Qualitative distinctions and similarities in the practice of clinical nurse specialists and nurse practitioners

ORIGINAL

ARTICLES

Qualitative Distinctions and Similarities in the Practice of Clinical Nurse Specialists and Nurse Practitioners MARY

V.

FENTON,

RN, DRPH* AND KAREN A. BRYKCZYNSKI,

Current debate over whether clinical nurse speclallst (CNS) and nurse practitioner (NP) roles should be combined or remain separate are largely theoretical. Minimal research has been conducted comparing these roles. Most studies to date con&t of graduate follow-up surveys and comparisons of curricula. Interpretive results of Fenton’s investigation of the practice of CNSs and Brykczynski’s study describing the practice of NPs were compared to highlight the commonalties and distinctions between the two roles. This comparison is significant in that it explores the actual practice of CNSs and NPs. Both studies were modeled after Benner’s research exploring the development of clinical expertise and produced adaptations of Benner’s domains and competencies of nursing practice specifically for CNSs and NPs. Partlcipant observations and small group interviews were the data-gathering methods used in these lnterpretlve research studies. The interpretive approach is described as a situational, contextual, or narrative research method for understanding the knowledge and meanings in everyday (naturalistic) settings. Comparatlve analysis of results of the CNS and NP studies showed a shared core of advanced practice compe tencies as well as distinct differences between the practice roles. These flndlngs have implications for curriculum development in advanced nursing practice. (Index words: Advanced nursing practice; Cllnical nurse specialist; Graduate nursing education;

*Dean andProfessor, The University of Texas Medical Branch School of Nursing at Galveston. tAssistant Professor, The University of Texas Medical Branch School of Nursing at Galveston. Address correspondence and reprint requests to Dr Fenton; School of Nursing, The University of Texas Medical Branch, 1100 Mechanic Rt J-29, Galveston, TX 77550. Copyright 0 1993 by W.B. Saunders Company 8755-7223/93/0906-0005$0%00/O

RN,

DNSc”f

Nurse practitioner; Primary health care providers) J Prof Nurse 9:313-326, 1993. Copyright 7993 by W.B. Saundefs Company

T

HREE DISTINCT ideologies exist regarding the future roles of the clinical nurse specialist

(CNS) and nurse practitioner

(NP). Some nurse edu-

cators and leaders advocate merging of the two roles based on the assumption that such a union is advantageous for schools of nursing, and

patients

maintain

(Elder

and

the health care system,

Bullough,

that the roles are distinct

1990).

Others

and should be kept

separate because of the differences in focus and setting (Zimmer, Brykczynski, Martin, Newberry, Price, & Warren, common

1990). The majority of leaders advocate a core of content appropriate for both the CNS

and NP roles, with the major focus of the NP role on primary care and the major focus of the CNS role on acute care. Further,

these leaders suggest

maintaining

distinct roles for the CNS and NP. (Forbes, Rafson, Spross, & Kozlowski, 1990; Pearson, 1990). The intent of the authors present

is not to settle this debate

research findings

but to

that reflect the commonali-

ties and uniqueness of each role and to describe implications for curriculum development. The rapidly changing health care system challenges graduate nurse educators to prepare nurses with advanced skills necessary to assume leadership and collaborative roles in advanced practice. Many barriers to advanced nursing practice from the past are disappearing, primarily because of economic reasons. The traditional health care system is no longer affordable, and nurses functioning in advanced clinical roles are shown to be more cost-effective than are physicians in

Journal of Profarsional Nursing, Vol 9, No 6 (November-December),

1993: pp 313-326

313

314

many

FENTON AND BRYKCZYNSKI

Thus,

settings.

clinical

nursing

situation

nurses

prepared

in advanced

roles are in increased

demand.

is right for nurses in advanced

to move toward active participation and future

needs.

researchers

have examined

CNSs and NPs.

The reality,

however,

comparisons

(Forbes,

1990; Sparacino

Ratson,

& Durand,

practice

of advanced

because

many

is that few the roles of

1990) and curricula Spross,

nursing

of nursing

& Kozlowski, roles is critical,

with

diminishing

resources may be forced to delete or combine and CNS roles. Without similarities potential

or refute

empirical

the NP

data to support

the difference

for inappropriate

to the knowledge

1986). Study of the actual

clinical

schools

care that occurred

both

curriculum

determined. results

qualitative the practice

This article

of two studies

of patient

War II and to respond of new technology

1987; Sills, 1983). The 1964 Nurse Training education,

was to support

was instrumental

ment of the role (Kalish & Kalish,

and upgrade

in the develop1978). Because the

CNS role was truly the response of nursing to a perceived controversy isted.

and the

of the health care system (Mon-

Act, the goal of which nursing

of a CNS in

need to improve

or opposition

However,

nursing

from nurse

this was in direct

response of nursing

education

education care,

little

educators contrast

ex-

to the

to NP programs.

in the roles, the decision

mak-

An important question is this: How can we assure that these roles will evolve to meet the challenges and needs of our future health care system? To answer this tions between

post-World explosion

complexity

temuro,

the concept

the fragmentation

the

ing exists.

question,

increasing

developed

to decrease

roles

to date consist of grad-

uate surveys (Elder & Bullough,

Nurse educators an attempt

a sys-

society’s current

or compared

Most studies

practice

in shaping

tem that will be effective in meeting

The

and quantitative

NP role was developed collaboratively by nurses and physicians in response to multiple factors. The

distinc-

of CNSs and NPs must be compares

conducted

and contrasts in the 1980s.

the One

The

NP

role was developed

nurses and physicians

by

factors.

Factors

qualitative methodology expert practice domains

expand the nursing role; dilemmas in the health care delivery system (maldistribution of providers, escala-

(1984a).

