I read with particular interest Thompson's article "The APRN Consensus Model: Curricular Implications for Clinical Nurse Specialist Education."1 The course, competency, and content grid for students in integrated curriculums was a helpful tool. However, I would like to correct some misinformation and also offer a differing view from Thompson's on the importance of moving now to change curricula to meet the recommendations of the Advanced Practice Registered Nurse (APRN) Consensus Model.
Thompson1(p327) stated: "Educational programs are expected to be transitioning in 2012 to meet the proposed full implementation of the model, which promotes the doctor of nursing practice (DNP) degree as entry into advanced nursing practiced, in 2015." It is imperative that both clinical nurse specialist (CNS) faculty and CNSs in practice recognize that neither the American Association of Colleges of Nursing (AACN) nor any of the organizations that endorsed the Consensus Model have authority to mandate either the DNP for entry into practice or a 2015 deadline. In addition, the AACN has recently backed away from the 2015 recommended implementation date.
At present, most DNPs are postmaster's programs. Gilliss and Hill2(p119) recently explained:
In 2004, the American Association of Colleges of Nursing (AACN) Board and, subsequently, the membership, voted to support the implementation of the DNP as a replacement for the MSN degree for APRN education by 2015. In fact, this implementation date was intended to be an aspirational goal. However, it was interpreted as a mandate, setting off a remarkably rapid proliferation of DNP programs, the majority of which are post-masters programs. The intention that master's programs stop educating APRNs has not taken hold and many schools have not closed their masters programs because they opened a DNP program.
Thompson urged faculty to change CNS curricula to fit the APRN Consensus Model recommendations. However, faculty should carefully consider 2 of the cornerstone components of the proposed Consensus Model that, if enacted, would be harmful to CNSs.
First, the APRN Consensus Model eliminates specialty content/foci from master of science in nursing (MSN) programs, reducing areas of expertise in practice to only 5 population foci (family/individual across the life span; adult-gerontology; neonatal; pediatrics, women's health/gender related; or psychiatric-mental health). The change would be harmful to the CNS practice and the specialty populations served because (1) specialty populations (eg, critical care, oncology, cardiology, neurology) have unique advanced nursing care needs due, at a minimum, to the differing complexities of physiological/pathophysiological dynamics and corresponding medical therapeutics (this is why medicine specializes to meet the medical care needs of patients) as well as differing psychosocial and self-care demands inherent in the nature of their conditions; and (2) the context for the experience of symptoms and functional problems differs across specialty populations. Although phenomena of concern to nursing often occur across specialty populations (eg, pain, skin breakdown, delirium, malnutrition, nausea, fatigue, falls) and can be taught in "core" advanced nursing courses, specialty contextual and evidence-based knowledge is required for accurate diagnostic and interventional reasoning in the nursing domain. Eliminating specialty practice from the curriculum puts patients at risk for not receiving the best possible nursing care that will prevent harm and/or enhance symptom control and functional ability.
Second, the model requires the same 3 separate advanced (not defined) comprehensive courses in physiology/pathophysiology, pharmacology, and physical assessment for all APRN roles. The typical 3 "P" courses will necessarily continue to have a focus in the medical domain. Adding or switching to these courses is harmful to CNSs because it results in a decline in the number of credit hours that can be devoted to (1) the altered physiological phenomena of concern to nursing and the scientific knowledge required for accurate diagnostic and interventional reasoning in the nursing domain,3 (2) holistic health assessment, and the (3) unique pharmacological needs of specialty populations.
The courses recommended in the APRN Consensus Model seem to be based on a presumption that all APRN roles are purposed toward the provision of primary healthcare and/or are purposed heavily in the medical domain, evidenced in Apple's4 reflection on the importance of the model:
This model has become more important, especially with the passage of healthcare reform legislation, because APRNs (nurse practitioners, clinical nurse specialists, nurse midwives and nurse anesthetists) have an increasingly important role to play in the delivery of primary care.
