If you speak to nursing leaders or read current nursing publications, you are well aware of the many problems facing nursing and healthcare in the next decade. The principal issue for nursing is the worsening shortage of nurses, nursing faculty, and advanced practice registered nurses (APRNs). Inherent in any solution to these shortages is the crucial challenge of quickly producing competent nurses while maintaining the integrity and quality of the nursing education provided (American Association of Colleges of Nursing [AACN], 2005). Many suggestions have been offered to address these issues including new titles and academic degrees, specifically the clinical nurse leader (CNL) and the doctorate in nursing practice (DNP) degrees proposed by AACN. What remains to be seen is whether these roles/degrees will have a positive or a negative influence on the shortage of nurses, nursing faculty, and APRNs.
CLINICAL NURSE LEADER
The AACN, in collaboration with leaders from the practice environment, has proposed this new nursing role to better serve patient care needs. AACN describes the CNL as "an individual prepared at the Masters-degree level as a generalist" (AACN, 2005). AACN is currently overseeing the implementation and evaluation of several academic programs to prepare CNLs.
The proposed functions of the CNL include the coordination of issues related to the care of a particular specialized patient group, comprehensive assessments of both of the patient and family, ongoing assessment, and changes to the plan of care as needed. Additional roles include direct patient care with accountability for patient care outcomes and education for staff, patients, and their families.
The CNL sounds like a great proposition for nurses and patients alike, but there are many unanswered questions. For example, there is significant overlap between the activities envisioned for this role and the scope of clinical nurse specialist practice. Will this create more confusion among consumers and our healthcare colleagues alike? Also, since CNLs will be prepared as generalists and not as specialists in a clinical area, will they truly be prepared to take on some of these functions? The CNL is not an advanced practice degree and appears to be intended for roles where non-master's prepared nurses currently function. One can argue that more education is always a good thing but can healthcare appropriately compensate nurses with master's preparation for these positions? Are enough nurses willing and able to undertake graduate education to prepare for these roles? Do we have room in the profession for another role and degree when we still have not solved the basic issue of entry-into-practice? Will healthcare systems be able to afford and integrate the role into practice?
DOCTORATE IN NURSING PRACTICE
In addition to their proposal for the creation of the CNL, the AACN is calling for all APRNs to be prepared with a practice doctorate for entry into practice as of 2015 (AACN, 2004). AACN is recommending that practice doctorate programs award only the DNP degree to clearly differentiate practice from research doctorates and to minimize confusion stemming from multiple degrees and titles (American Academy of Nurse Practitioners [AANP], 2006). The DNP is "a terminal practice degree whose goal is to prepare nurses to assume leadership roles in clinical practice, clinical teaching, and action research. The emphasis is less on theory and initiation of research and more on advanced clinical practice, research utilization, and evaluation of practice and care delivery models" (AACN, 2004).
The DNP degree was developed to provide parity with terminal practice degrees in other professions (e.g., physicians, pharmacists, dentists, psychologists; Steefel, 2005). "Master's prepared advanced practice nurses have identified additional knowledge that is needed for a higher level of advanced practice" (Steefel, 2005, p. 1). The impact on current advanced practice nursing roles, specifically the clinical nurse specialist (CNS), is not known. The identified role and future for CNS practice has not been clearly defined with regard to integration into the DNP model (National Association of Clinical Nurse Specialists [NACNS], 2005). The AANP "ldots continues to address these issues as steps are taken to implement activities that would lead to the development of DNP nurse practitioner educational programs in the future" (AANP, 2005, p. 1).
National nursing organizations are engaging in discussion to achieve consensus on the evolution of the emerging DNP role from the existing advance practice models. Currently, not everyone agrees that the DNP is the best way to go. While the proposed curriculum for DNP programs is laudable, there is concern that mandating a DNP for CNS and NP practice could actually exacerbate the shortage of APRNs. Will all candidates for these roles be willing and able to attend a DNP program? Will all nursing programs currently awarding master's degrees for CNS and NP preparation be able to offer doctoral education instead? And, PhD preparation will still be required for nursing faculty positions so the DNP movement may negatively impact the shortage of nursing faculty. Where will the faculty for the DNP programs come from? Can the healthcare system afford APRNs with this level of academic preparation?
We always encourage nurses to go back for graduate-level education because we believe education is inherently valuable. The CNL and DNP programs may prove to be wonderful assets to nursing and to healthcare. However, the real-world outcomes remain to be seen and the possibility of unintended and unanticipated consequences is a concern. Due diligence is required on the part of anyone exploring an advanced degree, with regard to both the actual academic program and future employment opportunities. Our advice: Buyer beware!!
K. Sue Hoyt, RN, PhD, FNP, APRN, BC, CEN, FAEN
Emergency Nurse Practitioner, St. Mary Medical Center, Long Beach, CA
Jean A. Proehl, RN, MN, CEN, CCRN, FAEN
Emergency Clinical Nurse Specialist, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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