A comparison of practice domains of clinical nurse specialists and nurse practitioners

ORIGINAL ARTICLES A Comparison of Practice Domains of Clinical Nurse Specialists and Nurse Practitioners LINDAL. LINDEKE,PHD, RN, CPNP,* BRENDAH. CANEDY,PHD, RN, CS,~ AND MARGARETM. KAY,MS, RN, CPNP$

This qualitative study was carried out to add empirical data to the discussion of the essentials of advanced practice graduate nursing education. Study participants were 15 nurse practitioners (NPs) whose original preparation was as clinical nurse specialists (CNSs). These nurses subsequently completed postmaster's preparation as NPs at a midwest US school of nursing. The nurses were interviewed regarding similarities and differences between the NP and CNS roles based on their own experiences. They stated that their 1-year post-master's NP educational program broadened their knowledge base and increased their skills of direct data collection in history taking and physical examination. They described increased NP role autonomy and clinical decision making. Comparison of study results with the six practice domains of the National Association of Nurse Practitioner Faculties (NONPF) Curriculum Guidelines appeared to verify the NONPF domains as being operant in advanced nursing practice. Each role had distinct expression of the NONPF practice domains, particularly in two areas: management of client health-illness states and the professional role. Results suggest that advanced practice graduate nursing curricular content needs to be explicit regarding CNS and NP role domains to retain the respective strengths of each. A "hybrid" CNS/NP curriculum faces the danger of lacking both the depth and specificity of knowledge that has resulted in the roles' past successes. (Index

*Assistant Professor,School of Nursing, Universityof Minnesota, Minneapolis,MN. ~Associate Professor, Department of Nursing, College of St. Catherine, St. Paul, MN. SDirector of Nursing, Moonlight Home Health, Minneapolis, MN. Address correspondenceand reprint requests to Dr Lindeke: 6-101 Weaver-DensfordHall, 308 Harvard St SE, Minneapolis, MN 55455-0324. Copyright© 1997 by W.B. SaundersCompany

8755-7223/97/1305-0006503.0010

words: Advanced practice; Clinical nurse specialist; Nurse practitioner; Practice domains)J Prof Nurs 13:281-287, 1997. Copyright © 1997 by W.B. Saunders Company

HE NURSING profession is focusing considerable attention on the delineation of curriculum content and the regulation of advanced nursing practice. Schools of nursing are rapidly expanding their clinically focused master's programs in response to marketplace demands for advanced practice nurses (APNs), particularly nurse practitioners (NPs). A process of consensus building is underway regarding the education of APNs. NP role preparation is described in curriculum guidelines of the National Organization of Nurse Practitioner Faculties (NONPF, 1995). The American Association of Colleges of Nursing (AACN) held a series of regional conferences regarding master's-level nursing curriculum content and published their curriculum recommendation,

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Essentials of Master's Education for Advanced Practice Nursino~(AACN, 1996). As well, the National Council of State Boards of Nursing (NCSBN) is proposing new regulatory structures to assure the public of APN competence (NCSBN, 1992). The literature contains numerous opinion pieces regarding conceptual issues of advanced practice nursing. However, few studies objectively compare or contrast the practices of clinical nurse specialists (CNSs) and NPs.

Review of the Literature

There has been considerable debate regarding the merger of the CNS and NP roles (Elder & Bullough,

JournalofProfessionalNursing, Vol 13, No 5 (September-October), 1997: pp 281-287

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1990; Frik & Pollock, 1993; Galassi & Wheeler, 1994). Nurses in practice urged that specific differences between the roles not be lost (Page & Arena, 1993). Educators, on the other hand, focused on CNS and NP similarities (Forbes, Rafson, Spross, & Kozlowski, 1990). Supporters of merging CNS and NP roles described the versatility and strengths that the blend of competencies would produce (Cronenwett, 1995). Forbes et al surveyed 108 schools and found great similarity between NP and CNS graduate programs, although there was increased emphasis on pharmacology, primary care, physical assessment, health promotion, nutrition, and history taking in NP curricula. Burns et al. (1993) surveyed 175 accredited master's programs and found 50 different areas of clinical concentration, 51 subspecialties, 12 program categories, 5 general role function categories, and 19 distinct names for roles. They concluded that master's education was diverse and rapidly evolving and recommended national dialogue regarding the proliferation of majors and subspecialties to enable the profession to clearly articulate the roles and expertise of nurses with master's degrees to the public.

