Clinical Nurse Specialists and Nurse Practitioners:

Is There a Need to Merge These Roles?

Roles of NP and CNS: Evolution

Psychiatric Nursing

Geriatric Setting

Cardiovascular Nursing

CNS as “Hospitalist”

Merger of CNS and NP’s

Prior to admission to the hospital for an acute healthcare crisis

After Discharge

Our nation faces a continual and growing shortage of qualified nurses to meet our healthcare needs. To date, there has been a stratification of nursing roles, which includes, among other classifications, clinical nurse specialists and nurse practitioners (Nursing, American Association of Colleges of, 1993) (Hamric, 2000). While there will always be the need for specialization within certain nursing areas, such as CICU and neonatal care, a merging of these roles offers key advantages to patient care, cost-effectiveness, and the career satisfaction of those in the nursing profession (Chaska, 2001). This paper argues that a merger of these two roles can result in an improved and more-efficient nursing practice, which will benefit the whole healthcare system.

Part of the reason for merging the two roles is to reduce the gulf between MSc in Nursing and Bachelor’s degrees in nursing science. While specialized knowledge is necessary, it may make sense for nurses to pursue a generalized nursing career, then achieve a specialist advanced degree.

This paper will argue that there is a continuity of healthcare delivery from the onset of illness, to acute treatment, and follow-on treatment outside the hospital setting. The success in America’s treatment of acute illnesses, such as a.M.I. And stroke, mean that many diseases which in the past led to relatively quick death of the patient are now ameliorated.

Hospitals, which used to play a role of short- and long-term care institution, are now relegated to short acute-care missions. As a result of these two trends, chronic health conditions are now more common, and require a continuity of care.

Roles of NP and CNS: Evolution

CNS’s specialize in certain medical areas, as do NP’s. Both achieve master’s degree specialization; the former in medical specialties, the latter in community care. With the evolution of acute to chronic illness, and the change in treatment modalities from hospital-based to hospital- and community-based longer-term care, the two roles have become somewhat combined. Those nurses who assist patients in a specialty, such as psychiatric or cardiac care nursing, would like to continue their therapy assistance after the patient leaves the acute-care setting. This section will deal with some specialties where this is particularly true.

Psychiatric Nursing

Nurses in a hospital setting generally see “failed” psychiatric patients: those patients who have either gone undiagnosed, or those who have undergone previous acute-care treatment, and for one reason or another have neglected their medications and other treatment. There is relatively little that a CNS nurse in the hospital can do to help the patient become better and more self-reliant, as in the Orem model of nursing. Since most psychiatric admissions from the Emergency Room remain for less than 72 hours, the CNS can do little to assist the patient to change behavior or compliance with medication prescriptions.

A model of nursing developed at Kent State University has changed the model of nursing care to merge the psychiatric CNS and nurse practitioner role (Cukr, 1997). The benefit is that the same nurse or nursing team can deal with patients in their community before potential ER admissions, and after discharge from the hospital. The advantage to this is that the patient has continuity of care, monitoring of his/her medical compliance and an early-warning system if the patient should go off track.

This work has been supported by trials of the ‘combined’ model in other settings. The Mental Health Nursing Department at East Tennessee State University has incorporated the combined nursing education into its psychiatric curriculum (McCabe, 1999)

Geriatric Setting

Geriatrics is one of the areas that is growing fastest in demand, as the population ages. A study performed in southern Illinois with nursing teams found that the nursing students received a better education in a combined interdisciplinary approach (Rosher, 2001). The adequate development of a geriatric quality improvement program involves the combined work of nursing home and hospital specialists to insure that the patient is well-cared-for in both settings (Rantz, 2006)

Cardiovascular Nursing

The practice of cardiovascular nursing can range from very specific, goal-based work, such as cardiac catheterization laboratory nursing, to more general work with cardiac patients. A life-long CNS, Dr. Susan Quaal, relates her experience in working with and teaching others. Her experience was primarily in-hospital, but she expresses frustration at seeing chronically-ill CHF and ACS patients who she knows need community care.