Background: Development of the CNS and NP Roles It is important

to know the histories

of the devel-

opment of both the CNS and NP roles to understand how the roles evolved to their current status and the dilemmas and obstacles they still face. The CNS role was described as early as the 1940s by Peplau with the development of psychiatric CNSs and later by Reiter (Peplau, 1965; Reiter, 1966). The first CNS program was established at Rutgers in 1954 by Peplau (Smoyak, 1976), almost concurrently with the publication of the American Nurses Association (ANA) definition of nursing in 1955. In contrast, the first recognized NP program was initiated more than 10 years later in 1965 at the University of Colorado to prepare Pediatric NPs. Although established more than 10 years apart, the development of the CNS role paralleled the development of the NP role in the early and mid- 1960s and was seen as a clinical option to the more traditional educator or administrative role in graduate nursing programs.

contributed

collaboratively to multiple

study examined the CNS role, and the second study examined the NP role. Both studies used the same and were analyzed using the developed by Patricia Benner

that

in response

NP role included

impetus

to the development in the nursing

of the

profession

to

tion of costs, predominance of specialists and subspecialists, and scarcity of primary care providers); and social activism and consumerism (Polfus & Bigbee, 1989).

The need for medical

the opportunity for professional ambulatory NP program

labor power

“provided

to test an expanded scope of practice nurses in the care of well children in

settings”

(Ford,

was initiated

1982, p. 232). The first as a demonstration

con-

tinuing education offering rather than as a graduate program partly because of opposition from nursing education. The first physician assistant (PA) program was established at Duke University also in 1965 as a response to the shortage of physicians and the negative response by organized nursing to a request to expand the role of nurses to include medical acts through the development of NP programs (Dilworth, 1970). This philosophical conflict about the role of medicine in nursing did not begin to be resolved until the 1980s and was fought out in the courts and published literature for many years. It is still an issue in some parts of the country, and the controversy directly impacted development of the NP role and programs. The opposition of nursing education to the NP role

315

DISTINCTION AND SIMILARITIES BETWEEN CNSs AND NPs

resulted

in the highly

different

types of NP programs

and 1970s (Ford, ated

with

disorganized

1982).

medical

There

and the length

or if part

uous federal support ning

Wood Johnson

Nurse

Care Program,

which lasted from

in content

and

velopment

varied from a few months

to 2

the ANA Council

education

variability

and role confusion for the training until

the development

constant

was contin-

of NPs begintoday.

of the role would and definition

CNS role was much more uniform.

of the

In 1965 the ANA

published a position paper stating that the title of CNS could be used only by nurses with a master’s degree in nursing, which helped establish the educational credential for specialized practice. the ANA defined the CNS as a practitioner

In the 1970s

were more similar

holding a master’s degree with a concen-

1980).

Care Nurse PracNurse Specialists

in 1986 claiming (Hanson

that the roles

(Sparacino

and Martin,

and Du1990) ar-

the CNS and NP roles

and ideal than real. She asks what of overlap? Although

the sim-

and the differences

few, the

may be many

differences significant.

are both quantitatively and qualitatively For example, Elder and Bullough (1990)

in their report on CNS and NP graduates point out that the NPs spent 73 per cent of their time in direct

physical

examinations,

prescribing

rals, and prescribing

ordering

medications,

and initiating

the roles were also validated scribed in this article.

of

labora-

making treatments,

they spent significantly less time conducting groups and teaching staff. These distinctions

role, and function

In 1982 the Council

Health

ilarities

Congress for Nursing Pracon nursing practice includ-

of the education,

de-

is the actual percentage

tory studies,

Specialty credentialing through national certifying examinations was developed by the ANA and other specialty nursing organizations in the mid 1970’s. In

of the CNS (ANA,

1982.

in the historical

of Clinical

gues that the overlap between

conducting

p. 5).

1980 the ANA-sponsored tice published a statement

in Primary

1975 until

than different

1986). Martin

NP

Robert

care, and CNSs spent 52 per cent of their time in direct care. The NPs spent significantly more time

tration in a specific area of clinical nursing. The role of the CNS is defined by the needs of a select client population, the expectation of the larger society and the clinical expertise of the nurse (ANA, 1976,

ing a description

an editorial

in the

of the NP and CNS roles,

of Primary

and the Council

published

to acquire

Fellowship

the major differences

is more theoretical development

Faculty

and enactment

titioners

rand,

Without

not have survived. In comparison,

faculty

culminating

were affili-

as continuing

in 1964 and continuing

federal support,

skills

and

Despite

was wide

all this conflict

for nursing

knowledge

of nursing

years. The one factor that seemed to remain during

were developed

pro-

schools, were developed quality,

of

the 1960s

Many programs

schools,

grams.

development

throughout

referand

support between

in the two studies

de-

Methods The purpose of this article is to present a comparison of the results and conclusions of two qualitative

Specialists was formed as part of the Through extensive discussion among

studies of advanced nursing practice roles that used the same research design, methodology, and concep-

nursing leaders, a consensus regarding the functions of the CNS emerged: the CNS was seen as an expert

tual framework. The purpose of Fenton’s (1984, 1985, 1992; Steele & Fenton, 1988) study of CNSs

practitioner, educator, well as change agent.

consultant, and researcher as However, these extensive ex-

and Brykczynski’s (1985, 1989) study of NPs was to describe the actual practice of these nurses in advanced

pectations often led to great role ambiguity on the part of the CNS graduates, the administrators who hired them, and the health professionals who worked with them.

practice roles. Both studies were modeled after Benner’s (1983, 1984a, 1984b) research and identified the domains and competencies of nurses in advanced

Clinical Nurse ANA structure.

