Nurse practitioners and clinical nurse specialists: roles and differences

ADVANCED PRACTICE NURSING ROLES: NP vs. CNS

Advanced Practice Registered Nurse Roles

The United States is home to nearly a quarter of a million advanced practice registered nurses (APRNs). Of these, the vast majority chose to pursue a Master of Science in Nursing (MSN) leading to licensure as a nurse practitioner (NP). The second most common choice is an MSN program leading to certification or recognition as a clinical nurse specialist (CNS). Both pathways provide the preparation necessary for greater responsibility and autonomy as a medical professional. NPs make the transition from care provider to care prescriber, while CNSs become the best-practice experts for their healthcare organization. The care settings are distinct, as well, with many NPs practicing in underserved rural communities and inner-city neighborhoods and CNSs practicing in hospitals and extended-care facilities. To better understand the similarities and differences in NP and CNS roles this essay will examine in detail what is known about these two professions.

Advanced Practice Nursing Roles: NP vs. CNS

As of March 2008 there were approximately 3 million licensed registered nurses (RNs) living and working within the United States according to the Health Resources and Services Administration (HRSA, 2010, p. xxvii). Of these, the Associate Degree in Nursing (ADN) was the most common academic track into nursing, while another 34% had attained bachelor's or graduate degrees. Diploma programs available through some hospitals were the least common, with approximately 20% of the RN population having attained licensure using this mechanism. Despite the cost and commitment required to complete an advanced degree in nursing, close to 250,000 RNs reported having done so in 2008 (HRSA, 2010, p. 5-1). These Advanced Practice RNs (APRNs) acquired the skills and credentials necessary to transition from providing to prescribing patient care. This shift brings with it a substantial increase in responsibilities, including ordering diagnostic tests, prescribing medications, and performing minor procedures.

The four most common APRN professions are nurse practitioners (NPs), clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), and certified nurse midwife (CNM) (HRSA, 2010, p.5-1, 5.2). The number of RNs in each profession will change from year to year, due in part to need and the availability of academic programs. Between 2004 and 2008, NPs increased in number from 123,000 to 139,000, while CNS declined from 57,000 to 42,000. CRNAs increased slightly from 31,000 to 34,000, but CNM increased substantially from 10,000 to 15,000. These statistics represent the number of APRNs who reported preparation for only one of these professions, but a sizeable proportion had received preparation for both NP and CNS (16,000). This brings the total number of NPs and CNSs in 2008 to 156,000 and 59,000, respectively. A much smaller number reported combined preparation for other APRN professions (< 3,000).

Since NP and/or CNS represent the most common choices among RNs seeking advanced practice preparation this essay will review and contrast the roles for these two professions. A number of different sources will be utilized for this information, including peer-reviewed publications, professional nursing organizations, and government agencies. This strategy is intended to provide a consensus view of these two nursing professions. In addition, the academic requirements and practice settings for each profession will be examined in detail to help with the comparison, with the assumption that the roles of each can be better understood by examining the academic pathways to licensure and practice setting choices.

Rural NP Roles

The needs of rural patient populations are somewhat distinct compared to their urban counterparts (Schmidt, Brandt, & Norris, 1995). The rural elderly tend to live longer, but longevity brings higher levels of chronic disease. Injury and death due to accidents is more common and rural residents tend to ignore health issues during peak periods of seasonal work. The value of industriousness is so prevalent in rural communities that NPs seeking to establish a successful rural practice must take this into consideration. The other considerations that define rural NP practices are isolation, geographic distance, increased autonomy, patient autonomy, patient frugality, reimbursement difficulties, and barriers related to provider 'outsider' status. Accordingly, NPs are encouraged to foster a positive public image through civic engagement and promote a public health agenda that seeks to improve the quality of prenatal and elderly care, in addition to reducing transportation-related injuries and death.

NPs working in rural settings must also find a balance between providing medical services for family members and friends, while at the same time protecting patient confidentiality (Schmidt et al., 1995). Studies that have examined the roles of NPs in rural settings have found that disease detection, chronic disease management, disease prevention, health promotion, patient teaching, and lifestyle counseling figure prominently. Although NPs are not physicians, between 50 and 90% of the primary care services typically provided by a physician are available from NPs. Collaborative arrangements with area physicians, clinics, and hospitals allow most NPs to provide complete primary care services within the practice setting and through referrals.

Hospital-Based NPs

Over half of all the registered NPs in Canada work within the Ontario Province (Van Soeren, Hurlock-Chorostecki, & Reeves, 2011). A study using a focus group design examined the roles of NPs within hospital settings and found that 46, 30, 8 and 7% of an NPs' time was spent in clinical practice, engaging in collaborative care teams, fulfilling leadership roles, and conducting research, respectively. The relative contribution from each of these activities was influenced to some extent by the nature of the hospital setting. For example, NPs working in adult community hospitals spent more time in clinical practice, whereas NPs staffing university teaching hospitals tended to allocate more time for research. A few of the clinical activities NPs engaged in included charting, patient assessment, ordering diagnostic tests, prescribing medications, performing special procedures, discussing care plans with patient and family members, making referrals, and conducting patient follow-ups. Care team participation involved making referrals, conducting rounds, developing care plans, improving care quality, teaching, and responding to communications from team members. The leadership roles included patient advocacy, mentoring nurses, evaluating programs, organizing rounds, and acting as professional representatives within and outside the organization. The research activities included poring through the research literature, writing grant proposals, conducting clinical research, implementing best practice guidelines, and data collection/analysis.