This specific need for a bridge between acute, in-hospital cardiac care and longer-term community care is recognized in “Family Care in the Coronary Care Unit: An Analysis of Clinical Nurse Specialist Intervention (O’Keefe, 1988).” The authors make it clear that the family needed to be educated and reassured just as the patient did. The family’s involvement in the patient’s treatment needs to continue into the community, as the chronic underlying conditions require medical compliance.

CNS as “Hospitalist”

No argument is absolute, and the need for nurses to span the healthcare continuum between hospital and community, although generally true, sometimes requires additional CNS-type support within the hospital. All who have been nurses in hospitals understand that one of the primary jobs is to make quick decisions about patient care, and to assume the responsibility to allocate scarce resources and improve patient outcomes.

As the “hospitalist” MD practice has developed in the past few years, so has the nurse’s role in improving outcomes and containing costs. A new method for wound management, demonstrated by CNS’s in a clinical setting, demonstrated how better technique both comforted the patient and led to savings for the institution. There are some patient problems which are acute, and are best dealt with at the hospital. These can include rape/sexual assault (Selig, 2000), improving the administration of intravenous drugs (Seemann, 2000) and improving the efficiency (of materials and total cost) in a surgical intensive care ward (McAlpine, 1997).

More generally, many problems which receive their first care in a hospital setting can ‘graduate’ to a community- and family-based therapeutic setting. The bridge between the acute care needs and those after acute care can be very different.

Merger of CNS and NP’s

The preponderance of work reviewed by this author covers the overlap between acute, in-hospital care and longer-term, chronic care. These clinical articles pursue common themes: the patient and medical staff benefit if there is a care continuum for the patient. This continuum benefits patient outcomes in three particular areas:

Prior to admission to the hospital for an acute healthcare crisis

This differs from patient to patient, but one can generalize from specific disease etiologies. For ACS and CHF patients, for example, the record for readmission due to recurrent heart attacks (ACS) and for other symptoms, particularly excess fluid accumulation (CHF) can be reduced by adequate monitoring of the patient by qualified nurses in the community setting. A nursing team developed a Woman’s Prevention Center, for example, which put together a team which included a cardiology fellow, a CNS and an exercise physiologist, plus an outreach professional, to assure that preventative healthcare measures were taken (Halm, 2003).

There is strong clinical documentation that early detection of breast anomalies can lead to a lowered incidence of breast cancer. A multidisciplinary team from a breast clinic organized a community outreach program which educated women on how to find such symptoms early, and to come to the clinic for treatment (Edge, 1999). The continuity from community outreach to acute diagnosis and treatment proved helpful to the overall healthcare setting. This program has been repeated in centers around the United States (Mary’s, 2007).

After Discharge

Many patients who have undergone traumatic events requiring hospitalization have difficulty understanding the causes of their disease, and how best to care for themselves upon discharge. They may find that drugs cause side effects which are inconvenient or painful. Patients who neglect to take Lasix at night, for example, may quickly find themselves back in the hospital for further treatment.

The hospital-based CNS may find her/himself in a frustrating position, as he/she sees patients several times in the hospital with acute problems caused by the patient’s inability to follow medication recommendations.

Community-based bridging projects have demonstrated with heart patients that continual, community-based and family-based ‘bridging’ programs help to increase compliance and reduce cases of rehospitalization (Jacavone, 1999). Psychiatric care bridging acute incidents and supporting the patient in the community (particularly with medications compliance and further diagnostic support) have been shown to reduce patient readmissions and improve management of chronic mental conditions (Kurz-Cringle, 1994) (Bennett, 1998).

Summary

The changes that we have witnessed in healthcare systems over past decades has been mirrored in nursing care changes as well. Moving from the Florence Nightingale “medical” theoretical structure to more modern community- and family- based and culturally-based nursing paradigms have enriched the profession, and resulted in a more effective practice of nursing. If one follows the Orem model of self-care and independence, one realizes that the hospital setting alone is not sufficient in which to both care for and teach the patient and his/her family and community.

