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The notion of a blended role emerged several years ago and has crept along without thoughtful debate by clinicians, educators, or the discipline as a whole. Blended means mix, merge together, or intermingle. In a blended program, how much of what is in the mix is unknown, as no practice competencies or educational standards exist for the blended role. Asking for a description of the blended role is reminiscent of the tale of the blind men and the elephant where each of 5 blind men are asked to describe an elephant. One man feels the trunk, one the tail, another an ear, another a foot, and another the back. The descriptions vary widely yet each man insists he is correct. No one has the complete picture; each experience is unique, isolated, and deficient. Likewise, each interpretation of the blended role is reflective of a school's individual interpretation of the intermingling of two roles.


A common aspect of blended programs is that the curriculum consists of some combination of clinical nurse specialist (CNS) content and nurse practitioner (NP) content. Combining two full curriculums within the traditional 40ish semester credit hours of a master's program is to shortchange one or both programs. The result is a graduate who is adequately prepared in one role and not the other or is inadequately prepared in both roles. Experience suggests that the CNS curriculum is most often the truncated curriculum. Consider one university whose Web site advertises a combined NP/CNS program. After completing the NP curriculum, including clinical experiences "with only one additional quarter of course work, students will be prepared to sit for both the American Nurses Credentialing Center (ANCC) examination for primary care practitioners and the certification exam for the clinical nurse specialization in medical-surgical nursing." Amazing. One quarter, 10 weeks, and graduates have mastered CNS entry-level competencies?


No list of schools offering blended programs is available; however, the above example is not an isolated illustration. According to enrollment and graduation data from the American Association of Colleges of Nursing approximately 20% of all CNS graduates are from blended programs (called combined programs in the report).1 It is not known, however, whether these graduates, who are reported to be eligible for CNS certification exams, actually take a CNS exam and function as CNSs.


The assurance that graduates are eligible to sit for one CNS certification exam and one NP certification exam is a common promised outcome across blended programs. Certification by ANCC is verification of minimum or entry-level competencies. The eligibility requirements for ANCC exams are identical for CNS and NP-candidates are required to have graduated from a program offered by an accredited institution granting graduate-level academic credit for all of the course work that includes both didactic and clinical components, and a minimum of 500 hours of supervised clinical practice in the specialty area and role.2 Thus, according to this standard, it takes a minimum of 500 supervised clinical hours to learn the CNS role and demonstrate proficiency in CNS practice, and likewise, 500 clinical hours are required to learn the NP role and develop proficiency in NP practice. It's curious how candidates from blended programs are documenting the requirement for clinical hours on each of two applications as it is doubtful that these graduates are completing 1000 hours of supervised clinical practice, 500 in each role. The overall pass rate of candidates from blended programs is not known. Collaborative initiatives between ANCC and the National Association of Clinical Nurse Specialists (NACNS) are addressing the issue of inadequate CNS clinical hours in blended programs.


Role refers to a constellation of functions for which an individual is responsible and role preparation occurs in an academic setting where an individual learns to perform the circumscribed role functions. The American Nurses Association recognizes four advanced practice roles-clinical nurse specialist, nurse practitioner, and nurse midwife and nurse anesthetist and states that the scope of practice for each role is distinguishable.3 Educational preparation for each role is accomplished through completion of a distinct curriculum that prepares graduates to function in the scope of practice of the role. Curricular content is determined by professional associations who represent experts in the role. In 1998, NACNS, after a rigorous process to assure national consensus and validation, released the first ever CNS core competencies and associated curricular recommendations.4 These recommendations addressed growing concerns within the profession for more standardized educational requirements for CNSs. The National Advisory Council on Nurse Education and Practice, an advisory body to the Division of Nursing, Health and Human Services, called for the profession to delineate core CNS competencies and standardize the educational requirements for CNS preparation.5


Since 1998, CNS programs have increasingly been using the national curricular recommendations and variability among CNS programs is decreasing.6 Updated in 2004, the framework for CNS practice, essential characteristics, practice outcomes, core competencies, and education-in fact, the essence of CNS practice and preparation is thoroughly described by the NACNS in the Statement on CNS Practice and Education.7 CNS students and employers need to hold blended/combined programs accountable for meeting nationally validated curricular guidelines and for preparing CNS graduates to function within the scope of practice defined by the profession and demonstrated through core competencies.




1. Berlin LE, Wilsey, SJ, Bednash GD. 2004-2005 Enrollment and Graduation in Baccalaureate and Graduate Programs in Nursing. Washington, DC: AACN; 2005. [Context Link]


2. ANCC Professional Certification for Advanced Practice Nurses. Available at: Accessed August 5, 2005. [Context Link]


3. American Nurses Association. Nursing Scope and Standards of Practice. Washington, DC; 2004. [Context Link]


4. National Association of Clinical Nurse Specialists. Statement on CNS Practice and Education. Harrisburg, Penn: National Association of Clinical Nurse Specialists; 1998. [Context Link]


5. National Advisory Council on Nurse Education and Practice. Federal Support for the Preparation of the Clinical Nurse Specialist Workforce Through Title VIII. Washington, DC: U.S. Department of Health & Human Services, Health Resources & Services Administration, Bureau of Health Profession Division of Nursing; 1999. [Context Link]


6. Walker J, Gerard PS, Bayley EW, et al. A description of clinical nurse specialists programs in the United States. Clin Nurse Spec. 2003;17(1):50-57. [Context Link]


7. National Association of Clinical Nurse Specialists. Statement on CNS Practice and Education. 2nd ed. Harrisburg, Penn: National Association of Clinical Nurse Specialists; 2004. [Context Link]