The 4 advanced practice roles exist to meet distinctly different societal needs, and only the nurse practitioner is prepared to be a primary healthcare provider as defined by the Institute of Medicine.5
Primary care is the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs, developing a sustained partnership with patients, and practicing in the context of family and community. (p32)
The term clinician refers to an individual who uses a recognized scientific knowledge base and has the authority to direct the delivery of personal health services to patients. A clinician has direct contact with patients and may be a physician, nurse practitioner, or physician assistant. For most families, this clinician is a physician. Additionally, primary care clinicians might turn to a variety of other individuals-both with and without healthcare training-for their assistance and skill in particular areas. (p36)
Majority of personal healthcare needs refers to the essential characteristic of primary care clinicians: that they receive all problems that patients bring-unrestricted by problem or organ system-and have the appropriate training to diagnose and manage a large majority of those problems and to involve other healthcare practitioners for further evaluation or treatment when appropriate. (p33)
If all APRN roles were purposed toward the delivery of primary care, then the APRN Consensus Model would indeed make a lot of sense. Although CNSs can be important members of multidisciplinary primary healthcare teams, their work is not purposed as a primary care clinician as defined by the Institute of Medicine. Instead, CNS work is purposed toward the diagnosis and treatment of factors other than disease that contribute to patients' symptoms and functional problems (in the context of extant disease and medical therapeutics or in the absence of disease) that require nursing interventions/therapeutics.
In addition to the concerns I have raised here, Thompson raised critical questions that also mitigate against the urging of faculty to "start now"1(p327) in changing curricula:
There are still many questions: for example, will students be able to be dually educated at the general (eg, adult-gerontology) and specialty levels (eg, palliative care) so as to qualify for the national and specialty certification examinations? If so, will practica hours be able to be shared-that is, acute care hours "count" for both the adult-gerontology and acute care CNS certifications? Will certification at the population and role levels be a prerequisite for specialty certification? Could 1 certification examination "count" for both state licensure and specialty certification? For example if the Oncology Nursing Society develops an examination that tests pediatric care and CNS role knowledge (population and role) and pediatric oncology content, would that test be accepted for state licensure, as well as for advanced oncology certification? Without answers to some of these critical questions, there could be a wide interpretation of the "rules"-and could possibly land us back to the same spot and reasons for the need for a consensus model in the first place-a lack of standardization. (p328)
I believe that it is imperative that faculty teaching in CNS programs think critically about the curricular requirements for preparing CNS graduates to meet the specialty needs of the populations they serve. For faculty who are concerned about accreditation implications of curricula that do not meet the recommendations of the APRN Consensus Model and therefore might be inconsistent with the Commission on Collegiate Nursing Education (an independent arm of AACN) MSN accreditation standards, it is important to remember that the Commission on Collegiate Nursing Education is not the only accrediting body for CNS MSN programs. The National League for Nursing Accrediting Commission also accredits MSN programs and, most importantly, MSN programs preparing CNSs. Beverly Malone,6 chief executive officer of the National League for Nursing, in her contribution to the "Commentary on Doctor of Nursing Science: A National Workforce Perspective," stated:
The NLN supports the recommendation that master's education should continue to be offered, valued, and accredited to prepare nurses for entry into Advanced Practice Registered Nurse (APRN) practice. [horizontal ellipsis]We believe in the concept of the practice-focused doctorate after specialty preparation at the masters' level.
I believe that faculty teaching in CNS programs and practicing CNSs must think critically about any curricular modifications and work to assure that the public will continue to benefit from the unique contributions of CNSs in their specialty areas. I urge CNS faculty to be good stewards of the discipline for the benefit of the patients we serve!
Brenda L. Lyon, PhD, CNS, FAAN
President, Health Potentials Unlimited
LLC and Professor Emeritus
School of Nursing, Indiana University
Indianapolis
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