Since modern medicine can sustain patients with proper medical follow-up for years, it becomes incumbent on the profession to follow the patients and provide them with the knowledge and tracking to insure that they are observing the procedures and medications which prolong their quality of life. Given hospitals’ short-term orientation with the patients, there is a need to bridge patient care before, during and after acute-care visits.

While there are some nursing specialties which can be regarded as solely hospital- or community-based, many of the specialties call for a more holistic notion of patient care. By combining the CNS and NP specialties, this profession has a better chance of assuring better patient outcomes, and a better quality of life for the patient.

Bibliography

Bennett, B.J. (1998). Psychiatric mental health nursing: thriving in a changing environment through outcomes-based measurements. Semin. Nurse Manage., 144-148.

Berger, a.M.-F. (1996). Advanced practice roles for nurses in tomorrow’s healthcare systems. Clinical Nurse Specialist, 250-255.

Chaska, N.L. (2001). The Nursing Profession Tomorrow and Beyond. Thousand Oaks: Sage.

Cukr, P.L. (1997). The psychiatric clinical nurse specialist/nurse practitioner: an example of a combined role. Arch Psychiatr Nurs, 2-12.

Edge, R.M. (1999). The development of a community breast center. Radiol Manag., 38-43.

Elder, R. & . (1990). Nurse Practitioners and Clinical Nurse Specialists: Are the roles merging? Clinical Nurse Specialist, 78-84.

Fenton, M.V. (1993). Qualitative distinction and similarities in the practice of clinical nurse specialists and nurse practitioners. Journal of Professional Nursing, 313-326.

Halm, M.A. (2003). Primary prevention programs to reduce heart disease in women. Clin Nurse Spec., 101-109.

Hamric, a.B. (2000). Advanced Nursing Practice. Philadelphia: Saunders.

Jacavone, J.B. (1999). CNS facilitation of a cardiac surgery clinical pathway program. Clin Nurse Spec., 126-132.

Kurz-Cringle, R.B. (1994). Nurse-managed inpatient program for patients with chronic mental disorders. Arch Psychiatr. Nurs., 14-21.

Lincoln, P. (2000). Comparing CNS and NP Role Activities: A replication. Clinical Nurse Specialist, 269-277.

Mary’s, S. (2007). Breast Services. Retrieved November 28, 2007, from Radiology/Diagnostics: http://smmmc.org/clinicalservices/radiology/breastservices.shtml

McAlpine, L.C. (1997). Reducing resource consumption through work redesign in a surgical intensive care unit: a multidisciplinary protocol-based progressive care area. Heart Lung, 329-334.

McCabe, S. a. (1999). Psychiatric nurse practitioner vs. clinical nurse specialist: moving from debate to action on the future of advanced psychiatric nursing. Arch Psychiatr Nurs, 111-116.

Nursing, American Association of Colleges of. (1993). Position Statement on Nursing Education’s Agenda for the Twenty-First Century. Washington: American Association of Colleges of Nursing.

O’Keefe, B.G. (1988). Family care in the coronary care unit: an analysis of clinical nurse specialist intervention. Heart & Lung, 191-198.

Rantz, M.J.-C. (2006). Entrepreneurial Program of Research and Service to Improve Nursing Home Care. Western Journal of Nursing Research, 918-934.

Rosher, R.B. (2001). Interdisciplinary Education in a Community-Based Geriatric Evaluation Clinic. Teaching and Learning in Medicine, 247-252.

Seemann, S.S. (2000). Hospital-wide Intravenous Initiative. Nurs. Clin. North Am., 361-373.

Selig, C. (2000). Sexual assault nurse examiner and sexual assault response team (SANE/SART) program. Nurs Clin North Am, 311-319.

The Clinical Nurse Specialists and Nurse Practitioners: Is There a Need to Merge These Roles?