Professional Roles For The Advanced Practice Nurse
1PA R TProfessional Roles for theAdvanced Practice nurseThe chapters in Part 1 of this book considerthe role of the advanced practice nursefrom historical, present-day, and futureperspectives. This content is intended toserve as a general introduction to selectissues in professional role development forthe advanced practice of nursing. As students progress in the educational processand develop greater knowledge and expertise, role issues and role transition shouldbe integrated into the entire educationalprogram.In Chapter 1, the editors defineadvanced practice nursing from a traditional perspective and trace the historyof the role. Traditionally, advanced practice has been limited to clinical roles thatinclude the clinical nurse specialist, nursepractitioner, certified nurse-midwife, andcertified registered nurse anesthetist;to practice, the last three roles require alicense beyond the basic registered nurse(RN) license. This book, however, uses anexpanded definition of advanced practicenursing that reflects current thinking. Asyou read this chapter, keep in mind thisexpanded definition and appreciate thedevelopment of the advanced clinical rolesfor nursing practice. This discussion laysthe foundation for a deeper understanding of the historical development, currentpractice, and future opportunities foradvanced practice in nursing.In Chapter 2, Stewart discusses the tipping point for nurse practitioners as weenter the age of healthcare reform and therole nurse practitioners will play in providing cost-effective, quality primary care toa demographically changing population.Stewart’s quantitative and qualitativeresearch resulted in the Stewart Modelof Nurse Practitionering that reflects keyattributes that make nurse practitionersunique. Much has transpired related to therole and education of nurses for advancedpractice. Most revolutionary is the mandate to have by 2015 the clinical doctoratebe the required degree for advanced clinical19781284072570 CH01 PASS01.indd 127/10/14 5:44 PM
2 n Part 1 Professional Roles for the Advanced Practice Nursepractice nursing (American Association of Colleges of Nursing, 2004). With this change, manymaster’s programs for advanced practice nurseswill transition to the doctoral level. The rationale for this position by the American Association of Colleges of Nursing (AACN) is based onseveral factors: The reality that current master’s degreeprograms often require credit loads equivalent to doctoral degrees in other healthcareprofessionsThe changing complexity of the healthcareenvironmentThe need for the highest level of scientificknowledge and practice expertise to ensurehigh-quality patient outcomesIn an effort to clarify the standards, titling,and outcomes of clinical doctorates, the Commission on Collegiate Nursing Education(CCNE)—the accreditation arm of AACN—hasdecided that only practice doctoral degreesawarding a Doctor of Nursing Practice (DNP)will be eligible for accreditation. In addition,the AACN has published the Essentials of Doctoral Education for Advanced Nursing Practice,which sets forth the standards for the development, implementation, and program outcomesof DNP programs.Needless to say, this recommendationhas not been fully supported by the entireprofession. For instance, the American Organization of Nurse Executives (AONE, 2007)does not support requiring a doctorate formanagerial or executive practice on the basis ofexpense, time commitment, and cost benefitof the degree. It also suggests that nurses maymigrate toward a master’s degree in business,social sciences, and public health in lieu of amaster’s degree in nursing. Further, AONE suggests there is a lack of evidence to support theneed for doctoral education across all aspects ofthe care continuum. In contrast, doctoral andmaster’s-level education for nurse managersand executives is encouraged.9781284072570 CH01 PASS01.indd 2For other advanced practice roles, including those of the clinical nurse leader, nurseeducator, and nurse researcher, a different setof educational requirements exists. The clinical nurse leader as a generalist remains a master’s-level program. For nurse educators, theposition of AACN—although not universallyaccepted within the profession (as demonstrated by the existence of master’s programsin nursing education)—is that didactic knowledge and practical experience in pedagogyare additive to advanced clinical knowledge.Nurse researchers will continue to be preparedin PhD programs. Thus, there will be only twodoctoral programs in nursing, the DNP andthe PhD. It is important for readers to keepabreast of this movement as the profession further develops and debates these issues becausethe outcomes have implications for their ownpractice and professional development withintheir own specialty. The best resource for thisis the AACN website and the websites of specialty organizations.The next three chapters in Part 1 discuss thefuture of advanced practice nursing