that if the profession standards, or certification procedures that warrant the profession's recognition that were to adopt the definition of advanced a person is an advanced practice nurse. practice in the proposed 1995 social Because CNS practice defined the policy statement, 23 there would be no
Short master's programs and certificate NP programs are producing graduates who will have to go back to school in the future.
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real conflict with the NCSBN model practice act. Both Nursing's Social Policy Statement and the NCSBN model practice act require specialization, expansion, and advancement as criteria for recognition for advanced practice. If the profession's credentialing bodies used these three criteria as the basis for certification, the outcomes of both professional and legal regulation would be the same, even if disagreement remained regarding the desirability of creating a second license for nurses in advanced practice. A SINGLE M O D E L OF A D V A N C E D PRACTICE
Nurses in basic practice will continue to need the leadership provided by advanced practice nurses, and it is clear that advanced practice nurses can make costeffective contributions to patient care if they are prepared for the full scope of advanced practice. How these two goals are accomplished, whether through one, two, or more roles, seems to be relevant only in response to an assessment of needs of particular patient populations or institutions. Roles change as systems change. We cannot predict which methods of meeting goals will be most effective; however, we can prepare nurses so that the full range of experimentation is possible. I return now to the arguments against merging roles, and respond to each identified problem.
The scope of practice remains different, as typically NPs are generalists in managing illness and promoting health, and CNSs are acute care subspecialists. 3 If NPs were all primary care generalists, we would not have specialties in adult, family, pediatric, geriatric, and nurse-midwifery care. Clearly, we also have acute care NP specialties (nurse anesthetists, NNPs, critical care) and NPs who specialize in the care of individuals as parts of communities, such as, in occupational health or school health. All of these NPs and CNSs are specialists in some form of primary, acute, or community-based care. Therefore all advanced practice nurses require preparation in a core of specialization and
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subsequent professional certification based on that core.
Legal entanglements exist with trying to include CNSs in existing advanced practice legislation. 3 That is true, unless we change the educational programs so all nurses have the requisite knowledge and skills for the expanded practice autonomy that states are willing to confer on them. If we change educational content to prepare one product, the advanced practice nurse, the argument will be irrelevant. Titling concerns exist regarding name rec. ognition and legal issues 3 Nurse-midwives, nurse anesthetists, and NPs believe that the public recognizes their current titles and would be confused by a change to use of the title "advanced practice nurse." As long a s people believe that is the case, why change? Nothing about creating a consistent meaning for the title of advanced practice nurse mandates that such nurses use that title instead of another title associated with their roles. The more important issue is to achieve consistency in the meaning of the title so that the legal and professional regulation and e d u c a t i o n of these nurses may be aligned. When states designate all advanced practice nurses as advanced registered nurse practitioners, the legal title is a negative feature for nurses in other roles. The NCSBN model practice act actually recommends " A P R N " - - a d vanced practice registered nurse. This title is inclusive of all groups of nurses who might qualify for legal recognition in the future, and its use contributes to the goal of creating consistency across meanings of legal/professional titles. All segments of the profession should try and help create this consistency. Graduate programs would need to be longer, adversely affecting enrollments. 3 Nursing is hardly experiencing a dearth of applicants for current NP programs. Rather, student enrollment in nursing master's programs rose 10.7% in NURSING OUTLOOK
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the 1994-95 school year over the previous year. zs Short master's programs and certificate NP programs are producing graduates who will have to go back to school in the future. Students and faculty need to insist that educational programs prepare nurses for the full scope of advanced practice as soon as possible and with programs t h a t meet the profession's standards for preparation of qualified graduates.
Practitioners will experience too much role strain, role blurring, and role confusion if CNS and NP roles are merged, z Since the problems of role confusion and role strain have plagued the CNS role since its inception, 29 it is understandable that this argument would be
Today, all health care professionals are becoming clear that the health care of populations is their only legitimate primary focus.
The profession will be jeopardized because nurses in merged roles might find it difficult to keep nursing, rather than medicine, as their primary focus.2 Over the last 30 years, nursing has come of age. We identified our contributions to patient care, naming the diagnoses and t r e a t m e n t s t h a t are common to nursing practice. 3° In the process we identified patient care issues that were subsequently adopted as important by health care providers from many disciplines. Rather t h a n c l a r i f y i n g rigid b o u n d a r i e s among medicine, nursing, psychology, or social work, our work served to inform others, just as nursing's work has been informed by the knowledge base and practice skills of other health disciplines. Today, all health care professionals are becoming clear that the health care of populations is their only legitimate primary focus. Certainly, nurses and physicians share many aspects of the same patient care mission. It is time for nurses to drop the defensive rhetoric of "nursing versus medical models." Furthermore, for nurses in advanced practice, it is time to embrace the reality that there will always be significant collaboration and overlap with physician practice.
