The Cherry Ames books * remind me of the variety of roles available for nurses. Cherry seemed to do it all-army nurse, flight nurse, veterans' nurse, visiting nurse, school nurse, supervisor nurse, and, of course, the more interesting translations of nursing practice into the roles of cruise nurse, camp nurse, department store nurse, mountaineer nurse, and, my personal favorite, dude ranch nurse.
Similar to Cherry's practice, today's nursing practice occurs in several settings-hospitals, clinics, schools, homes, and in specialty units, such as critical care, rehabilitation, maternity, emergency, and palliative care. We have specialties defined by physiology, such as cardiovascular, pulmonary, orthopedics, neurology, and specialties defined by diseases, such as oncology and diabetes. There are population specialties-infants, children, adolescents, women, men, older adults; and specialty problems, such as wound care. The practice of nursing in each area requires the application of specialty knowledge and skill-commonly referred to as practice competencies. Basic practice in a specialty requires basic competencies. Advanced practice requires advanced practice competencies.
Advanced practice competencies define the clinical nurse specialist (CNS). It's been a long time coming, but the1998 National Association of Clinical Nurse Specialist Statement on Clinical Nurse Specialist Practice and Education1 was the first document in the 50-year history of CNS practice to delineate CNS practice competencies. The essence of CNS practice is core competencies integrated into specialty clinical expertise and demonstrated across 3 spheres of influence. The practice competencies differentiate a CNS in a specialty from any other a nurse, basic or advanced, in the specialty.
Graduate-level study in nursing, including coursework and supervised clinical experience, is how CNS practice competencies are initially acquired. An earned graduate degree is evidence of having achieved the competencies. Some state boards of nursing require CNSs to validate competencies beyond the academic degree. To date, certification examinations are used for additional validation. Because the core advanced practice competencies of a CNS are different from those of other advanced practice nurses, examinations must test CNS practice competencies.
CNSs competencies that are core to all CNSs, regardless of specialty, are grounded in advanced knowledge and skills for nursing diagnoses and nursing interventions. Core practice competencies for other advanced practice nurses, such as those for nurse practitioners (NPs), include diagnosing and treating disease. Because the core practice competencies are different, examinations for each advanced practice group-NP, nurse midwife, and nurse anesthetist-must be different. There are no core advanced practice competencies common for all advanced practice nurses. There may be core knowledge elements, such as advocacy, ethics, theory, and other foundational knowledge; however, these are not practice competencies.
Historically, CNS education focused on nursing diagnosis and interventions. In newly emerging programs, the emphasis remains on practice in the nursing domain, as authorized by the registered nurse (RN) license. Beginning in the 1990s, however, some CNSs began to extend practice into the medical domain. The impetus for this shift is likely related to the American Association of Colleges of Nursing's Essentials of Master's Education, with its recommendation for 3 courses for all clinical majors-physiology, pharmacology, and physical assessment. Many schools began offering these three courses to both CNS and NP students. Frequently, the courses were, and are, taught by NP faculty and focus on differential medical diagnosis of disease-leading to the mistaken notion that these courses represent core practice competencies for all advanced practice nurses. The disease emphasis that emerged in these courses also led to increased interest among CNSs for prescriptive authority.
CNS core competencies do not now, nor have they ever, included accountability for medical diagnoses and treatment. Prescriptive authority for medical pharmacotherapeutics is considered optional for CNSs-and requires additional coursework and supervised experience. This issue of the journal includes an article by Sharon Tucker outlining a course to prepare CNSs for prescriptive authority. It is included for those readers who are interested in adding coursework to prepare students for prescriptive authority. On balance, O'Malley and Mains, in the Pharmacology Consult column, outline options to prescriptive authority and identify some important considerations for CNSs who are contemplating prescriptive authority.
To be sure, the master's degree in nursing, earned by completing a program that prepares CNSs, is the credential for entry into CNS practice. It attests to the holder's acquisition of the core CNS competencies. Any examination used by a regulatory agency as further evidence of CNS competencies must be based on the core CNS practice competencies, which center on nursing diagnoses and nursing interventions across 3 spheres of influence. CNS core competencies do not now, nor have they ever, included accountability for medical diagnoses and treatment. Prescriptive authority for durable medical equipment is within the core competencies for CNS practice. Prescriptive authority for pharmacotherapeutics is considered optional.
Cherry Ames, a fictional character from a bygone time, possessed basic competencies acquired at the fictional Spencer Hospital School of Nursing. She practiced those basic core competencies in several roles-even as a dude ranch nurse! Leave it to Cherry to show us the way. It's not about the role, it's about practice competencies.
FOOTNOTES
*The Cherry Ames stories for young readers were written between 1943 and 1961. The series includes 22 books, 15 books by author Helen Wells and 7 books by author Julie Tatham. The complete series includes the following titles:Cherry Ames, Student Nurse; Cherry Ames, Senior Nurse; Cherry Ames, Army Nurse; Cherry Ames, Chief Nurse; Cherry Ames, Flight Nurse; Cherry Ames, Veterans' Nurse; Cherry Ames, Private Duty Nurse; Cherry Ames, Visiting Nurse; Cherry Ames, Cruise Nurse, Cherry Ames, Boarding School Nurse; Cherry Ames, Department Store Nurse; Cherry Ames, Camp Nurse; Cherry Ames at Hilton Hospital; Cherry Ames, Island Nurse; Cherry Ames, Rural Nurse; Cherry Ames at Spencer; Cherry Ames, Night Supervisor; Cherry Ames, Mountaineer Nurse; Cherry Ames, Dude Ranch Nurse; Cherry Ames, Rest Home Nurse; and Cherry Ames, Country Doctor's Nurse.[Context Link]