Clinical nurse specialist practice—spheres of influence - Education

AORN Journal, Feb, 2003 by Patti Rager Zuzelo

AORN describes the perioperative advanced practice nurse (APN) as a "registered professional nurse who uses specialized knowledge and skills in the care of patients and families undergoing operative and other invasive procedures." (1) There are four established APN roles: clinical nurse specialist (CNS), nurse practitioner (NP), nurse midwife, and nurse anesthetist. (2)

Awareness of the similarities and differences among the four established APN roles may help perioperative nurses understand advanced practice opportunities. Most nurses are familiar with the roles of the certified RN anesthetist and the certified nurse midwife. Many have difficulty, however, articulating the role differences between a CNS and an NP. In fact, the literature supports the premise that the overlapping role domains of the CNS and NP can lead to practice challenges and role confusion. (3)

The perioperative RN may have difficulty distinguishing differences between CNS and NP practice domains given the nature of AORN's "Definition of perioperative advanced practice nurse" position statement and its applicability to both APN roles. The AORN position statement describes the responsibilities of the perioperative APN as follows:

   ... conducts comprehensive health assessments
   and demonstrates autonomy and skill in
   diagnosing and treating complex responses of
   clients (ie, patient, family, community) to
   actual and potential health problems that are
   related to the prospect or performance of
   operative or other invasive procedures. The
   perioperative APN formulates clinical decisions
   to manage acute and chronic illness by
   assessing, diagnosing, and prescribing treatment
   modalities, including pharmacological
   agents. The perioperative APN promotes
   wellness. The perioperative APN integrates
   clinical practice, education, research, management,
   leadership, and consultation into a
   single role. The perioperative APN functions
   in a collegial relationship with nurses, physicians,
   and others who influence the health
   environment. (4)

This article describes the role of the perioperative CNS within the context of the spheres of influence conceptualized by the National Association of Clinical Nurse Specialists (NACNS) Statement on Clinical Nurse Specialist Practice and Education, (5) after first discussing

* the graduate education preparation of CNSs and NPs,

* the national organizations representing CNSs and NPs, and

* the CNS role compared to that of the perioperative NP.

EDUCATIONAL PREPARATION

Consistent with the definition of advanced practice, the perioperative APN is required to possess a graduate degree in nursing. Most master's degree in nursing programs range from 36 to 48 credit hours. In general, nurses who attend graduate programs on a part-time basis should anticipate requiring approximately three years for degree completion, assuming that each semester includes six credit hours of course work. The number of required credits varies among institutions and should be explored carefully. Variation is due in part to differing curriculum designs as well as possible certification and degree combinations or dual degree opportunities available within programs. The American Association of Colleges of Nursing (AACN) has delineated the curriculum content essential to master's degree in nursing programs.

Advanced practice nurse curriculum content. The essential elements of curricula include graduate and advanced practice nursing cores and specialty content. (6) There typically is a deliberate curricular overlap between the four types of APN educational programs at the levels of graduate nursing and advanced practice nursing cores. Graduate nursing core curriculum content includes

* research,

* health care policy,

* organizational theory,

* health care finance,

* ethics,

* role development,

* theoretical foundations of nursing,

* diversity,

* social issues,

* health promotion, and

* disease prevention.

Advanced practice nursing core curriculum content includes

* health and physical assessment,

* physiology,

* pathophysiology, and

* pharmacology. (7)

This advanced content builds on the theory and practice content included in baccalaureate programs and experienced in work settings. Specialty content pertains to clinical and classroom learning experiences that are unique to the particular APN role of interest. This content typically is controlled or influenced by relevant specialty organizations and regulatory boards.

Clinical nurse specialist and NP curriculum content There are similarities and dissimilarities between the CNS and NP practice and theory domains. Typically, students enrolled in either of these advanced practice educational programs share a significant number of master's level courses, as the graduate core and advanced practice nursing core content provide the foundation for advanced practice. The model of graduate education used at La Salle University School of Nursing, Philadelphia, offers an example of shared and separate components of graduate education (Figure 1). Graduate students share the core courses and track courses. After these clustered course work components are completed successfully, graduate students move into specialty courses specific to their selected area of study. La Salle University's model is consistent with the curricular plan recommended by the AACN. (8)