advanced by CNSs. z Yet a common preparation of nurses for advanced practice might enhance nursing's ability to S U M M A R Y define roles that do not cause role con- During this time when the walls that fusion. If the assessments and diagnoses divide inpatient, outpatient, primary, of all advanced practice nurses could be tertiary, and community care are comfollowed by the initiation of appropri- ing down, society should expect that ate treatments, nurses in basic practice, the nursing profession will prepare and patients, physicians, and all of our pub- regulate advanced nursing practice for lics might understand the purpose of the good of patient care and society as advanced practice better than they do a whole. To do so, schools with clinitoday. cal practice graduate programs must The proponents of this argument may create a consistent product; profesmean that it is important that an ad- sional credentialing bodies must use vanced practice nurse does not have a consistent criteria to acknowledge adjob that encompasses so many functions vanced practice knowledge and experthat it cannot be accomplished. Of tise; and state boards of nursing must course, that must be true. But advanced give legal recognition for advanced practice roles are being created through- practice to these same nurses. Within out the country. Future evaluations will this environment, advanced practice determine what functions may be in- nurses will be prepared to serve socicluded and in what ways, so that role ety, even if their skills are applied in a strain is not a barrier to practice. variety of roles. • Cronenwett
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REFERENCES 1. Mezey MD, McGivem, DO. Nurses, nurse practitioners: evolution to advanced practice. New York: Springer, 1993. 2. Page NE, Arena DM. Rethinking the merger of the clinical nurse specialist and nurse practitioner roles. Image: J Nurs Sch 1994;26:315-8. 3. Soehren PM, Schumann, LL. Enhanced role opportunities available to the CNS/nurse practitioner. Clin Nurse Spec 1994;8:123-7. 4. Diets D. Preparation of practitioners, clinical specialists, and clinicians. J Prof Nuts 1985; I: 41-7. 5. Williams CA, Valdivieso GC. Advanced practice models: a comparison of clinical nurse spe. cialist and nurse practitioner activities. Clin Nurse Spec 1994;8:311-8. 6. Davis EA. Factors influencing the implementation of the CNS role in a private practice. Clin Nurse Spec 1994;8:42-7. 7. Lin EM. A combined role of clinical nurse specialist and coordinator: optimizing continuity of care in an autologous bone marrow transplant program. Clin Nurse Spec 1994;8:48-55. 8. Richmond TS, Keane A. The nurse practitioner in tertiary care. J Nurs Admin 1992;22( 11): 11-2. 9. Bullough B. Alternative models for specialty nursing practice. Nuts Health Care 1992;13: 254-9. 10. Aiken LH, Sage WM. Staffing national health care reform: a role for advanced practice nurses. Akron Law Rev 1992;26:187-211. 11. Sekscenski ES, Sansom S, Bazell C, Salmon ME, Mullan E State practice environments and the supply of physician assistants, nurse practitioners, and certified nurse-midwives. N Engl J Med 1994;33i:1266-71.
12. Fenton MV, Brykczynski KA. Qualitative distinctions and similarities in the practice of clinical nurse specialists and nurse practitioners. J ProfNurs 1993;9:313-26. 13. Mundinger MO. Health care reform: the best of times or worst of times? Speech at the American Academy of Nursing Annual Conference, Oct. 2I, 1994, Phoenix. 14. Knickman JR, Lipkin M, Finkler SA, Thompson WG, Kiel J. The potential for using nonphysicians to compensate for the reduced availability of residents. Acad Med 1992;67:429-38. 15. Snyder JV, Sirio CA, Angus DC, et al. Trial of nurse practitioners in intensive care. New Horizons 1994;2:296-304. 16. Spisso J, O'Callaghan C, McKennan M, Holcroft JW Improved quality of care and reduction of housestaff workload using trauma nurse practitioners. J Trauma 1990;30:660-5. 17. Schultz JM, Liptak GS, Fioravanti J. Nurse practitioners' effectiveness in NICU. Nurs Manage 1994;25(10):50-3. 18. Brown SA, Grimes DE. Nurse practitioners and certified nurse-midwives: a meta-analysis of studies on nurses in primary care roles. Washington: American Nurses Publishing, 1993. 19. ShortelI SM, Gillies RR, Anderson DA, Mitchell JB, Morgan KL. Creating organized delivery systems: the barriers and facilitators. Hosp Health Serv Admin 1993;38:447-66. 20. Hegyvary ST. Nursing education for health care reform. J Prof Nurs 1992;8:3. 21. Hartshorn JC. A national board for nursing certification. NuRs Ot0TLOOK1991;39:226-9. 22. American Nurses Association. Nursing: a social policy statement. Washington: American Nurses Publishing, 1980. 23. American Nurses Association. Nursing's social policy statement [Under review].
