Expanded Nursing Roles
Professional nursing is adapting to meet changing health needs and expectations. One such adaptation is through the expanded role of the nurse, which has developed in response to the need to improve the distribution of health care services and to decrease the cost of health care. NPs, clinical nurse specialists (CNSs), cer-tified nurse-midwives, and certified registered nurse anesthetists are identified as advanced practice nurses. The nurse who func-tions in an advanced practice role provides direct care to patients through independent practice, practice within a health care agency, or collaboration with a physician. Specialization has evolved within the expanded roles of nursing as a result of the recent explosion of technology and knowledge.
Nurses may receive advanced education in such specialties as family, critical care, coronary care, respiratory care, oncologic care, maternal and child health care, neonatal intensive care, rehabili-tation, trauma, rural health, and gerontologic nursing, to name just a few. With the expanded role of the nurse, various titles have emerged that attempt to specify the functions as well as the edu-cational preparation of nurses, although functions are less distinct than in previous years. In medical-surgical nursing, the most sig-nificant of these titles arenurse practitioner and clinical nurse spe-cialist, and the more recent title of advanced practice nurse, whichencompasses both NPs and CNSs.
Initially the educational preparation for NPs was in certificate programs. Most states now require both NPs and CNSs to have a graduate-level education. The two programs, which originally differed significantly in scope and in their definition of role com-ponents, now have many similarities and areas of overlap.
NPs are, for the most part, prepared as generalists (eg, pediatric NP, geriatric NP). They define their role in terms of direct provi-sion of a broad range of primary health care services to patients and families. The focus is on providing primary health care to patients and collaborating with other health professionals. NPs practice in both acute and nonacute care settings. The 1997 Balanced Budget Act provided for NPs to receive direct Medicare reimbursement. In addition, in some states—and with new legislation possibly nationwide—NPs have prescriptive authority (Boyd, 2000).
CNSs, on the other hand, are prepared as specialists who prac-tice within a circumscribed area of care (eg, cardiovascular CNS, oncology CNS). They define their role as having five major com-ponents: clinical practice, education, management, consultation, and research. Studies have shown that in reality the CNS focus is often on the education and consultation roles: education and counseling of patients and families and education, counseling, and consultation with nursing staff. Some states have granted CNSs prescriptive authority if they have the required educational preparation. CNSs practice in a variety of settings, including the community and the home, although most practice in acute care settings. Recently, CNSs have been identified by many nursing leaders as ideal case managers. They have the educational back-ground and the clinical expertise to organize and coordinate ser-vices and resources to meet the patient’s health care needs in a cost-effective and efficient manner.
With advanced practice roles has come a continuing effort by professional nursing organizations to define more clearly the practice of nursing. Nurse practice acts have been amended to give nurses the authority to perform functions that were previ-ously restricted to the practice of medicine. These functions in-clude diagnosis (nursing), treatment, performance of selected invasive procedures, and prescription of medications and treat-ments. The board of nursing in each state stipulates regulations regarding these functions. The board defines the education and experience required and determines the clinical situations in which a nurse may perform these functions.
In general, initial care, ambulatory health care, and anticipa-tory guidance are all becoming increasingly important in nursing practice. Advanced practice roles enable nurses to function inter-dependently with other health care professionals and to establish a more collegial relationship with physicians. As changes in health care continue, the role of advanced practice nurses, especially in primary care settings, is expected to increase in terms of scope, re-sponsibility, and recognition.
Throughout this we have explored the changing role of nursing. Many references have been made to the significance of the nurse as a member of the health care team. As the unique competencies of nurses are becoming more clearly articulated, there is increasing evidence that nurses provide certain health care services distinct to the profession. However, nursing continues to recognize the importance of collaboration with other health care disciplines in meeting the needs of patients.
Some institutions use the collaborative practice model (Fig. 1-3). Nurses, physicians, and ancillary health personnel function within a decentralized organizational structure, collaboratively making clinical decisions. A joint practice committee, with rep-resentation from all care providers, may function at the unit level to monitor, support, and foster collaboration. Collaborative prac-tice is further enhanced with integration of the clinical record and with joint patient care record reviews.
The collaborative model, or a variation of it, should be a primary goal for nursing—a venture that promotes shared participation, re-sponsibility, and accountability in a health care environment that is striving to meet the complex health care needs of the public.