Recognition

and definition

of the NP

role came

practice roles. Benner served as Fenton’s research consultant and Brykctynski’s dissertation advisor. Data

through similar channels including credentialing procedures by various organizations, the incorporation of

from both studies

primary care skills into baccalaureate nursing programs, the definition of the nurse practitioner role by the ANA Congress on Nursing Practice in 1974, and the development of ANA standards for preparation of NPs in continuing education programs in 1975. In addition, a variety of continuing education programs

tion-based interviews. These descriptive data were interpreted using hermeneutic phenomenology to describe the everyday practices of these advanced practice nurses. Data for Fenton’s study consisted of 105 situationbased interviews (yielding 157 situations) and 53 par-

ticipant

observations

consisted

of field notes from par-

and written

transcripts

of situa-

316

FENTON AND BRYKCZYNSKI

ticipant

observations

tal of 242 clinical

(yielding

85 situations)

situations.

These

lected over a period of 6 months master’s_prepared

based

in a variety of roles

care center consisting

and iarge

Brykczynski’s

from a sample of 30

CNSs employed

in a large tertiary pitals

ambulatory

interviews

133 situations)

observations

(yielding

for a total of 199 situations.

tions)

collected

over a period

enced NPs practicing

Data

for

and

apeutic

interventions

80

66 situa-

of 8 months

of health

organization

and

role competencies;

helping

the situation.

Reliability

function;

and

changing

situations.

limits

possible

and validity

of the interpre-

An overall

guideline

is to judge if a particular

interpretation

is reasonable

given

a specific

1980). Guba’s (198 1) criteria of qualitative

describe the approaches and reliability concerns

context

for assessing

the

research will be used to

employed to address validity in these studies.

The truth value or credibility of the interpretations is addressed by seeking consensual validations from participants

who relate how well their actual experi-

ences are conveyed by the interpretations. Applicability refers to how well the meaning of situations transfers to other contexts. Narrative data are provided in the research meaning

report

to allow

of the situations

for assessment

by readers.

of the

Consistency

or

auditability refers to the ability to follow the researcher’s interpretive decisions throughout the study. This was handled in Fenton’s study by the participation of the research team in data interpretation and validation by the participants themselves and in Brykczynski’s study by an interpretive seminar group, the dissertation committee, an outside expert, and the study participants. Neutrality or confirmability is quite different in qualitative research where the researcher seeks engagement, rather than detachment, from the parThe threat of spurious findings resulting ticipants. from observer bias is managed by the strategies of multiple stages of data interpretation and consensual validation by participants and colleagues.

Results Benner originally ing practice: ing function;

identified

(1) the diagnostic (2) administering

of rapidly domains

and competencies

and

specific

in each study

to are

the CNS is much more kolvecf in promoting the overall functions of the organization . . .

is

interpretation

trustworthiness

original

the CNS and NP role identified

ambula-

for qualitative (Agar,

management

Benner’s

from 22 experi-

the unit of analysis

meanings.

(4)

(5) the

(6) the teaching/coaching

(7) effective domains

care practices;

shown in Fig 1.

tations of the descriptive data are based on details of the situational context. It is the situational context that

work

role of the nurse;

tory care settings. studies

(3) monitoring

the quality

These data were

in four hospital-based

In these interpretive

and regimens;

and ensuring

the additional

of 62 hours of situation-

(yielding

hours of participant

of seven hos-

care services.

study consisted

for a to-

data were col-

seven domains

of nurs-

and patient monitorand monitoring ther-

In Fenton’s

research

Benner’s domains study

CNSs,

were present

of CNSs Fenton

tencies for three domains and developed

with

evidence

in practice.

identified

of all

From her

additional

compe-

from Benner’s original

one additional

domain,

study

the Consulting

Role with related competencies (Fig 1). In Brykczynski’s research with NPs she developed one additional domain, Management of Patient Health/Illness Status in Ambulatory Care Settings, which consolidates and replaces two of Benner’s domains that were more typical of inpatient nursing agnostic and Monitoring and Monitoring mens-and

practice, Function

Therapeutic

interpreted

specifically the Diand Administering

Interventions

the remaining

and Regi-

five of Benner’s

seven domains as valid for the practice of the NPs studied (Fig 1). Results of the two studies are presented and compared according to domain. from each domain are described below.

Examples

DOMAIN: ORGANIZATIONAL AND WORK ROLE COMPETENCIES

The demonstration of competencies under this domain by the advanced nurse appears to be a function of the role and scope of the nurse’s position in the organization.

The narrative

data suggest

that

these

competencies are more characteristic of the practice of CNSs than the practice of NPs. It was found that the CNS is much more involved in promoting the overall functions of the organization by supporting staff, patients and families in coping with the bureaucracy. Additional competencies that were identified by Fenton include: (1) coping with staff and organizational resistance to change; (2) grooming staff to see their roles as part of the whole organization; and (3) providing support for nursing staff. These competencies

Figure 1.

Expert

practice

domains

of the CNS and the NP.

consultation to MDs and other

Domain identifiedby Benner

t

lntetpreting theroleof nurshg to others: role modeling

~_.___.._,____.__;

Consulting Rdeofthe Nurse

0

2i

‘““5

)

i :

NP competency identified by Brykczynski

CNS competency identifiid by Fenton

NP domain identified by Brykczynski

:----I 1 CNS domain identified by Fenton

1----t

I

J

; ;

,_________________ me

318

FENTON AND BRYKCZYNSKI

may be evidenced

in the practice

have a significant

administrative

work role; however, tioner

they are not typical

in a direct provider

Illustrations

showing

begins

until

of a practi-

listen,

competency analyze,

formal

that

stances

The skill involves

in-depth

being feelings

gradually

interpret,

research

requires

and synthesize

The

the ability

extensive

to

literature

reviews and then the ability

to speak to the opposition

with

and clinical

documented

research

findings.