24. Safriet BJ. Health care dollars and regulatory sense: the role of advanced practice nursing. Yale J Regulation 1992;9(2):417-88. 25. American Association of Colleges of Nursing. Nursing education's agenda for the 21st century. Washington: American Association of Colleges of Nursing, 1993. 26. Barnes D, Eribes C, Juarbe T, et al. Primary health care and primary care: a confusion of philosophies. NuRs OUTLOOK1995;43:7-16. 27. National Council of State Boards of Nursing. Position paper on the licensure of advanced nursing practice. Chicago: National Council of State Boards of Nursing, i992. 28. American Association of Colleges of Nursing. 1994-95 Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington: American Association of Colleges of Nursing, 1995. 29. Montemuro MA. The evolution of the clinical nurse specialist: response to the challenge of professional nursing practice. Clin Nurse Spec 1987;1:106-10. 30. McCormick KA, Lang N, ZielstorffR, Milholland K, Saba V, Jacox A. Toward standard classification schemes for nursing language: recommendations of the American Nurses Association Steering Committee on Databases to Support Clinical Nursing Practice. JAMIA 1994;1: 421-7.
L I N D A R. CRONENWETT is director of
Nursing Research & Education at the Dartmouth-Hitchcock Medical Center and was chairperson of the A N A Congress of Nursing Practice from 1990 to 1994.
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V O L U M E 43 • N U M B E R 3
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A plea for consistency in the regulation and education of nurses for advanced practice.
Few
questions in nursing have generated as much passion as the question of the future of advanced practice nursing. >3 The focus of the debate has been the issue of whether to merge clinical nurse specialist (CNS) and nurse practitioner (NP) roles, assuming that if separate roles exist, separate educational programs and professional certifications are required. In contrast, in this article I argue that all segments of our profession need to work together toward a common goal, a future in which the legal and professional regulation and education of nurses at the graduate level are aligned so that one educational product, the advanced practice nurse, is prepared to fill a variety of roles in the health care system. Soehren and Schumann 3 recently presented a summary of the arguments for and against the merger of NP and C N S roles. A r g u m e n t s in favor of merger were as follows: • Many similarities already exist in roles. • Practice settings for both are expanding and overlapping. * Adapted from a paper presented at the American Association of Colleges
of Nursing's Master's Education Conference, San Antonio, Texas, December 1994. NuRs OUTLOOK 1995;43:112-8. Copyright © 1995 by Mosby-Year Book, Inc. 0029-6554•95•53.00 + 0 3511165249
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• Unity and an increase in numbers would give more power to advanced practitioners. • Many similarities already exist in educational preparation. • Increased cost-effectiveness for colleges and universities would result if graduate programs were combined. • Graduates with both credentials would be more marketable. Arguments against merger: • Scope of practice remains different, as typically NPs are generalists in managing illness and promoting health and CNSs are acute care subspecialists. • Legal entanglements exist with trying to include CNSs in existing advanced practice legislation. • Titling concerns exist regarding name recognition and legal issues. • Graduate programs would need to be longer, adversely affecting enrollments. Page and Arena z added to the list of arguments against role merger the following issues: practitioners will experience too much role strain, role blurring, and role confusion if the roles are merged, and the profession will be jeopardized because nurses in merged roles might find it difficult to keep nursing, rather than medicine, as their primary focus.
