In most curricula, to enroll in an advanced course, a student must first complete a basic course. Faculty arrive at a distinction between basic and advanced subject content using a combination of knowledge about the state of the science, informed consensual opinion, and conventional wisdom, yet it remains an uncertain decision. Basic anatomy is different from advanced anatomy, but some basic courses are more advanced than others. It is not an exact distinction. In advanced practice nursing education, much energy has gone into promoting and supporting advanced courses for physiology, pathophysiology, physical assessment, and pharmacology; however, the distinction between basic and advanced is far from clear. Undergraduate nursing education prepares nurses to be generalists; therefore, undergraduate is basic. However, a difference exists between lower and upper division undergraduate courses. It is common for undergraduate curricula to require that students complete a basic anatomy and physiology course before enrolling in upper division nursing courses with more advanced content in pathophysiology, pharmacology, and physical assessment. So where does basic end and advanced begin?
Take physical assessment for example. Almost every undergraduate medical-surgical textbook includes techniques for physical assessment. Many books have whole chapters or sections dedicated to physical assessment, including history taking, system-focused physical examination, and complaint or symptom investigation. Some undergraduate nursing programs require a separate textbook on physical assessment, and some require a separate course for physical assessment. NCLEX examination review texts and practice questions include content on physical examination techniques and interpreting physical findings. Therefore, generalist nurses entering graduate programs have physical assessment knowledge and skills.
Role competencies should direct the content of advanced assessment courses for advanced practice nurse programs. Clinical nurse specialist (CNS) practice competencies focus on illness and risk behaviors. Illness, defined in the tradition of Nightingale, means symptoms and functional problems, and risk behavior, in Nightingale tradition, means health and safety practices aimed at preventing disease. For too long, CNS education has included courses on physical assessment, physiology, pathophysiology, and pharmacology inconsistent with CNS practice-focusing not on illness and risk behaviors but on primary care disease diagnosis and management. The mismatched focus between CNS competencies and curricula is reminiscent of the story of the inebriated fellow who, having dropped his house key some distance away, was searching under a street lamp. Questioned by a passerby why he did not look where he dropped the key, the man replied "Because it's lighter here." CNS curricula are filled with courses that are "in the light" rather than matched with CNS practice competencies.
To move us out of the light and into the dark, I am offering the following ideas for thinking anew about advanced courses in physiology, pathophysiology, physical assessment, and pharmacology for CNS curricula. Begin with a list of nurse-sensitive outcomes. Sort the list into 3 groups: symptoms, functional problems, and risk behaviors. Under symptoms, put nausea, fatigue, pain, dyspnea, and so forth. Under functional problems list unsteady gait, dysphagia, impaired fine motor coordination, altered cognition, and other problems with functional consequences. Under risk behavior include things like smoking, obesity, and no regular exercise. Now, consider developing a physiology course that provides an exquisite understanding of symptoms and functional problems. Include the physiology of nausea, fatigue, pain, and dyspnea. Think of the possibilities for transforming nursing care where CNSs have in-depth knowledge about the physiology of symptoms. How many interventions could be designed to interrupt the pain pathway if CNSs really understood pain pathways? Consider the possible interventions to reduce patient falls when CNSs understand that fall prevention is more than identifying patients at risk-its modifying risk, and that means knowledge of the physiology of gait, balance, and muscle strength.
Next, include assessment parameters in the course. Concede that undergraduate courses cover basic assessment content and move the CNS advanced course to sophisticated levels of physical and psychometric assessment of symptoms. Apply assessment techniques to generating nursing diagnoses related to symptoms and functional problems. And think about outcome measures. The same parameters that are used to assess gait can also be used to evaluate outcomes of gait interventions.
Include pharmacology content in the course. Many medically necessary pharmacologic interventions for chronic diseases contribute to symptoms and functional problems. A seemingly endless number of medications list nausea as a side effect. Knowledge of the physiology of nausea can lead to identifying physiologic mechanisms related to drug-induced nausea. Consider medications that have postural hypotension as a side effect. Frame postural hypotension not as a side effect but as a functional problem in the context of the physiology of gait and balance. The side effects of pharmacological therapies now become symptoms and functional problems to be managed with nursing interventions. What a great course this could be-an advanced course that contributes to advancing the practice of nursing.
To modify risk behaviors like smoking, CNSs need knowledge of psychoeducational-behavioral theories. CNS interventions that lead to behavioral outcomes such as cessation of smoking will be based on theory, not an understanding of the pathophysiology of lung cancer. Create a course filled with knowledge about theory for modifying behavior. Include theory-based interventions and psychometric instruments for assessing motivation and measuring behavior change. Add in review and critique of behavioral intervention research. Help students design educational interventions, complete with evaluation parameters that include both clinical and fiscal outcomes.
Nurses come to graduate education with knowledge of physiology, pathophysiology, pharmacology, and physical assessment. A nurse who forgets the techniques for assessing cranial nerves can check any medical-surgical textbook. Personal data assistants are portable encyclopedias of pharmacological information. Advanced nursing education for CNSs should focus on knowledge and skills for designing and evaluating innovative interventions for illness and risk behavior. More of the same does not move a course from basic to advanced. CNS practice competencies are unique, and so must be CNS education. It is time to stop searching in the convention of the light and create advanced nursing courses that prepare CNSs to practice advanced nursing.