A

duction

or mandated system change system change enables the

and implement

of other policy changes.

the successful Examples

intro-

given were

Joint Council on Accreditation of Healthcare Organizations accreditation visits, the opening of new services, moving into new buildings or space, and the hiring of new administrators. Further exploration of the importance of the CNS in providing support for nursing staff is validated in a study of the clinical practice of CNSs by Schaefer (1991). She found that the CNSs in her sample took care of the caretakers (nurses) as well as the patients and their families. A further

competency

identified

this domain

was Making

the Bureaucracy

Patients’

and Families’

Needs,

by Fenton

under

Respond

hospital admission minimal

patience

and persis-

handled

familiarity

to

ie, Being an Advocate.

This competency was obviously developed in response to the fact that patients’ and families’ needs are often not met in a timely fashion because of bureaucratic policies and functions. Most policy changes cannot be initiated in time to meet immediate patient needs, so the nurse develops ways to work through and around the system. The CNSs in Fenton’s study had impressive networks of contacts throughout the organization who would bend or break the rules to meet a patient’s or family’s immediate needs. It is significant that this competency was developed independently in Brykczynski’s study and was labeled “managing the system.” On further interpretation of the data in concert with concurrent literature review, it became apparent that this competency was identical

no ill feel-

resident.

To accom-

such as this, the NP uses his or her

with how the bureaucracy

While

communication

needs. identified

was Obtaining

Remaining

indicate

works in concert

developed

competency

this domain

Data

by the NP with

and virtually

skills to meet the patient’s

vider.

and an emergency

medical

his or her highly

for Patients

this

set of circum-

was choreographed

plish an objective with

complicated

stress to the patient

An additional

effective competencies identified to cope with organizational resistance to change was the ability to recognize the most strategic timing for change. The rec-

nurse to prepare

a particularly

was successfully

ski under

third example is using concurrent or mandated change to facilitate other system changes. One of the most

ognition that concurrent is a facilitator of other

label for

into Brykczynski’s

involves

ings from the admitting

findings

the need for change.

is involved

so Fenton’s

was incorporated

This competency

of staff persons’

and acknowledge

to document

study.

competency,

the person who is resisting

is using

and knowledge

had described,

this competency

from the study

to accept the change as a good idea. A second

example

to the one Fenton

tence. In one example of an NP’s skill illustrating

acceptance

need to resist system change. able to sit, actively

in their

role.

of these competencies

of CNSs include

repeatedly

of NPs when they component

that

by BrykczynSpecialist

the Primary

this

competency

Care

Care Prois more

evident in the practice of the NPs studied than the CNSs. Many examples of the careful monitoring of holistic care of patients over time while they were referred to specialist physicians for care were evidenced in the NP situations. For example, a patient with chronic

obstructive

pulmonary

was followed up in Pulmonary idents, however, the patient’s tion as his overall Medical sulted

Clinic.

primary

The

in the diagnosis

disease (COPD)

Clinic by medical resNP continued to func-

care provider

NPs

thorough

in General

assessment

of lung cancer.

re-

This situation

was particularly illustrative of the comprehensive nature of the NPs care and the more narrow limits of physician specialist care. The patient had COPD and was complaining of shortness of breath and significant weight loss. His COPD management and course were monitored

and determined

to be without

problems

terms of the Pulmonary Clinic’s concern. practitioner ordered a chest roentgenogram the assessment was thereby

of the weight discovered.

in

The nurse as part of

loss, and the lung mass

This example

illustrates

the

significance of the broad perspectives of NPs. The case manager role--which is described by Papenhausen (1990) as being directed toward increasing self-care abilities of patients; coping with altered health states; preventing complications and unnecessary hospitalizations; and providing increased access to quality health care that is continuous, comprehensive, and cost-effective-is similar in many ways to the NP role except for not actually being a primary care provider. As more NPs and CNSs assume case manager roles, these distinctions may be further clarified. However, it is essential to be aware of the major differences between being a facilitator of care (case manager) and a provider of care (NP).

319

DISTINCTION AND SIMILARITIES BETWEEN CNSs AND NPs

DOMAIN: MONITORING AND ENSURING THE QUALITY OF HEALTH CARE PRACTICES

An additional

competency

der this domain problem

identified

by Fenton

ofa recurring

was recognition

that could be solved by a policy change.

skill involves an isolated

the ability event

to discriminate

that

may

un-

generic This

between

jeopardize

(1)

a patient’s

health or safety but is not likely to occur again, therefore not requiring recurring

a policy change and (2) potentially

events

that

threaten

a patient’s

health

or

safety and are likely to recur if policy changes are not made. The competency tive policies policies,

about

restraints,

tries to avoid creating

such issues as visiting ambulation,

dures just because a current

restric-

and family

or emergency

proce-

policy was not appropriate

during an isolated incident. This competency is more typical of extant CNS practice, especially for those with an administrative role component, than of the practice of NPs. However, this competency is evidenced by NPs who have significant administrative responsibility in their posi-

safe care practices. communicating

cians. This skill is further bulatory sultation

selectively.

that involves

An additional NP competency expanded czynski under this domain was Developing Strategies

When

sultation.

This competency

Concerns

by BrykFail-Safe

Arise Over Physician was developed

develop

developed

situations,

This

recognition

skill

security

by NPs in am-

trust,

and

munds,

finely

is a complex

in one’s identity

base of knowledge, tuned

in

with physicon-

competency

of the uncertainty

broad

of clinical

as a nurse,

establishment

a

of mutual

communication

skills

(Ed-

1984).