CNS Preparation

Around the same time that the NP profession was beginning to develop in rural and inner city settings the CNS role was developing in hospital acute care and psychiatric departments (HRSA, 2010, p. 5-26). In the 1960s, academic graduate programs leading to CNS certification were beginning to emerge. The current academic pathway to CNS certification depends on completion of an MSN degree program, but in contrast to NPs, state licensing boards do not acknowledge the CNS job title as an APRN profession. Accordingly, some states even allow RNs to be classified as CNSs. Although MSN is the typical academic requirement for CNS certification or recognition on the national or state level, respectively, this can also occur after completion of a doctoral program in nursing. In 2008, only 55% of nurses with a CNS MSN were certified or recognized as a CNS on the national or state level. Despite this low level of certification, over 40% claimed certification was required for their position. The amount of time it typically takes to complete a graduate CNS program is between 1 and 3 years.

CNS Roles

Of the APRNs with a CNS job title, 85.4% had attained state recognition or national certification; however, this represented only 18.8% of all CNSs (HRSA, 2010, p.5-30). Other common job titles were teaching (21%), management (18%), staff nurse (16%), and NP (16%). The nurses with both CNS and NP preparation (27.6% of CNS) were most frequently holding NP positions (55%).

The primary aim of a nurse with a CNS job title is to improve the quality of clinical care provided in hospitals and extended care facilities (HRSA, 2010, p.5-26). The common roles associated with the CNS position is helping care teams coordinate patient care, mentoring nurses in the administration of patient care, identifying patient care issues, and offering solutions (Goudreau et al., 2007). These roles define the three spheres of influence associated with the CNS job title: (1) patient/client, (2) nurses/nursing, and (3) system/organizational. In addition, CNSs typically have training and expertise in one or more specialties, including psychiatric, pediatric, geriatric, obstetric, acute/trauma, oncology, and public health (HRSA, 2010, p.5-26).

The decline in the number of CNS professionals is due in part to the aging of this demographic; however, the need for CNSs continues to grow. The aging of CNSs is due to an increased emphasis on non-specialty, broad disciplinary training by some nursing professional organizations, resulting in prospective APRN students to choose other professions (Goudreau et al., 2007). This emphasis has led to fewer CNS graduates, despite continued CNS shortages in some geographic locations. In addition, several academic nursing departments terminated their CNS programs during the 1980s, although this trend has begun to reverse in recent years (Muller, McCauley, Harrington, Joblonski, & Strauss, 2011). The National Association of Clinical Nurse Specialists (NACNS) issued a policy statement declaring the CNS profession critical for improving patient care quality. This policy position was based on the need for CNS prepared nurses to handle the exponential growth in research literature and manage the increasingly technology-driven care environment.

According to Harwood (2013), CNS-prepared nursing professionals represent the optional choice in care settings where there is a need for advanced nursing assessment, advanced clinical management, care team collaboration in complex settings, patient and nurse teaching/coaching/counseling, and leadership in cost-effective best-practice implementation. Although some of these needs can be filled by RNs or NPs, when the need is for system-wide, multidisciplinary planning of patient care quality improvements only a CNS will do. As Muller and colleagues (2011) suggest, CNSs are the "… knowledge keepers, knowledge seekers, and knowledge disseminators & #8230;" (p. 140), who are able to improve patient care quality through education and best practice implementation system-wide.

Discussion and Conclusions

The academic requirements for NP and CNS are similar, but the content of the programs will be distinct. After obtaining certification or recognition to practice as an NP or CNS, both are expected to engage in activities that will limit how much time can be devoted to direct patient care. NPs, through the statutory authority conferred by state nursing boards, become prescribers of care; they can order diagnostic tests, prescribe medications, and perform minor procedures. By comparison, CNS preparation alone will not confer APRN status or the statutory authority to become prescribers of care.

The care settings are also distinct. A large percentage of NPs will work within underserved communities, including rural and inner-city neighborhoods. Within these settings, NPs will be expected to provide many of the same primary care services typically offered by family physicians. In some communities, the NP may be the only medical professional providing services; they not only become the local doctor, but also the public health department for the whole community. Accordingly, NP preparation should be broad-based. By comparison, CNSs typically work within hospitals and extended-care facilities. The best academic programs will provide specialty training in one or more disciplines, along with extensive exposure to research methods. Upon graduation, CNSs will be expected to work within three spheres of influence: (1) patient care, (2) nurse mentoring, and (3) system/organizational, with the goal of improving the quality of patient care system-wide. CNSs are expected to stay current with the research literature, translate research findings into best practice recommendations, and then evaluate the efficacy of best practice implementation.

When the NP and CNS roles are examined in detail there can be vast differences; however, NPs are found everywhere, but CNS preparation would be inappropriate for a rural or inner-city primary care practice. On the other hand, NP preparation would not be ideally suited for a CNS position where the demand for system-wide evaluations and best-practice implementation is substantial. Although both could adapt over time to the needs of each position, why try to fit a square peg into a round hole. There is still a strong and growing need for distinct academic programs for NPs and CNSs.