The future of nursing practice is never stable because of a number of new regulations, constant improvements, and specific interventions. In the middle of the 20th century, the first categories of nurse specialists were introduced, provoking the importance of defining the scope of practice, certification requirements, and collaboration arrangements. In the United States, there are four main types of advanced practice registered nurses, including a clinical nurse specialist (CNS), a nurse practitioner (NP), midwives, and anesthetists (Parker & Hill, 2017). On the one hand, these professions have a list of common characteristics in clinical settings and education programs. On the other hand, certain legal issues and differences in the scope of practice cannot be ignored. Therefore, at this moment, there are many debates about the possibility of merging the roles of CNSs and NPs. Some researchers and theorists admit the benefits of blending because of the necessity to improve the quality of care and contribute to the achievement of a common goal in nursing. Reshaping of the healthcare delivery system is an obligatory step that is based on the blended CNS-NP role.
Terms and Definition
Advanced practice registered nurses (APRNs) are nurses with masters or post-graduate education in the field of nursing who coordinate patient care in accordance with federal rules and standards.
The Doctor of Nursing Practice (DNP) is a degree for APRNs to emphasize leadership, management, and quality improvement.
A clinical nurse specialist (CNS) is an APRN who aims at providing patients with consultations about specific conditions and treatment plans.
A Master of Science in Nursing (MSN) is an advanced degree in terms of which nurse leaders develop their skills and identify their needs for clinical and non-clinical purposes.
A nurse practitioner (NP) is an APRN who cooperates directly with patients to assess their needs, diagnostic tests, and treatment plans.
The effectiveness of the blended roles has to be traced back to the first regulations of the 20th century. The idea to differentiate nursing workers was promoted by Katherine DeWitt at the beginning of the 1900s. She believed that new nurses had to be useful to not only doctors and their convenience around patients but to patients and their families (Dunphy, 2018). In 1943, another American nurse, Frances Reiter, developed the term “nurse-clinician” to underline the depth of understanding of a nursing profession as the direct care of patients (Ahmed & Wolf, 2018). CNSs were responsible for providing patients with care and consultation and facilitating clinical research. In the middle of the 1970s, the American Nurses Associated approved the master of science in nursing degree as a critical requirement for CNSs.
The history of the NP term began in the 1960s. Ford and Silver proposed a pediatric NP program to expand the concept of nursing practice and to focus on health promotion and decrease prevention as a part of public health (Ahmed & Wolf, 2018). This profession provided an opportunity for the nursing staff to recognize their societal needs and potential. The education requirements for NPs are increased compared to those of CNSs and include the possibility of getting a doctor of nursing practice (DNP) (Mohr & Coke, 2018). In total, the roles of CNSs and NPs were discussed through the prism of different goals, with consultation, education, analysis, and research for the former and direct holistic care to patients and their families for the latter.
Taking into consideration the already made achievements and distinctions and analyzing the current needs and expectations of nurses, patients, and other stakeholders, there is a possibility to merge the roles of CNSs and NPs. The nursing practice continues changing and discovering new aspects of this profession and the goals that different APRNs have. The development of an evidence-based practice (EBP) project is not only a chance to improve nurse skills and working conditions but also to make certain contributions to the quality of care and service delivery. EBP helps to align ordinary people with medicine and nursing, in particular by analyzing and testing various tasks, treatments, and behaviors (Karnick, 2016). In the majority of cases, the application of the EBP intervention is characterized by the improvement of healthcare quality, cost control, and positive patient outcomes. In this situation, the consequences of the blended role of the CNS and the NP are hard to predict. Still, the analysis of health services, consumer needs, and nurse functions should show if the merger is a necessary step at this particular moment.
Strategies that Address the Problem
Problem-solving strategies are developed to identify a plan of steps to be taken to find a solution. In this project, the problem is the lack of information about the blended role of CNSs and NPs in a healthcare setting. Many facilities and communities have already come to the conclusion that the merger is an effective solution to improve the quality of care and nurse-patient and nurse-nurse interrelationships. However, there are no specific actions to achieve this goal and deal with all the associated changes, threats, and opportunities. Cooper et al. (2019) discuss the similarities and differences between nurses and their roles, specifying existing ambiguity and potentials. Algorithms are hardly effective in solving the problem because of limited resources and poor experience. The use of a heuristic problem-solving method will help to investigate the chosen topic and compare the results, either positive or negative. The main idea of this approach is to create conditions that are suitable for finding (Grünig & Kühn, 2017). It means that there are no guarantees that the solution to the problem is correct, but all decision-making activities play a crucial role in finding the answer.