A major theme was frustration decisions. tient’s

nurses

care where they learn to use physician

health

mission

that surfaced

and conflict

Assuming status

in the NP situations

over hospital

responsibility nursing

admission

for assessing

and recommending

is an area where

a pa-

hospital

practice

ad-

intersects

medical practice. The NP, after struggling to get a patient admitted to the hospital, has no control over when he or she is discharged. This is frustrating because the NP sees the consequences of premature release from the hospital in the emergency room. was identified as an area where interprofessional laboration

tions.

Hospital

clearly and convincingly

is needed

in both education

This col-

and practice

sector.

Con-

as an ex-

pansion of Benner’s competency of Building and Maintaining a Therapeutic Team to Provide Optimum Therapy. The data indicate that this competency is evidenced equally in the practice of NPs and

A major theme that surfaced in the NP situations was frustration and conflict over hospital admission decisions.

CNSs. An example of this competency from the NP study was one in which the NP was not comfortable with a physician’s

assessment

of what she believed was

a rectal mass. The NP scheduled return visit when another physician

the patient for a was available, and

indeed a rectal mass was verified on examination. NPs

studied

referred

to this practice

The

as “collateral

consultation.” This competency involves of the uncertainty in clinical situations

recognition (Edmunds,

Providing evaluative feedback to others for improvement is always difficult. Giving constructive feedback

to physicians

a particularly physicians

difficult have little

to ensure safe care practices skill because NPs, opportunity

is

CNSs, and

for interacting

and

evaluating one another during their clinical training, and they lack a shared background on which to build

1984). It takes some time for NPs to realize that they may get five different recommendations from five dif-

such practices. Situations involving NPs and physicians who were not connected with the institutions

ferent While

where the NPs practiced were most problematic. In fact, often there were no communication lines estab-

gaining

physicians for the same patient’s problem. they are acquiring this awareness, they are also experience

with clinical

situations,

and over

time they come to trust their own clinical judgments in patient situations and learn to balance this against the physician’s advice so they can determine when they really need another opinion. Additional NP competencies under this domain identified by Brykczynski were Using Physician Consultation Effectively and Giving Constructive Feedback to physicians and other care providers to ensure

lished between

NPs and physicians

in the private

sec-

tor. Several NPs described less than ideal situations when they contacted private physicians in the community for consultation and referral. Situations involving attempts by NPs to provide evaluative feedback to these physicians indicate that these skills and communication lines need to be further developed and refined. There were also examples of this competency in the

320

FENTON AND BRYKCZYNSKI

CNS data,

especially

took

or coached

over

through

complex

Physicians

when experienced

technical

do not hesitate

skills

evaluative

feedback

other than physicians. cate that further interprofessional

and

assess the patients

experiences.

These difficult

to promote

to

professionals

situations

indi-

of care through

monitoring.

direct patient

cluding

supervising

domain

DOMAIN: THE HELPING ROLE OF THE NURSE

identified

by Fenton

Informational

under

this domain

was Providing

Support

other

Patient

ing Staff to the dilemmas ilies. This competency

to Patients’

Emotional Families

tionship as and

during

identified Advocacy

to physicians

and other

this competency

the mother

and fam-

however,

it is

of NPs in rela-

NPs.

occurred

An example when

a CNS

of a child with spina bifida

had been hospitalized

this

by Sensitiz-

in the practice

to staff nurses; in the practice

in-

out the under

faced by patients

is more evident

the

or family and

and follow-up

observed

that reflects invited

patient

staff in carrying

One competency

of CNSs in relationship

competency

In the other method

intervention

was Providing

commonly

An additional

involved.

provides

intervention.

is needed in nurs-

quality

staff and may or may not directly

CNS is asked to see a particular

feedback

yet they are reluctant from health

skill development

ing and medicine

nurses and other

physicians

to give evaluative

to other health professionals, accept

CNSs either

less-experienced

who

to the head nurse’s staff meeting

the crisis of illness. The narrative research data indicate that this competency is shared equally by NPs

to talk about her experiences in the hospital. She told how she felt like a piece of furniture when the nurses

and CNSs. This competency

walked

is a major component

the CNS role in acute care hospitai often

asked

to intervene

with

patients

when there are illness crises. Nurse also involved in providing support their families agement

during

settings.

They are

and families

practitioners to patients

the crisis of diagnosis

of both acute and chronic

of

are and

and man-

illnesses.

in the room to give medicine

child’s IV but did not acknowledge She described until

finally

to adjust

or speak to her.

how she was afraid to touch one nurse helped

the

her baby

her pick up the infant

and said it was okay. The end result was that other head nurses invited the mother to come to work with their staff to improve communication with parents.

DOMAIN: THE TEACHING/COACHING FUNCTION

This domain

NP practice tends to be more health-oriented, and that of CNSs tends to be more focused on episodes of iliness.

was shared equally by NPs and CNSs.

No additional competencies were identified for the CNS, whereas several were identified for the NP (Fig 1). A logical explanation came from hospital However,

is that Benner’s original

settings

the NPs studied

tient settings

data

as did the CNS sample. were primarily

and were primary

providers

in outpawith a broad

health orientation. One competency identified by Brykczynski was that of assisting patients to alter their life-styles to meet changing health care needs and capacities, ie, teaching for self-care. This competency is an expansion of Benner’s competency about meeting illness care needs to incorporate the broader health promotion and illness prevention focus of NPs. NP practice

tends

to be more health-oriented,

and

that of CNSs tends to be more focused on episodes of illness. NEW DOMAIN: THE CONSULTING ROLE OF THE NURSE

This additional domain, the Consulting Role, emerged out of the many examples given by CNSs who consistently provide expertise and guidance, both formally and informally, to other health care providers. There appeared to be two methods of consultation. One occurs when the CNS consults directly with

An additional competency identified under this domain was interpreting the role of nursing to others, ie, role modeling equally evidenced but ing and, role

for staff. This competency is again in the practice of NPs and CNSs

with different emphasis. CNSs interpret the nursrole for patients, families, staff nurses, students, to some extent, physicians. NPs interpret their to patients, families, physicians, other NPs, and

students

but

minimally

to other

staff nurses.