Combining... roles would enhance the ability of CNSs to obtain reimbursement...

Concern has been expressed about role confusion and dilution of role components if CNS and NP education is combined (Nelms, 1993). NP educators fear less emphasis on competencies that have led to the success of the NP role, such as autonomy, direct care provision, primary care, and health promotion. Burns (1993) pointed out that CNS preparation does not include primary care management of minor and chronic illnesses of all body systems but instead focuses on in-depth understanding of problems of nursing practice in a specialty such as cardiology, oncology, and the like. CNSs have voiced concern that their particular areas of expertise (eg, consultation, system management, system change) will be lost in a combined role (Page & Arena, 1993). Confusion related to title recognition by the public is a relevant issue. Hockenberry-Eaton and Powell (1991) stated that the CNS title is less recognized by the public because the CNS generally does not function as a direct care provider. On the other hand, compared with the NP title, the CNS title has had

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more recognition and status among nurses because CNSs have served as role models of expert professional practice. This is due to the CNS history of having been structured originally at the master's level and continuously housed in schools of nursing. In contrast, the NP role has a mixed history of master's and certificate levels of education and has been situated in a variety of educational settings (i.e., schools of nursing, medicine, or public health). Legislatively based autonomy has moved faster for NPs, however, particularly in the form of laws regarding prescribing and reimbursement. Because the NP title is more likely to appear in reimbursement and prescribing laws, and because certification confers certain titles, the issue of APN titling is central to discussions of role merger. Combining NP and CNS education and roles would enhance the ability of CNSs to obtain reimbursement and prescriptive authority in most states. Page and Arena (1993) worry that graduates of combined CNS/NP educational programs might suffer from role strain and role confusion, which could result in "imposter phenomenon." They describe this phenomenon as a sense of insecurity about competence in the practice setting, which leads to a feeling of not being what one purports to be. They caution that bJending CNS and NP practice will not strengthen the profession but could instead produce a hybrid nurse who lacks the qualities that made the CNS and NP roles viable. Looking at similarities and differences in practice of CNSs and NPs is timely. There is an abundance of opinion about these distinctions, but there is a dearth of research-based literature. Two nurses, Fenton (1984, 1985) and Brykczynski (1985, 1989) carried out seminal work examining role similarities and differences between NPs and CNSs. They subsequently combined their individual work m formulate a comparison of CNS/NP roles (Fenton & Brykczynski, 1993). They recommended that their model serve as a framework for curriculum development and further study of the roles: "Without empirical data to support the similarities or refute the differences in the roles, the potential for inappropriate curriculum decision-making exists" (p. 317). Hence this study- was undertaken to further expand Fenton and Brykcynski's model.

Study Design ORGANIZING FRAMEWORK

Research regarding master's-level role domains and competencies by Fenton and Brykczynski (1993) led them to develop a model to guide CNS and NP

CNS/NP PRACTICE DOMAIN COMPARISON

curriculum development. Their work modified Benner's domains of expert nursing practice (1984). Fenton (1984, 1985) studied CNSs, whereas Brykczynski (1985, 1989) examined NP practice. The NONPF used the work of these authors as a starting point for the National Guidelinesfor Nurse Practitioner Education (Zimmer et al., 1990). This document was revised as NONPF's Curriculum Guidelines and Program Standards for Nurse Practitioner Education (NONPF, 1995). The six domains of the 1995 document contributed to the organizing framework for this study (Fig 1). STUDYPURPOSE

This study investigated the similarities and differences between CNS and NP practice domains by examining interview data from 15 NPs who were previously educated as CNSs. A domain was defined as a cluster of related similar competencies. The assumption was made that the respondents had valid insights regarding CNS and NP roles.

