What Does It Take to Make a Nurse? Considerations of the CNL and DNP Role Development

Perspectives in Psychiatric Care, Nov 2006 by McCabe, Susan

You can know the name of a bird in all the languages of the world, but when you're finished, you'll know absolutely nothing whatever about the bird ... So let's look at the bird and see what it's doing-that's what counts. I learned very early the difference between knowing the name of something and knowing something.

-Richard Feynman

What does it take to make a nurse? The substance of such a question is the measure of any profession. The identification and structuring of what it takes to make a nurse is reflected in our education and it establishes how much autonomy and control we maintain over what we are, where we practice as nurses, and who gets to enter into nursing practice. The educational processes of nursing contain our past and future, our epistemology, and our profession's values and beliefs. The curricula we put in place reflect what we believe to be essential to our functioning and reflect our collective identities as nurses. The programs of study, the courses we require students to take, the content we espouse, and the clinical experiences that we organize are all designed to produce a nurse. So what does it take to make a nurse? What educational pathway is the yellow brick road that best produces competent nursing care? This question has divided us as a professional group, pitting associate and technical against professional and bachelors, 2 years against 4 years, clinical nurse against practitioner. We have muddled and puzzled and thought and reacted, yet through much of the rhetoric the concept of just what a nurse is has remain surprisingly elusive and a cohesive consensus of what it takes to make a nurse is not well established.

Interestingly the public is clearer than we seem to be as a profession. For the average person, what it takes to be a nurse is quite simply, caring. The word "nurse" is a resonant term having a clear, visceral identity that engenders compassion, caring, a collective comfort, and yields respect for our profession. Consistently in Gallop polls of the most trusted professions, we as nurses rise to the top, above lawyers and doctors and police and senators. Gallop's annual poll has changed little in relation to how nurses are perceived on issues of honesty and ethics, and nurses continue to be rated most positively, by a substantial margin (Jones, 2005). But the more one moves beyond the coarse generalization of the word "nurse," our image and the sense of what we are and what we do becomes fuzzier and fuzzier. We are a veritable alphabet soup of initials conveying an endless number of educational entry points, specialty focus, certifications, and educational paths. We are RN, APRN, ARNP, AS, BSN, CNS, FNP, ANP, ND, PMHNP, BC, and PC. These pieces of our alphabet soup represent discrete educational curricula; represent diverse perspectives of roles and opportunities. But what do they say about what we are as a nurse? What do they say about what it takes to make a nurse? Does the initial soup advance us as a profession or does it squander some of the capital reflected in our Gallop poll number? Ultimately, are we professionally stronger, or are we mudding other's ability to understand what we do, and often confusing even our selves?

These are not new questions and many of us have pondered the relative value of our alphabet. And yet we are at it once again, with apparent enthusiasm and great speed. One of our respected organizations, the American Association of College of Nursing (AACN), has initiated the development of two new sets of credentials, new initials to add to the lengthy soup list we have already grown. We find ourselves road testing the Clinical Nurse Leader (CNL) and the Doctorate of Nursing Practice (DNP) titles. The rapid emergence of these two new roles, with their associated educational curricular structures, have given me pause as I think about the wisdom of yet two new initials added to nursing's repertoire. I have been thinking about what it means to have yet again new initials and I have been thinking about what it says regarding what we think and what we know about making a nurse.

The first of the new roles, the CNL, is identified, oxymoronically, as a generalist master's degree. In and of itself, this might give one pause. The CNL degree is seen by many as the new entry into professional practice degree and has been touted as a true leader role in the healthcare delivery system. It is conceptualized as a master's level degree, preparing nurses for a role of central manager for aspects of patients' health. On the surface, the concept seems appropriate and future oriented. It reflects a centrality for nursing within healthcare systems and reflects just how complex modern health care has become. Unfortunately, once one moves beyond obvious conceptual rationale for the role's development, one is hit with what appears to be an inescapable conclusion-how is it different from what good and experienced nurses do now? Yet across the country many schools of nursing, my university included, have or are planning to move to a CNL degree, in conjunction with identified practice partners. Fundamental aspects of the clinical nurse leader role have been identified, content to prepare such nurses has been named, and competency statements have been written (AACN, 2003, 2004). Based on the identified educational preparation, the CNL nurse is expected, in a dizzying and frankly tiring assertion, to provide leadership in the care of the sick in and across all environments, design and provide health promotion and risk reduction for diverse populations, practice evidence-based nursing, provide population-based health care to individuals, clinical populations, and communities, delegate and oversee care delivery and outcomes, team management and collaboration with other health professional team members, utilize information management systems and material resources, and manage and use client-care information technology (AACN, 2003, 2004).