This

competency was most often seen when nursing staff were faced with working with patients and families who were labeled dzffictdt by staff and also with dying patients and their families. The CNS often identifies needs in patient care situations that other less expert nurses fail to recognize or deal with, because they do not seem to have a clear picture of what the nursing role should be with these patients. In one example a CNS worked with staff clinic nurses to support them in talking to a child who was dying and who wanted to talk about it.

321

DISTINCTION AND SIMILARITIES BETWEEN CNSs AND NPs

An

additional

competency

that

emerged

Brykczynski’s

research for this domain

Consultation

to Physicians

Staff on Patient idenced

equally

Advanced

practice

nurses

for consultation

system,

medication

control

dosages

NP providing

and community

consultation

and CNSs.

4. Selecting and recommendingappropriatediagnostic and therapeutic interventions and regimenswith attention to safety, cost, invasiveness, simplicity,

out as resource negotiating

and side effects, family

from the NP study

is ev-

resources.

include

acceptabilityand efficacy. This is another

the health

counseling,

petency evidenced

pain Specific

terventions

prob-

up all patients

anticoagulants

and intervened

ist physicians

in terms

dicated

discharged

and

tend to practice

.

NEW DOMAIN: MANAGEMENT OF PATIENT HEALTH/ILLNESS STATUS

although

m .

1. Assessing, monitoring, coordinating, and mumging the health status ofpatients overtime, ie, being

are direct

petencies

care providers,

although

may lessen if the case man-

ager role is incorporated

into CNS practice.

2. Detecting acute and chronic diseaseswhile attending to the experienceof illnars. This competency refers to formulating and following through on both medical and nursing diagnoses and is an area where NP and CNS practice differs. CNSs are more likely nursing

to focus primarily

on

and have more of a tradi-

focus, although

they do have

to understand and incorporate the disease processes. NPs diagnose specific diseases, and at the same time they attend to patient responses to illness processes. Thus, they formulate and intervene with both medical and nursing diagnoses; however, NPs do not usually identify specific nursing diagnoses as such in their charting. 3. Scheduling fohw-up visits to closelymonitorpatients in uncertain situations. This is a competency evidenced by NPs in direct provider

there practice

is a

core

of

compefencles

nurses are also present in the practice of NPs and CNSs. Fenton and Brykczynski also demonstrated that

tional

nurs-

There is ample evidence that the domains of skilled practice identified by Benner in her study of the development of expertise in the practice of hospital

a primuty care provider. This competency is evidenced more in the practice of NPs who

diagnoses

CNSs nursing

both roles share, there are also distinct differences.

that

A new domain identified by Brykctynski was the management of patient/health illness status in ambulatory care settings. Competencies in this new domain for nurse practitioner practice are:

nursing

whereas

in more traditional

in-

of what drugs were contrain-

advanced

these differences

treatments,

and nursing

with the many special-

for these patients.

primary

in the practice of

roles where they select and recommend ing interventions.

on

com-

roles. NPs are more

likely to order both medical

lems for other NPs and house staff and anticoagulation NPs who followed

primarily

NPs in direct provider

a dermatology

on dermatological

CNSs may be involved

with follow up postdischarge.

Professional

of NPs

regarding

and teaching,

measures,

examples

Other

are sought

than CNSs; however,

was Providing

This competency

in the practice

persons

maintenance

and

Management.

roles. It is more typical of the practice of NPs

from

some domains

practice

are more prevalent

in advanced

than others and that some domains are more characteristic

and com-

of the CNS role, and

others are more typical of the NP role. Possible reasons for these differences will be discussed further.

Discussion Both studies illustrate the expert practice and CNSs with rich and exquisite descriptions ical situations.

They also demonstrate

there is a core of advanced both

roles share,

there

practice

of NPs of clin-

that although

competencies

are also distinct

that

differences.

Three primary areas of difference emerged from the findings of the studies: role ambiguity, setting, and curriculum

implications. ROLE AMBIGUITY

A separate and unexpected observation that emerged from the comparison of the two studies was the difference in how role ambiguity evolved for both roles. Role ambiguity appeared to be more prevalent in the CNS sample than the NP sample. One reason may be that the CNS’s role expectations of expert practitioner, educator, consultant, and researcher as

322

FENTON AND BRYKCZYNSKI

well as change agent have not been as clearly defined

conjunction

and developed

ers, and other nurse professionals.

in the clinical

setting.