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approximately 1 hour. Interviews were conducted by two doctorally prepared nurse researchers with previous experience in qualitative research. All interviews were audiotaped and transcribed verbatim. Throughout the study the voice of each respondent was preserved by identification as respondents A through O. Data consisted of transcriptions of the interviews and analysis notes. The unit of analysis was a stated similarity or difference of NP and CNS practice. Analysis occurred in stages. First, open coding detected data unit topics, which then were grouped under themes. Themes were grouped under the six framework domains to develop a chart of themes, using constant comparison to draw conclusions. The chart of themes (Table 1) was then mailed to the respondents; 11 respondents returned the chart with extensive comments regarding the preliminary analysis, which were then incorporated into the analysis.

TRUSTWORTHINESS OF CONCLUSIONS METHODOLOGY

This study used qualitative methodology and related findings to an existing conceptual framework. A semistructured interview guide posed open-ended questions regarding distinctions between CNS and NP practice and elicited comments regarding the changes that respondents experienced in moving from the CNS to the NP role. Subjects Respondents had master's degrees from eight states with wide geographical distribution. These respondents were recruited from the population of postmaster's graduates with previous CNS education who completed a post-master's NP curriculum. All respondents stated that they had experience with the CNS role. Ten had been employed as CNSs after completing their original programs. The remaining five had been employed in education, administration, and research. The respondents completed a three-trimester course of NP study at the a single institution and were prepared as adult, pediatric, or gerontologic NPs. The mean number of years since completion of the NP program was 4.5 years (range, 1-10). Data Collection A semistructured interview guide was used to obtain respondents' views regarding differences between NP and CNS practice. Each interview lasted

The research team members had complementary backgrounds, skills, and professional preparation. The third member joined the team after the interviews were completed and served as a "fresh eye" during the analysis process. Because of their expertise, the researchers expected there to be congruence (a "good fit") between the domains and the data, which Guba (1981) describes as applicability. Careful bracketing of preconceived notions was employed. The organizing framework guided the analysis at specific stages and was consciously set aside at other stages to assure that it did not constrain the analysis. The analysis was based on a series of readings of transcripts with periodic cycling back into the data after discussion by team members. At each stage the intent was to read for resonance with the team's preliminary hunches, taking care to discard hunches that did not resonate with the data.

Results

Data obtained from the respondents in this study easily clustered under the six 1995 NONPF domains of practice (Table 1), and there were no themes from the interviews that did not fit the conceptual framework. Therefore, this study appears to support the appropriateness of the domains for guiding graduate nursing curriculum development. However, distinc-

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TABLE 1. D i f f e r e n c e s B e t w e e n N u r s e P r a c t i t i o n e r a n d Clinical N u r s e S p e c i a l i s t Practice D o m a i n s NONPFDomains(1995)

NP Themes

CNS Themes

Site: clinic and/or hospital H & P: complete, primary care, holistic Knowing: broad

Site: acute care, hospital H & P: focused on body system Knowing: deep, focused

Nurse-client relationship

Continuity: own caseload over time Knowing: broad awareness of client over time

Continuity: short-term with acute illness or exacerbation Knowing: specific to situation at hand

Teaching-coaching

Teaching-coaching: health, health promotion, general, or condition-specific Population: specific to certification (adult, pediatric, etc)

, Teaching-coaching: system-focused in terms of specialty, consultation to situation Population: specific to CNS specialty (cardiology, oncology, etc)

Professional role

Autonomy: clinical decision making, role components Accountability: direct care, outcomes clearer, patient satisfaction Collaboration: with MDs, based on site of practice (office, long-term care, etc) Role development: nontraditienal, selfdefined; need to define self to health care team, public Consulting: client concerns (eg, lactation, behavioral concerns, etc)

Autonomy: less so; reports to administrative structure Accountability: more diffuse, outcomes indirect because care generally indirect, accountable for quality of other nurses' care, works in committee structures Collaboration: with other nurses, less with MDs; consult re: nursing care Role development: generally defined by organization (not so for CNS in ambulatory site or psych-mental health) Consulting: very large part of role; may focus on specific client, client issues, nursing structure, organizational structure, etc