and theevolution of doctoral education—in particular,the practice doctorate. Within today’s rapidlychanging and complex healthcare environment,members of the nursing profession are challenging themselves to expand the role of advancedpractice nursing to include highly skilled practitioners, leaders, educators, researchers, andpolicymakers.In Chapter 3, Chism defines the DNP degreeand compares and contrasts the research doctorate and the practice doctorate. The focus ofthe DNP degree is expertise in clinical practice.Additional foci include the Essentials of DoctoralEducation for Advanced Nursing Practice as outlinedby the AACN (2004), which include leadership,health policy and advocacy, and informationtechnology. Role transitions for advanced practice nurses prepared at the doctoral level call foran integration of roles focused on the provisionof high-quality, patient-centered care.27/10/14 5:44 PM
References n 3In Chapter 4, White discusses emergingroles of DNP graduates as nurse educators,nurse executives, and nurse entrepreneurs andadvanced practice nurses’ increased involvement in public health programming and integrative and complementary health modalities.In Chapter 5, Barker sets the foundationfor advanced practice nurses to recognize andembrace their role as leaders and influencers ofpractice changes in healthcare organizations.Complexity science, organizational change theory, and transformational leadership are usedas a platform for advanced practice nurses torealize their leadership potential and their roleas agents of change.Last, in Chapter 6, Ash and Miller providean in-depth look at interdisciplinary and interprofessional collaborative teams as means toeffect positive health outcomes. They discuss9781284072570 CH01 PASS01.indd 3both barriers to successful collaborative teamsand factors for successful team development.Advanced practice nurse leaders educatedat both the master’s and doctoral levels areuniquely positioned to overcome the workforceand regulatory issues that might otherwisediminish the success of collaborative teams—inparticular, those involving participants fromthe nursing and medicine disciplines.ReferencesAmerican Association of Colleges of Nursing (AACN).(2004). AACN position statement on the Doctorate inNursing. Retrieved from htmAmerican Organization of Nurse Executives (AONE).(2007). Consideration of the Doctorate of NursingPractice. Retrieved from ocs/PositionStatement060607.doc27/10/14 5:44 PM
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CHAPTER1introduction to the Role of AdvancedPractice nursingsusan deNisco and Anne BarkercHAPteR oBJectiVes1. describe the four roles used to define advanced practice nursing inthe united states.2. Identify the differences between the clinical nurse leader role and thetraditional advanced practice nursing roles.3. Recognize factors that currently influence the supply and demand ofnurse educators.INtROduCtIONConsiderable confusion exists regardingthe terminology advanced nursing practice,advanced nurse practice, and advanced practice registered nurse. Based on the definitiongiven by the American Association of Colleges of Nursing (AACN) and other widelyaccepted usages, the term advanced practiceregistered nurse (APRN) has been used to indicate master’s-prepared nurses who providedirect clinical care. This term encompassesthe roles of nurse practitioner (NP), certifiednurse-midwife (CNM), certified registerednurse anesthetist (CRNA), and clinical nursespecialist (CNS). The first three roles requirea license beyond the basic registered nurse(RN) license. The role of the clinical nursespecialist requires a master’s degree but doesnot require separate licensing unless theCNS is applying for prescriptive authority.Complicating the titling and definition of roles, the AACN (2004) definedadvanced practice nursing as follows:Any form of nursing intervention thatinfluences health care outcomes forindividuals or populations, includingdirect care of individual patients,management of care for individuals and59781284072570 CH01 PASS01.indd 527/10/14 5:44 PM
6 n Chapter 1 Introduction to the Role of Advanced Practice Nursingpopulations, administration of nursing andhealth care organizations, and the developmentand implementation of health policy. (p. 2)The Consensus Model for APRN Regulation is aproduct of substantial work done by the APRNConsensus Work Group and the National Council of State Boards of Nursing (NCSBN) APRNAdvisory Committee in an effort to address theirregularities in regulation of advanced practiceregistered nurses across states. As defined inthe model for regulation, there are four roles:certified registered nurse anesthetist, certifiednurse-midwife, clinical nurse specialist, and certified nurse practitioner (CNP). These four rolesare given the title of advanced practice registeredfigure 1-1nurse (APRN). APRNs are educated in one ofthe four roles and in at least one of the following population foci: family/individual acrossthe life span, adult-gerontology, pediatrics,neonatal, women’s health/gender-related, andpsych/mental health (APRN Consensus WorkGroup & National Council of State Boards ofNursing APRN Advisory Committee, 2008)Advanced practice registered nurses are licensedindependent practitioners who are expected topractice within standards established or recognized by a licensing body. The model furtheraddresses licensure, accreditation, certification,and education of APRNs. Figure 1-1 depictsthe APRN Regulatory Model.APRN Regulatory Model.FPONational Council State Board of Nursing: The APRN Consensus Model 20089781284072570 CH01 PASS01.indd 627/10/14 5:44 PM