With these arguments in mind, and returning to them at the end, in this article I summarize recent initiatives in practice patterns and the regulation of nursing practice and analyze the effect of these changes on the question of how the profession should mold the future for advanced practice nursing. CHANGES
IN P R A C T I C E
Clinical Nurse Specialist During the period from the 1960s to the 1980s, considerable emphasis was placed on identifying nursing as a scientific discipline and practice profession separate and distinct from medicine. Students in master's programs were more exposed to metatheories about the profession than to theories that would guide practice. 4 They learned more about the conduct of
Graduates of master's programs often came to clinical agencies with no discernible expansion of practice skills. research than about how to use research in practice. Time that might have been spent in the curriculum to master a body of knowledge for specialty practice was often spent on the fine points of concept analysis, clinical decision making, or role theory. Although physical assessrnent skills were taught, too little time was allotted for students to apply, with faculty supervision, these and other clinical management skills to patient populations. Graduates of master's programs often
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tions of the CNS. Under the current system, the NNPs are doing much of the on-the-spot staff development work with the neonatal intensive care unit nurses, while the CNS (who also has NNP certification but does not use those skills in her practice) performs the rest of the CNS role. The NNPs have little time away from clinical practice. Because they are employed by the physician practice, they are expected to teach medical students and residents but receive less support for teaching nursing students
The meaning of community health nursing as a specialty in the current environment is also becoming less clear. and nursing staff. Overall, the NNPs are bothered by their lack of colleagueship with other advanced practice nurses and with nursing in general. In contrast, CNSs are well integrated in communication and colleagueship networks in our department of nursing. They, are fully supported to be preceptors for nursing students. Their problem is that requests at the unit, division, department, and regional level for leadership of professional practice projects, research use projects, and teaching overwhelm them. Their time for patient care, even the consultation aspect of patient care, is limited, and they are constantly subjected to criticism for not being available on the nursing units. The CNSs and NPs report mirrorimage complaints: not enough clinical time for CNSs, not enough nonclinical time for NPs. Both groups of nurses, however, can envision advanced practice nursing roles that would improve the quality of patient care, the quality of their contributions to basic nursing practice, the quality of their teaching and scholarship, and the quality of their job satisfaction. A major barrier to testing new advanced practice nursing models, 114
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however, is the lack of preparation of all CNSs and NPs for the full scope of advanced practice. PROFESSIONAL REGULATORY INITIATIVES
During my tenure on the American Nurses Association's (ANA) Congress of Nursing Practice, from 1990 through 1994, the most difficult issues involved questions of how advanced practice should be defined, reimbursed, and regulated. Working definitions of advanced practice were developed and adopted, and the ANA consistently took the position that, in speaking for advanced practice, it was speaking about CNSs, NPs, nurse-midwives, and nurse-anesthetists. A number of professional regulatory initiatives occurred during this period.
Development of the American Board of Nursing Specialties Beginning in 1988, with the support of the Josiah Macy, Jr. Foundation, national nursing leaders worked together to create a unified approach to standards for professional certification programs, zl By 1990 eight organizations, collectively representing about 65% of the total number of certified nurses, became charter members of the American Board of Nursing Specialties. Certification boards approved by this body have a plan that provides for: • A specialty nursing practice certification requiring a minimum of a baccalaureate degree in nursing and a specified educational program in the area of practice to be implemented for new certificates by the year 2000. • An advanced specialty nursing practice certification requiring a graduate degree in nursing or the appropriate equivalent, including content in the specified area of specialty practice. 21 One other organization has since joined. Additional organizations that are not members because they do not require the baccalaureate for basic specialty practice certification have agreed to the
master's requirement for certification in advanced practice. This initiative helped the profession increase consistency in the meaning of advanced practice by requiring the master's degree for professional certification; however, the board continues to approve programs that certify nurses as either CNSs or NPs. This practice resuits in significant problems for new acute care NPs, whose content of specialty knowledge is similar to that tested in CNS credentialing examinations, yet who need NP certification (with examinations still oriented to primary care) to practice in many states. One advanced practice credentialing examination for each area of specialty would eliminate this problem.
The ANA's Revision of Nursing: A Social Policy Statement During the debates over definitions of advanced practice, the profession was working with a 1980 social policy document in which the term advanced practice was not even used. = Instead, one chapter dealt with specialization in nursing practice. Nurses who were not specialists were called generalists. Politically, as well as in the real world of practice, there were problems in
The CNSs and NPs report mirror-image complaints: not enough clinical time for CNSs, not enough nonclinical time for NPs. claiming that nurses without graduate degrees were generalists. Few nurses in the country maintained a practice that could be described as generalist, in the common understanding of the term. In fact, the credentialing bodies of the ANA and nursing specialty organizations were certifying nurses at the generalist level for the specialty practice knowledge they had acquired through continuing education and experience. If
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came to clinical agencies with no discernible expansion of practice skills. CNSs were, however, nurses who had been socialized to be professional leaders and critical thinkers; motivated to learn and to teach others, they contrib-
CNSs were nurses socialized to be professional leaders and critical thinkers; motivated to learn and to teach others, they contributed immensely to the improvement of basic nursing practice throughout the country. uted immensely to the improvement of basic nursing practice throughout the country. Health agencies used CNSs to provide nursing staff development and continuing education and to lead practice committees that developed, monitored, and evaluated standards of patient care. Most practice initiatives, both interdisciplinary and within the discipline, were led by these nurses. CNSs, in comparison to NPs, spent significantly less time in direct practice and more time in research, education, consultation, and administration. 5 Now, market-driven reforms have forced reductions in health care costs. CNS positions have been lost as institutions struggle to survive financially during times of inadequate funding for the uninsured, dramatic decreases in hospital patient-days, and competition for managed care contracts with bids that do not support the numbers of nurses in their workforces. In response to this job insecurity, CNSs have sought positions in private practice with physicians or as coordinators or case managers of patient care or have returned to school to acquire acute care nurse practitioner knowledge and skills. 68 NURSING OUTLOOK
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Nurse Practitioner In contrast to the evolution of CNS practice and education, the NP movement developed initially outside of the mainstream of nursing education. 9 Special roles for nurses, such as nurse anesthetist, nurse-midwife, and nurse practitioner, were born out of societal need during periods of physician shortage. The roles involved collaboration and considerable overlap in function with physicians. Many nursing leaders were initially unwilling to accept such programs into their schools; however, federal grants for NP education provided positive motivation, and eventually preparation for the NP role was one option for master's education in nursing. Nurse anesthetists, nurse-midwives, and NPs have, by and large, a clearly defined base of practice knowledge and skills. What some of these nurses have lacked historically is graduate-level preparation, with its attendant integration of theoretical, research and practice-based knowledge, accompanied by preparation and socialization for leadership of the profession. Nevertheless, the practice skills of nurse anesthetists, nurse-midwives, and NPs have been consistently evaluated as making a costeffective contribution to health care3 ° Opportunities to practice have been affected primarily by state practice environments, n rather than health care budgets.