Managing & negotiating health care delivery systems

Site: dfice or community-based Communication: between systems and health care professionals (eg, case management)

Site: institution-based; accountability to system; may be large part of role Communication: generally within system; may also do case management

Monitoring & ensuring quality of hearth care practices

Site: practice site Focus: patient outcomes, patient satisfaction

Site: institution-based Focus: patient outcomes, new technology, cost anarysis, research on interventions, QA/CQI, staff development

Management of client health-illness status

Abbreviations: NONPF, National Organization of Nurse Practitioner Faculties; NP, nurse practitioner; CNS, clinical nurse specialist; H & P, history taking and physical examination; ME3,medical doctor; QA, quality assurance; CQI, continuous quality improvement.

tions between the two roles were apparent within each domain.

rather than having someone else diagnose and then write a referral for a CNS to come in."

DOMAIN 1: MANAGEMENT OF CLIENT HEALTH-ILLNESS STATUS

DOMAIN 2: NURSE-CLIENT RELATIONSHIPS

Domain themes showed differences of knowledge, data collection, and diagnosis. CNS knowledge was delineated by a specialty area, whereas NP knowledge reflected broad primary care knowledge. Compared with NPs, CNSs were less likely to gather data by taking histories and performing physical examinations. Finally, NPs diagnosed client illnesses, whereas CNSs generally dealt with problems related to previously diagnosed illnesses. Stated repondent O, "Diagnosing and patient monitoring is more my NP role,

Distinctions focused on the themes of continuity and knowledge. NPs had regular contact with clients over time, whereas short-term involvement during acute illness or exacerbation was typical of CNS practice. Knowledge of the client and family was generally broad and extended over time for NPs, in contrast to CNSs, who had knowledge of the client and family relevant to the situation at hand, often in short-term relationships. Respondent J stated, "I think in taking care of patients in the hospital [as a CNS], one of the things that always impressed me was how

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LINDEKE, CANED~ AND KAY

you only had contact with one patient for this isolated moment and that it was not always the person's real life." DOMAIN 3: TEACHING-COACHING FUNCTION

Differences involved topics and populations for patient teaching and coaching. NPs in the sample carried out general health promotion and conditionspecific teaching and coaching, whereas CNSs focused on body systems and related nursing interventions. As well, the NP client population was delineated by the NP certification area (eg, gerontology, adult, pediatrics). The CNS client population was delineated both by the CNS specialty area (eg, cardiology, oncology) and by the employment site (eg, home health, acute care). Stated respondent J, "The CNS would be preparing nurses to teach clients on an inpatient level and she becomes middle management. The teachingcoaching function of the NP is the direct patient care of primary care." DOMAIN 4: PROFESSIONAL ROLE

The increased caseload autonomy of NPs contrasted to the autonomy of CNSs, which was defined more by the administrative structure. NPs were accountable for direct care and patient satisfaction measures, whereas CNSs were accountable for indirect outcomes, some of which were reflected in the quality of other nurses' care. NPs collaborated with MDs and others at the practice site, whereas CNSs collaborated with groups of nurses regarding nursing care. Respondents in this sample described a process whereby NPs created their own job descriptions and expanded their practice autonomy over time. In contrast, respondents described CNS roles as explicitly defined by the employing organizations. Compared with NPs, consuiting was a larger part of the CNS role, which focused on specific client issues, nursing process, and organizational structure. Respondent B stated, "I think that there is a world of difference as far as professional autonomy. I think that the NPs have quite a bit more autonomy than the CNSs do. Functioning within the hospital with all the rules and regulations restricts your autonomy." DOMAIN 5: MANAGING AND NEGOTIATING HEALTH CARE DELIVERY SYSTEMS

The themes in this domain involved the practice site and communication patterns. The site of NP

practice usually was the office or the community, whereas CNSs' sites usually were tertiary-care institutions where accountability for systems was a large part of the role. Communication for NPs was between systems and health care professionals (eg, case management). Communication for CNSs was generally within the system, although the role sometimes include case management with outside agencies. Stated respondent B, "I look at the CNS more and more in acute and episodic care." DOMAIN 6: MONITORING AND ENSURING THE QUALITY OF HEALTH CARE PRACTICES