Other Advanced Practice Nursing Roles and the Nursing Curriculum n 7Other Advanced PracticeNursing Roles and the NursingCurriculumConsequently, nurse administrators, publichealth nurses, and policymakers are considered advanced practice nurses albeit they donot provide direct care or obtain advancedpractice licensure per the state they practice in.As this book goes to press, there is an initiative to expand and clarify the definition of andrequirements for advanced practice nursing. Nomatter the final outcome of this deliberation,all nurses need the same set of essential knowledge. The Essentials series outlines the necessarycurriculum content and expected competenciesof graduates of baccalaureate, master’s, anddoctoral nursing practice programs and theclinical support needed for the full spectrumof academic nursing (AACN, 2006, 2011a,2011b). Although the terms advanced practicenursing, advanced practice nurses, advanced nursingpractice, and advanced practice registered nurses areused interchangeably throughout this text, theauthors are addressing any students enrolledin master’s or doctoral programs that aredesigned, implemented, and evaluated by theAACN Essentials. Chapter 2 provides an overview of the master’s and doctoral essentials.Clinical Nurse LeadersClinical nurse leaders (CNLs) were not considered in the definition of advanced practice becausethe CNL role did not exist when the aforementioned roles were defined. Some argue that theCNL is a generalist, and thus CNL should notbe considered an advanced practice role. Theauthors disagree. The clinical nurse leader rolerequires advanced knowledge and skill beyondthat attained with the baccalaureate degree, andit requires a master’s degree for certification.According to the AACN (2007), the clinical nurse leader is responsible for patient careoutcomes and integrates and applies evidencebased information to design, implement, andevaluate healthcare systems and models of9781284072570 CH01 PASS01.indd 7care delivery. The CNL is a provider and manager of care at the point of care for individualsand cohorts of patients anywhere healthcareis delivered (AACN, 2007). In fact, as recommended in the AACN white paper on the CNLrole, all CNL curricula across the countryrequire graduate-level content that builds onan undergraduate foundation in health assessment, pharmacology, and pathophysiology. Inmany master’s-level programs, NP and CNLstudents sit side by side to learn these advancedskills. Also, the inclusion of these three separate courses—health assessment, pharmacology, and pathophysiology—facilitates thetransition of master’s program graduates intoDoctor of Nursing Practice degree programs(AACN, 2007). Moreover, the CNL programgraduate has completed more than 400 clinicalpractice hours, similar to number required ofNP graduates, and is eligible to sit for the CNLCertification Examination developed by theAmerican Association of Colleges of Nursing.The clinical nurse leader, similar to theclinical nurse specialist (discussed next),has developed clinical and leadership skillsand knowledge of statistical processes anddata mining. The CNL brings evidence-basedpractice to the bedside, creates a culture ofsafety, and provides quality care. This alignsdirectly with the American Organization ofNurse Executives (AONE) guiding principlesfor the nurse of the future (Haase-Herrick &Herrin, 2007).Clinical Nurse SpecialistsClinical nurse specialists (CNSs) have beenproviding care to patients with complex casesacross healthcare settings since the 1960s.The CNS role originated largely to satisfythe societal need for nurses who could provideadvanced care to psychiatric populations. Sincethe passage of the National Mental HealthAct in 1946, the National League for Nursing(NLN) and the American Nurses Associationhave supported the CNS role. The first program at Rutgers University educated nurses27/10/14 5:44 PM