Blurring of Practice Roles in Primary, Tertiary, and Community Care Historically, NP practice has been associated with primary care. Fenton and Brykczynski12documented that NP practice tended to be more focused on health, whereas CNS practice focused more on episodes of illness. As Mundinger 13 said recently, "It seems that nurse practitioners care for patients while they're standing up, and CNSs care for patients when they're lying down." These distinctions, however, are breaking down as reduced physician housestaff and the increase in primary care versus specialist residency programs create new opportunities for nurse practitioners in h0spitals) 4"16Evi-
dence of NP effectiveness in the acute care setting is beginning to appear, 16'17 matching findings of NP effectiveness in primary care. 18All of a sudden there are a variety of NPs whose practices are not oriented to the delivery of primary care. The meaning of community health nursing as a specialty in the current environment is also becoming less clear. With or without governmental health care reform, the market is embarking on experiments with capitated payments for populations of patients. The care of communities may become the province of vertically and horizontally integrated health care delivery systems) 9 As a resuit, graduates of all nursing master's programs need to gain a longitudinal perspective on the care of clients that includes population-based concepts of health promotion and disease prevention relevant to their areas of specialization. 2° Conversely, most communitybased nurses need advanced practice skills for at least one area of specialty in the care of patients (e.g., in school health or occupational health). Thus the way we define specialties and roles may be becoming obsolete.
All of a sudden there are a variety of NPs whose practices are not oriented to the delivery of primary care. The State of Practice in One Academic Health Center Recently the director of the neonatal nurse practitioner (NNP) service at my institution suggested substituting an advanced practice nursing service for the current system, which divides work into CNS and NP roles. She envisions a group-type practice in which most of the advanced practice nurses would be on the clinical service each month, but each would rotate "off-clinical" some percentage of the time, during which time he or she would perform the funcCronenwett
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specialization occurred in both generalist and specialist practice, what was the distinguishing feature of specialist practice? Another complicating factor was the profession's and public's increasing use of the term advanced practice. Was advanced practice just a new term for the 1980 statement's description of specialist practice, or did it have a different meaning? The lack of clarity regarding these issues was preventing the A N A from using Nursing: A Social Policy Statement zz with policymaking bodies, so the arduous process of revision began. The first draft of a new social policy statement, released to organized nursing in June 1994, was debated in numerous meetings within and among organizations. A second draft was distributed in December 1994, z3 and the document was completed in March 1995, with the input of hundreds of nurses throughout the country. It has been submitted to the A N A Congress of Nursing Practice and Board of Directors for final review. In the professional debates on drafts of what will be the 1995 social policy statement, there was support for using the terms basic and advanced practice to describe clinical nursing practice instead of the terms generalist and specialist practice. Respondents agreed that nurses in both basic and advanced practice could (1) focus on an area of specialty and (2) demonstrate competence along a continuum from novice to expert. Furthermore, individual nurses and nursing organizations, with few exceptions, supported using the term advanced practice to describe nurses who have acquired the knowledge base and practice experiences to prepare them for specialization, expansion of practice skills, and advancement.
Specialization is concentrating or delimiting one's focus to part of the whole field of nursing. Expansion refers to the acquisition of new practice knowledge and skills, including the knowledge and skills that legitimize role autonomy within areas of practice that overlap the traditional boundaries of medical practice. Advancement involves both specialization and expansion and is characterized by the integration of a broad range of NURSING OUTLOOK
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theoretical, research-based, and practical knowledge that occurs as a part of graduate education in nursing, z3 This vision of advanced practice is grounded in the present. NPs, CNSs, nurse-midwives, and nurse anesthetists all possess at least two of these three characteristics of advanced practice. Many in each group would qualify as advanced practice nurses if the definition that represents the vision for the future were applied strictly today. By describing advanced practice in terms of the characteristics of specialization, expansion, and advancement, rather than roles, a future with evolving or totally new roles may be accommodated. If this social policy statement is adopted and used to guide the development of educational programs and professional certification procedures, advanced practice nurses will be prepared for a variety of roles in health care systems.