These expecta-

tions are very broad and could be defined ferently

according

to the setting

quite

dif-

or type of institution

in which the CNS is employed. In contrast,

Having

the graduates

to figure out.

they are often surprised

experienced

role prepa-

confusion

ity, resistance

from staff nurses,

ration in both areas, the authors propose that this may

data to demonstrate the multiple

developed,

was developed

way that the roles were con-

and implemented.

in conjunction

suffers from very little

The NP role

with medicine,

role ambiguity.

which

The question

consultant,

researcher,

research studies

scope of nursing

with

incorporate

certain medical acts within

This question

was resolved

focus and yet that practice?”

in the practice

arena be-

of research

and difficulty

throughout

physician

developing

of clinician,

educator,

agent.

ciency, abundant

to determine

and cost-effectiveness data document

of multiple

the 1970s and 1980s be-

need to compare

practice

practice,

a lack of authorabsence

and change

that

a lack of support

The role of the NP was the subject cause of the apparent

and holistic

worth,

role components

was “How can a nurse retain and develop an advanced practice

So it is no wonder

to discover

of titles and preparation,

result from the original ceived,

nurse manag-

This is often left to

for the role, a lack of legal basis for advanced

there appears to be less role ambiguity

on the part of NPs.

with nurse administrators,

NP practice safety,

effi-

of the role. Therefore,

these aspects of the NP role.

tween nurse educators, NP students and graduates, and collaborating physicians. It appears that the

In contrast, there was no comparison group for the CNS, and the need to study the CNS role was not as

greatest role ambiguity for NP students occurs during their program when they ask themselves, “Am I becoming a junior doctor or am I still a nurse?” They

compelling. A troubling aspect of the CNS role that emerged in Fenton’s study was that CNS expert practices and

often express discomfort

competencies

with the “medical”

practice

appear

to be hidden

from those in the

component of the role. Students respond by placing greater emphasis on medical diagnosis and treatment

health care arena who are most unsure about using nurses in advanced practice roles, ie, nursing admin-

in the beginning

istrators, physicians, and other nursing staff. Nurses in the CNS sample were sometimes reluctant to talk

tice. However,

of the program as the students

and skills and become

than nursing

prac-

gain more knowledge

more confident,

they begin to

step back and look at patients from a more holistic view. They begin to see themselves again fundamentally as nurses

who now incorporate

acts into practice. Therefore, by the time

certain

they graduate

medical

and begin

working, many NPs have experienced a major portion of their identity crises as advanced practice nurses. Their area of practice is usually more limited

than that

of the CNS, and they are not often called on to manage major organizational change nor to influence large groups of health care workers. Their role with physicians is more well defined, because it is a major focus of an NP program. This does not mean that they do not face many of the same dilemmas as the CNS, but they occur on a more manageable scale. In contrast, the CNS appears to suffer less role ambiguity while in graduate school. There is less confusion about developing an advanced role in nursing. The majority of a student’s time is spent focusing on identified nursing problems and issues. Contact with physicians may vary from minimal to frequent depending on the situation and philosophy of the faculty. In most situations the role of the CNS is developed in isolation from physicians in the clinical setting, and only in some cases is it developed in

about their practice, although through participant observation expert clinical judgment was easily validated. Much of their practice with patients and families is in private or “hidden” work as Wolf (1990) defines it. And because CNSs traditionally have difficulty articularing their roles, especially in the first few years of practice, physicians, administrators, and other staff often do not have a clear perception contribution to patient care and organizational The NP role attempts and nursing

through

of their goals.

to blend aspects of medicine

a nursing

perspective;

the CNS

role attempts more to distinguish between medicine and nursing and to keep the roles more distinct. This may be changing primarily based on the need in the practice setting for the CNS to make more decisions of a medical nature because of the increased acuity of patients and the increased focus on high technology both in hospitals and the community. Steel (1992) stresses the importance of organized nursing maintaining control over the expanding role of nursing in inpatient settings. The result of this role blending between medicine and nursing appears to be that the nurse becomes more useful in the clinical setting and less expendable. For example, it is a trend in occupational health for occupational health nurses to develop NP skills so

DISTINCTION

they

AND SIMILARITIES

can manage

problems

using

backup. health

Public nurses

common

and

a physician health

who

acute

primary

as a consultant

agencies

need

can also provide

basic

the need for graduate

and

istrators,

an issue of economics,

health

force,

nurse educators,

It is

and the

nursing

CNSs, and others to conduct

on the role of advanced

primary

as well as communities. labor

care

community

health care to individuals expanding

323

BETWEEN CNSs AND NPs

setting.

practice

nurses in the clinical

Because of the lack of a comparison

has been more difficult cost-effectiveness

admin-

investigations

to validate

group,

the efficiency

it and

of the role.

need for services. CURRICULAR IMPLICATIONS SElTlNG

As Hanson

points

out,

clear-cut

tween CNSs and NPs by setting as NPs move into hospitals community according

(Hanson to Martin

distinctions

are becoming

be-

blurred

and CNSs go out into the

and Martin,

1990).

in the same article,

NP and CNS roles and functions

However,

differences

are maintained

in re-

gardless of setting, with CNSs focusing on acute and intense phases of illness and NPs emphasizing health promotion, illness prevention, and long-term management of chronic stable conditions. There is ample evidence from the comparison of the two studies reported here that the setting or environment demands different emphasis from the CNS and the NP. The NP normally functions as a primary care provider in an ambulatory setting and usually interacts with a relatively small group of physicians, nurses,

and other health care providers.

ally not expected and ensuring that in getting groups together, in other

They are usu-

to play a major role in developing the organization meets its goals and of people to collaborate and work words, to make the system work.

This is demonstrated by the identification of the new NP competencies, almost all of which focus primarily on meeting

direct

patient

care needs.

There is evidence from these studies that there is an advanced

competencies the clinical are distinct The domains

the settingof environment

demands different emphasis from the C/US and the W.