Themes in this domain revealed site and focus differences. NPs were involved in monitoring quality of care at the practice site or within care teams, whereas CNSs monitored practices within institutions or nursing units. NPs focused on patient outcomes and patient satisfaction as well as cost-effectiveness of care. CNS concerns were patient outcomes, new technology, cost analysis, interventions, research, quality assurance/continuous quality improvement, and staff development. Respondent J stated, "I look at the CNS doing more in terms of auditing charts. I look at the NP as getting clients back to make sure interventions, regimens, and therapies were effective."

• . . although practice domains are similar, there is distinct expression of the domains in each APN role.

Discussion

In practice at the present time, CNS and NP roles are distinct. This study demonstrates that although practice domains are similar, there is distinct expression of the domains in each APN role. Respondents stated that knowledge and skills were different between CNS and NP roles. The need to be explicit regarding APN roles and domains of practice appears to be supported by this study. Debate continues as to whether CNS and NP education and credentialling must remain differentiated. Study participants clearly articulated that they learned extensive new content in their post-master's NP education and further developed their autonomous clinical decision making. It is therefore not

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CNS/NP PRACTICE DOMAIN COMPARISON

appropriate to assume that a CNS practice domain is so similar to an NP practice domain that little needs to be altered in a CNS curriculum to bring its graduates into the NP role. Similarly, it is apparent that an NP curriculum that does not incorporate organizational analysis, consulting, and group process components in which CNSs have made valuable contributions to health care. Master's-level educational programs in nursing that combine NP and CNS roles into a single advanced practice role face the danger of diluting the strong competencies of each role. It appears erroneous to believe that a CNS can move into an NP role with little or no additional education. The 15 respondents stated that they experienced significant role change in the transition from CNS to NP roles and that they

valued the intense year of educational preparation in their post-master's NP program.

Implications for Further Study The views expressed by the 15 respondents reflected their individual preparation and work experiences. Domains might be described in different ways by other groups of individuals, and regional variations may exist. However, the consistency of theme expression and the validation of these findings with descriptions of CNS and NP practice in the literature lend credibility to the findings. Further study of nursing practice within the rapidly changing health care system is warranted to guide the profession in making crucial education and practice decisions.

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Forbes, K., Rafson, J., Spross, J., & Kozlowski, D. (1990). The clinical nurse specialist and nurse practitioner: Core curriculum survey results. Clinical Nurse Specialist, 4(2), 63-66. Frik, S., & Pollock, S. (1993). Preparation for advanced nursing practice. Nursing and Health Cam, 14(4), 190-195. Galassi, A., & Wheeler, V. (1994). Advanced practice nursing: History and future trends. Ontology Nursing, */(5), 1-8. Guba, E. (1981). Criteria for assessing the trustworthiness of naturalistic inquiries. Educational Communication and Technolo~Journal, 29, 75-92. Hockenberry-Eaton, M., & Powell, M. (1991). Merging advanced practice roles: The NP and CNS. Journal of Pediatric Health Care, 5(3), 158-159. National Council of State Boards of Nursing (1992). Position paper on the licensure of advanced nursing practice. Chicago, IL: Author. National Organization of Nurse Pratitioner Faculties (1995). Curriculumguidelines &program standardsfor nurse practitioner education (2nd ed.). Washington, DC: Author. Nehns, B. (1993). Advanced practice: Confusion, complexities, and questions. Journal of Pediatric Health Care, Z 253-254. Page, N. E., & Arena, D. M. (1993). Rethinking the merger of the clinical nurse specialist and the practitioner roles. Image--The Journal of Nursing Scholarship, 26(4), 314-318. Zimmer, E, Brykczynski, K., Martin, A., Newberry, Y., Price, M., & Warren, B. (1990). National guidelines for nursepractitioner education. Seattle, WA: National Organization of Nurse Practitioner Faculties.