The focus of education should be content related to the core of specialization. National Nursing Summit Concurrent with the work on Nursing's Social Policy Statement, 23 the profession was influenced by other events. In August 1993 the Tri-Council organizations hosted a national nursing summit for representatives of all nursing organizations. Nurses and other health care leaders involved in developing President Clinton's health reform plan spoke as plainly as they could about the importance of speaking with one voice, particularly as it applied to advanced practice nursing. Barbara Safriet told us, in no uncertain terms, that nursing's future depended on an ability to reach consensus on consistent titles and consistent preparation for anyone holding such titles, z4 At the end of that meeting, representatives of 63 out of the 66 organizations agreed that master's education in nursing should be a requirement for advanced practice.
National Organization of Nurse Practitioner Faculties In 1990 the National Organization of Nurse Practitioner Faculties established a policy endorsing master's preparation for all nurse practitioners. In 1994 they received a grant from the Pew Foundation to bring together all nursing organizations to try to reach consensus on documents containing model program standards, curriculum guidelines, and graduate outcomes. These documents are vitally important, because at this critical point when opportunities to expand advanced practice nursing exist in every part of the health care sector, we must produce consistently qualified graduates. If consensus can be reached, the A N A and the Tri-Council organizations can lobby the federal government to fund only programs that meet the identified standards. If the language of the proposed social policy d o c u m e n t is adopted, z3 the terminology used in the National Organization of Nurse Practitioner Faculties' documents could be changed to refer to advanced practice, rather than NP programs, because the documents clearly describe programs that prepare nurses for the full scope of advanced practice.
American Association of Colleges of Nursing: Nursing Education's Agenda Finally, the American Association of Colleges of Nursing is currently holding a series of consensus-building conferences on issues related to CNS and NP education. The end product will be a definition of the essential core curriculum for advanced practice nursing. AACN's current document, Nursing
Education's Agenda for the 21st Century, states: Advanced nursing practice requires graduate preparation, which may focus on primary health care, case management, specialization, education, or administration across health care settings. 25 First, I hope that specialization and expansion of practice skills will, in the end, be considered essential to preparation Cronenwett
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for advanced practice, and not be an •profession's view of advanced practice for issue of student choice. Second, the title decades, many state nurses associations "advanced practice" will have meaning have urged state boards to include CNSs only if it is used consistently to refer to as advanced practice nurses. Yet the state advanced clinical practice, rather than is concerned only about nurses to whom being inclusive of other advanced roles they are considering granting privileges in the profession, such as in research, that will not be available to nurses in education, and administration. Finally, basic practice, typically prescriptive auprimary health care (as opposed to pri- thority and the ability to write orders for mary careZ6)and case m a n a g e m e n t treatments for acute and chronic illness. should not be considered foci of gradu- CNS education in the past did not preate preparation. Courses including such pare nurses for the clinical management content will certainly be offered to of acute and chronic illness or prescripgraduate students, but the focus of edu- tive authority. Therefore the state may cation should be related in content to have a legitimate interest in ensuring that the core of specialization. nurses who receive designation for these privileges have the knowledge base and LEGAL R E G U L A T O R Y certification that is relevant to the priviINITIATIVES leges being conveyed. In 1993, amid much dissent within the The ANA tried to gain the profesprofession, the National Council of sion's consensus on criteria for advanced State Boards of Nursing (NCSBN) practice with an ad hoc committee on adopted a position in support of second credentialing (a group of organizational licensure for advanced practice, z7 The A N A and its constituent member organizations have traditionally argued for one scope of nursing practice, one license for registered nurses, and minimal statutory language about advanced practice. Although many state nurses associations are not opposed to special designations for advanced practice nurses, they prefer such language in rules and regulations, as opposed to law, and they believe, along with the ANA, that the states should defer to the profession's certification mechanisms for deciding who qualifies for advanced practice nursing. representatives of all possible types of For people who support this position, advanced practice nurses) that met beit is important that the profession retain fore the NCSBN vote. But disagreement the responsibility and accountability for about the requirement for master's edudefining scope of practice, setting stan- cation remained. The NCSBN then dards of practice, and credentialing ad- chose to try to create the consistency vanced practice. Because the boundaries by endorsing their position on second of our profession are constantly chang- licensure, which included a requirement ing, it is risky to commit distinct scopes for master's preparation, z7 The debate of basic and advanced practice to statu- now moves to the states, where legislators, state boards of nursing, and repretory language. The profession, however, has not sentatives of nursing organizations will been able to achieve consensus on the decide the extent to which each state level of education, educational program adopts the NCSBN model practice act. The irony is that if the profession standards, or certification procedures that warrant the profession's recognition that were to adopt the definition of advanced a person is an advanced practice nurse. practice in the proposed 1995 social Because CNS practice defined the policy statement, 23 there would be no
Short master's programs and certificate NP programs are producing graduates who will have to go back to school in the future.