8 n Chapter 1 Introduction to the Role of Advanced Practice Nursingfor the role of psychiatric clinical specialist(McClelland, McCoy, & Burson, 2013). Following this implementation, the usefulness ofthe role became apparent, and schools of nursing began to educate nurses across specialties,including oncology, medical-surgical, pediatric, and critical care nursing.The literature of the 1980s and 1990s showsthat care provided by clinical nurse specialistsproduced positive patient outcomes related toself-management and early hospital discharge(Fulton, 2014). More recently, studies showimprovement in patient satisfaction and inpain management, and reduced medical complications in hospitalized patients (McClellandet al., 2013).The recent trend toward hospital andhealthcare system mergers and the focus oncost containment force the CNS role into aprecarious position. Hospital administratorsTable 1-1have a difficult time showing that CNSsdecrease hospital costs, and they cannot billfor specialty nursing services. The AACN statesthat there are significant differences betweenthe CNS and CNL roles; however, few differences are clearly articulated by those beingeducated in or practicing in these roles or inrecent documents created by AACN (NationalAssociation of Clinical Nurse Specialists[NACNS], 2005). This has created role confusion and uncertainty regarding the role thesenurses should play in the inpatient hospitalsetting. Table 1-1 compares role competenciesof the CNS and the CNL.In addition, the APRN Consensus Modelstates that graduate nursing roles that do notfocus on direct patient care will not be eligiblefor APRN licensure in the future (APRN Consensus Work Group & National Council of StateBoards of Nursing APRN Advisory Committee,Comparison of Select Role Competencies for the CNS and the CNLClinical Nurse SpecialistClinical Nurse LeaderDirect careCritical thinking/clinical decision making AssessmentSystems leadershipNursing technology and resource tationResearchAssimilates and applies research-based information todesign, implement, and evaluate client plans of careEthical decision making, moral agency,and advocacyEthicsAccountabilityProfessional values, including social justiceProfessional developmentSources: American Association of Colleges of Nursing. (2007). White paper on the role of the clinical nurse leader.Retrieved from apers/cnl-white-paper; National CNS Competency Task Force. (2010). Clinical nurse specialists core competencies: Executive summary 2006–2008. Retrieved roch.pdf9781284072570 CH01 PASS01.indd 827/10/14 5:44 PM
Other Advanced Practice Nursing Roles and the Nursing Curriculum n 92008). This creates further challenges for theCNS, such as variability in state title protection,inconsistency among states grandfathering inthe CNS role, lack of a regulatory approach toaccepting grandfathered CNSs to practice inother states, and job loss based on misperceptions of the model (NACNS, 2005).Nurse EducatorsThe role of nurse educators may be one of themost contentious issues in nursing education.According to the National League for Nursing(2002), the nurse educator role requires specialized preparation, and every individual engagedin the academic enterprise must be preparedto implement that role successfully. Nurseeducators are key resources in preparing thenursing workforce to provide quality care tomeet the healthcare needs of a rapidly agingand diverse population. Whether in academicor clinical settings, nurse educators must becompetent clinicians. However, whereas being agood clinician is essential, some would say it isnot sufficient for the educator role. Much of thedebate in nursing education centers on the factthat the nurse educator student primarily needsadvanced knowledge and skills in clinical practice in order to teach, and therefore graduateTable 1-2education should be directed toward enhancing clinical expertise. According to the AACN(2014), the master’s-level curriculum for thenurse educator builds on baccalaureate knowledge, and graduate-level content in the areas ofhealth assessment, pathophysiology, and pharmacology strengthen the graduate’s scientificbackground and facilitate understanding ofnursing and health-related information (AACN,2014). In this model students are required totake courses beyond the graduate core curriculum and that provide content expertise in the“3 Ps” (pharmacology, pathophysiology, andphysical assessment), similar to the educationof nurse practitioners and clinical nurse leaders.On the other side of the argument, many clinicians who become nurse educators are alreadyclinical experts and are content experts. Theyneed the advanced degree to learn teaching/learning theories and strategies, curriculumdevelopment, and student evaluation content.Nurse Educator Supply and DemandThe Health Resources and Services Administration (HRSA) has projected a large increase indemand for nurses, from approximately 2 million full-time equivalents in 2000 to approximately 2.8 million in 2020. See Table 1-2.Supply, Demand, Shortage of 1,941,2001,886,1001,808,000Demand2,001,5002,
master’s-level education for nurse managers and executives is encouraged. For other advanced practice roles, includ-ing those of the clinical nurse leader, nurse educator, and nurse researcher, a different set of educational requirements exists. The clini-cal nurse leader as a generalist remains a mas-ter’s-level program. For nurse .
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