In contrast, CNSs may function in a wide variety of ways ranging from covering an entire hospital for a specific specialty to being unit- or service-based. They may also have patient and staff education roles, be involved in research, assist with administration, or act primarily as consultants. This broad range of responsibilities was also reflected in the new competencies and domain. The majority of the new competencies for CNSs were identified under Benner’s domain of Organizational and Work Role competencies and the new Consulting Role domain. It also demonstrates

role for both the CNS and the NP and many skills and

are shared depending situation.

on the setting

There is also evidence

differences

and emphases

and competencies

for both

of nursing

and

that there roles.

practice

as

described by Benner and expanded by Fenton and Brykczynski can be used as a framework for curricuturn development (Price, Martin, Newberry, Zimmer, Brykczynski,

&z Warren,

1992; Zimmer

et al.,

1990). The domains and competencies have been used by nurse educators as the model for an entire curriculum, the structure

for a course,

class, or a framework curriculum guidelines

the framework

for a role

for curriculum evaluation. developed by the National

ganization of Nurse Practitioner Faculties directed, and they conceive of the domains

The Or-

are future and com-

petencies as a career plan that can be used for professional development of advanced practice nurses. In other words, if the domains and competencies are used in the context of the Dreyfus (1986) model of skill acquisition, then nurses can assess their skills in the various areas along the continuum from novice to expert.

. . .

practice

and that much of the knowledge

expert

For example,

a new NP graduate

in all the NP domains

would

and competencies

not be any

more than a new CNS graduate would be. They would be expected to be competent in some areas, proficient in some areas, and expert in some areas. Education programs generally strive to produce competent graduates. Higher levels of skill (proficiency and expertise) are further developed in practice and career development courses. A potentially useful strategy for combining the common areas of NP and CNS skills and knowledge and identifying the unique areas would be to attend to the similarities and differences observed in the findings of the present studies. Several examples can be described from the graduate nursing program at The University of Texas at Galveston. The curriculum model depicted in Fig 2 illustrates how the program is organized to maximize similarities between CNSs

324

FENTON AND BRYKCZYNSKI

after gaining

Advanced Nursing Practice Clinical Nurse Practitioner Primary Health Care Nursing Management: Family, Pediatric, OB/ GYN, Adult or Geriatric tracks

skill in these areas do they take a family

course that focuses on counseling promotion

Clinical Nurse SPecialist Advanced Clinical Nursing Management: Critical Care, Adult Health, Child Health or High-Risk Maternity tracks

In addition, prevention,

the NP

illness

of diseases,

manifestations

are also presented it is obvious

and inter-

of disease.

time the role components

issues and problems.

Practice/Administration/Consultation Research/Teaching/Change Agent

more time

spend more time on nursing

for advanced

the present

management

health course.

growth and development,

and medical

the CNS students ventions

and family management

the NP courses devote much

to health promotion,

though

Role Components

as their third clinical

At

of the CNS and

in separate

courses,

al-

that they share many of the same The CNS students

could benefit

from the NP perspective of physician collaboration and integrating medical acts when appropriate, and the NP students

Clinical Core

nizational

could benefit

role and function

Advanced Assessment/Decision Making Pharmacology/Pathophysiology

from the broad orga-

of the CNS.

Summary

Graduate Core Theory/Research/Health Figure 2.

Curriculum

The authors believe that a comparison of the results of their interpretive studies provides a unique oppor-

Policy

model for advanced nursing prac-

tice. and NPs with core courses and yet maintain

the sig-

nificant clinical distinctions with separate clinical management courses. In the first semester of the graduate program the Advanced Health Assessment course is required for all advanced clinical students, NPs as

tunity

to highlight

qualitative in particular

participates ences that

in selected

seminars

are more oriented

member

and clinical

also

experi-

to severe responses

to

illness. The same strategy is used in the pharmacology course. In addition to the core pharmacology course given by a clinical pharmacologist, practitioner faculty direct a seminar and evaluate case studies for the NP students, and critical care faculty direct a seminar and evaluate case studies for the CNS students. To date, all the advanced nursing clinical courses are separate for the NP and CNS students.

Although

a com-

ponent of the knowledge and skill is shared, students appear to need the information at different points in their programs. Gaining the necessary knowledge and skills for working with families is a good example of this problem. The CNS students take a course focusing on vulnerable families at the beginning of their program as a basis for the advanced clinical nursing courses. The NP students take courses focusing on assessment and clinical management in the beginning, and only

and simi-

comparing these studies it is essential to incorporate criteria of scientific merit that are appropriate for

for CNS students

care faculty

distinctions

tations convey the complexity of the issues and distinctions, because they show up more readily in narrative data than they do in numerical comparisons. In

well as CNSs. The students all share the majority of the classes provided by the practitioner faculty, but a critical

qualitative

larities between the advanced practice roles of CNSs and NPs, because cumulative research is so rare in qualitative research. In addition, qualitative interpre-

from

methods needs

a randomly

(Guba,

198 1). Generalitability

to be clarified. selected

sample

Generalitability to a population

based on probability theory as required by quantitative research is less appropriate for qualitative research. Instead, Guba proposes that applicability is a more appropriate criterion for assessing the meaning that the findings from a qualitative study have for others outside the particular context and location of the study. Applicability (generalitability) in an interpretive study refers to the fit or transfer ings into other contexts.

of the mean-

In summary, there is evidence that the findings of both studies have applicability to understanding the differences and similarities between the CNS and NP role. There is evidence that there is an advanced practice role for both the CNS and the NP and that much of the knowledge, skills, and competencies are shared depending on the setting and the clinical situation. There is also evidence that there are distinct differences and emphasis for both roles. There have been both successes and failures in the development of the

325

DISTINCTION AND SIMILARITIES BETWEEN CNSs AND NPs

two

roles.

aspects

It is now time

to combine

Acknowledgment

the successful

of both roles that are most needed to function

in the health care system and to model the educational programs

to fit the needs of the health

that is currently

evolving

care system

for the next century.

The authors would like to gratefully acknowledge

the col-

laboration and assistance of Patricia Benner, RN, PhD, without whom these studies would not have been possible.

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