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real conflict with the NCSBN model practice act. Both Nursing's Social Policy Statement and the NCSBN model practice act require specialization, expansion, and advancement as criteria for recognition for advanced practice. If the profession's credentialing bodies used these three criteria as the basis for certification, the outcomes of both professional and legal regulation would be the same, even if disagreement remained regarding the desirability of creating a second license for nurses in advanced practice. A SINGLE M O D E L OF A D V A N C E D PRACTICE
Nurses in basic practice will continue to need the leadership provided by advanced practice nurses, and it is clear that advanced practice nurses can make costeffective contributions to patient care if they are prepared for the full scope of advanced practice. How these two goals are accomplished, whether through one, two, or more roles, seems to be relevant only in response to an assessment of needs of particular patient populations or institutions. Roles change as systems change. We cannot predict which methods of meeting goals will be most effective; however, we can prepare nurses so that the full range of experimentation is possible. I return now to the arguments against merging roles, and respond to each identified problem.
The scope of practice remains different, as typically NPs are generalists in managing illness and promoting health, and CNSs are acute care subspecialists. 3 If NPs were all primary care generalists, we would not have specialties in adult, family, pediatric, geriatric, and nurse-midwifery care. Clearly, we also have acute care NP specialties (nurse anesthetists, NNPs, critical care) and NPs who specialize in the care of individuals as parts of communities, such as, in occupational health or school health. All of these NPs and CNSs are specialists in some form of primary, acute, or community-based care. Therefore all advanced practice nurses require preparation in a core of specialization and
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subsequent professional certification based on that core.
Legal entanglements exist with trying to include CNSs in existing advanced practice legislation. 3 That is true, unless we change the educational programs so all nurses have the requisite knowledge and skills for the expanded practice autonomy that states are willing to confer on them. If we change educational content to prepare one product, the advanced practice nurse, the argument will be irrelevant. Titling concerns exist regarding name rec. ognition and legal issues 3 Nurse-midwives, nurse anesthetists, and NPs believe that the public recognizes their current titles and would be confused by a change to use of the title "advanced practice nurse." As long a s people believe that is the case, why change? Nothing about creating a consistent meaning for the title of advanced practice nurse mandates that such nurses use that title instead of another title associated with their roles. The more important issue is to achieve consistency in the meaning of the title so that the legal and professional regulation and e d u c a t i o n of these nurses may be aligned. When states designate all advanced practice nurses as advanced registered nurse practitioners, the legal title is a negative feature for nurses in other roles. The NCSBN model practice act actually recommends " A P R N " - - a d vanced practice registered nurse. This title is inclusive of all groups of nurses who might qualify for legal recognition in the future, and its use contributes to the goal of creating consistency across meanings of legal/professional titles. All segments of the profession should try and help create this consistency. Graduate programs would need to be longer, adversely affecting enrollments. 3 Nursing is hardly experiencing a dearth of applicants for current NP programs. Rather, student enrollment in nursing master's programs rose 10.7% in NURSING OUTLOOK
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the 1994-95 school year over the previous year. zs Short master's programs and certificate NP programs are producing graduates who will have to go back to school in the future. Students and faculty need to insist that educational programs prepare nurses for the full scope of advanced practice as soon as possible and with programs t h a t meet the profession's standards for preparation of qualified graduates.
Practitioners will experience too much role strain, role blurring, and role confusion if CNS and NP roles are merged, z Since the problems of role confusion and role strain have plagued the CNS role since its inception, 29 it is understandable that this argument would be
Today, all health care professionals are becoming clear that the health care of populations is their only legitimate primary focus.
The profession will be jeopardized because nurses in merged roles might find it difficult to keep nursing, rather than medicine, as their primary focus.2 Over the last 30 years, nursing has come of age. We identified our contributions to patient care, naming the diagnoses and t r e a t m e n t s t h a t are common to nursing practice. 3° In the process we identified patient care issues that were subsequently adopted as important by health care providers from many disciplines. Rather t h a n c l a r i f y i n g rigid b o u n d a r i e s among medicine, nursing, psychology, or social work, our work served to inform others, just as nursing's work has been informed by the knowledge base and practice skills of other health disciplines. Today, all health care professionals are becoming clear that the health care of populations is their only legitimate primary focus. Certainly, nurses and physicians share many aspects of the same patient care mission. It is time for nurses to drop the defensive rhetoric of "nursing versus medical models." Furthermore, for nurses in advanced practice, it is time to embrace the reality that there will always be significant collaboration and overlap with physician practice.
advanced by CNSs. z Yet a common preparation of nurses for advanced practice might enhance nursing's ability to S U M M A R Y define roles that do not cause role con- During this time when the walls that fusion. If the assessments and diagnoses divide inpatient, outpatient, primary, of all advanced practice nurses could be tertiary, and community care are comfollowed by the initiation of appropri- ing down, society should expect that ate treatments, nurses in basic practice, the nursing profession will prepare and patients, physicians, and all of our pub- regulate advanced nursing practice for lics might understand the purpose of the good of patient care and society as advanced practice better than they do a whole. To do so, schools with clinitoday. cal practice graduate programs must The proponents of this argument may create a consistent product; profesmean that it is important that an ad- sional credentialing bodies must use vanced practice nurse does not have a consistent criteria to acknowledge adjob that encompasses so many functions vanced practice knowledge and experthat it cannot be accomplished. Of tise; and state boards of nursing must course, that must be true. But advanced give legal recognition for advanced practice roles are being created through- practice to these same nurses. Within out the country. Future evaluations will this environment, advanced practice determine what functions may be in- nurses will be prepared to serve socicluded and in what ways, so that role ety, even if their skills are applied in a strain is not a barrier to practice. variety of roles. • Cronenwett
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12. Fenton MV, Brykczynski KA. Qualitative distinctions and similarities in the practice of clinical nurse specialists and nurse practitioners. J ProfNurs 1993;9:313-26. 13. Mundinger MO. Health care reform: the best of times or worst of times? Speech at the American Academy of Nursing Annual Conference, Oct. 2I, 1994, Phoenix. 14. Knickman JR, Lipkin M, Finkler SA, Thompson WG, Kiel J. The potential for using nonphysicians to compensate for the reduced availability of residents. Acad Med 1992;67:429-38. 15. Snyder JV, Sirio CA, Angus DC, et al. Trial of nurse practitioners in intensive care. New Horizons 1994;2:296-304. 16. Spisso J, O'Callaghan C, McKennan M, Holcroft JW Improved quality of care and reduction of housestaff workload using trauma nurse practitioners. J Trauma 1990;30:660-5. 17. Schultz JM, Liptak GS, Fioravanti J. Nurse practitioners' effectiveness in NICU. Nurs Manage 1994;25(10):50-3. 18. Brown SA, Grimes DE. Nurse practitioners and certified nurse-midwives: a meta-analysis of studies on nurses in primary care roles. Washington: American Nurses Publishing, 1993. 19. ShortelI SM, Gillies RR, Anderson DA, Mitchell JB, Morgan KL. Creating organized delivery systems: the barriers and facilitators. Hosp Health Serv Admin 1993;38:447-66. 20. Hegyvary ST. Nursing education for health care reform. J Prof Nurs 1992;8:3. 21. Hartshorn JC. A national board for nursing certification. NuRs Ot0TLOOK1991;39:226-9. 22. American Nurses Association. Nursing: a social policy statement. Washington: American Nurses Publishing, 1980. 23. American Nurses Association. Nursing's social policy statement [Under review].
24. Safriet BJ. Health care dollars and regulatory sense: the role of advanced practice nursing. Yale J Regulation 1992;9(2):417-88. 25. American Association of Colleges of Nursing. Nursing education's agenda for the 21st century. Washington: American Association of Colleges of Nursing, 1993. 26. Barnes D, Eribes C, Juarbe T, et al. Primary health care and primary care: a confusion of philosophies. NuRs OUTLOOK1995;43:7-16. 27. National Council of State Boards of Nursing. Position paper on the licensure of advanced nursing practice. Chicago: National Council of State Boards of Nursing, i992. 28. American Association of Colleges of Nursing. 1994-95 Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington: American Association of Colleges of Nursing, 1995. 29. Montemuro MA. The evolution of the clinical nurse specialist: response to the challenge of professional nursing practice. Clin Nurse Spec 1987;1:106-10. 30. McCormick KA, Lang N, ZielstorffR, Milholland K, Saba V, Jacox A. Toward standard classification schemes for nursing language: recommendations of the American Nurses Association Steering Committee on Databases to Support Clinical Nursing Practice. JAMIA 1994;1: 421-7.
L I N D A R. CRONENWETT is director of
Nursing Research & Education at the Dartmouth-Hitchcock Medical Center and was chairperson of the A N A Congress of Nursing Practice from 1990 to 1994.
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