Changes in nursing practice require the evaluation of the current state of affairs and the incorporation of research and interpersonal relationships. Through the prism of the already identified problem and the heuristic problem-solving approach, the direct contributions of nurses have to be mentioned. The combination of primary, secondary, and tertiary interventions helps to manage human activities in the most effective way. Nurses use various strategies to improve decision-making, interactions, and care delivery (Cleary et al., 2018). Primary interventions aim at eliminating conditions that promote a problem (the analysis of CNS and NP roles and responsibilities). Secondary interventions are used to influence the participants and stabilize their reactions (communication and assessment of nurses’ behaviors and changes in healthcare services). The worth of tertiary interventions is to facilitate a refreezing period (after the change is implemented). Being a part of a nursing strategy, this step makes it possible to compare the initial conditions and the results that have been achieved after the merger.
The role of theories in nursing cannot be ignored because they introduce clear and already improved plans on how to improve care, patient outcomes, and nurse practice. There are many theorists who offered their ideas and approaches on how to change nursing practice at different periods of time. According to Smith (2020), nursing is a discipline that strengthens the connection between humans and the environment where services are offered and received. Any nursing theory includes four concepts (also known as metaparadigm) that influence nursing practice according to the principles chosen by a theorist. The concept of person describes a direct recipient of care (patients, families, or communities). Nursing evaluates the attributes and actions of nurses as the main providers of care. Health focuses on the degree of well-being that is promoted, and the environment explains all internal and external factors of care that affect patients. Each theorist has a specific vision of how to care and relationships between patients and nurses are developed. Therefore, the theoretical basis of a project usually includes one particular theory and its relation to the problem.
In this project, Hildegard Peplau’s theory will be used due to its attention to the principles of interpersonal relationships and the importance of learning others’ behaviors to deal with difficulties. The main idea of Peplau is that patients are not objects but subjects, and the responsibility of nurses is to participate with patients not to control (Peden et al., 2020). Nurses should increase patients’ interest in their treatment by means of collaboration, supervision, and effective problem-solving. To succeed in their duties, nurses must have solid background knowledge about how to take care of patients, educate them, and monitor all activities at the bedside and in a setting. The differences between CNSs and NPs are evident in terms of the care they offer to patients. Despite the fact that both professions require high education and experience, nursing procedures vary (“Nurse practitioner vs. clinical nurse specialist,” n.d.). The chosen theory helps a patient promote health and well-being, and the blended role of CNSs and NPs turns out to be a perfect solution and contribution because such nurses would be able to combine research and communication, knowledge and cooperation.
Plan to Introduce Intervention
To fit the needs of patients and the opportunities of healthcare settings, the blended role intervention has to be properly explained and planned. The shifts in the healthcare system and service delivery enhance the importance of the blended nurse role. This intervention is a chance to analyze the already made achievements and the effectiveness of role distributions. When nurses with different backgrounds cooperate with patients, they gather enough information and evaluate a situation to provide a person with the best care services. It is expected that one nurse is trained to perform the functions of a CNS and an NP. This program should help to save time and improve the quality of care by promoting patient satisfaction and a decrease in complaints. The outcomes will be the establishment of trust in nurse-patient relationships, fast reaction to changes in the patient’s condition or behavior, and health education. Instead of bothering a patient by several nurses with different tasks, one nurse takes responsibility for the overall well-being of an individual.
Outcome evaluation is a tool with the help of which researchers determine the level of success of a program. The main goal of this intervention is to improve the quality of care and expand the relationships between a nurse and a patient. As soon as the objectives are defined, it is necessary to measure how the goals were achieved. In the majority of cases, it is enough to ask several questions to participants and executors (e.g., “Have all goals been achieved?”, “What are the main behavioral or organizational changes?”, or “ Are you satisfied with the way the intervention was implemented?”). Finally, the analysis of the results is performed in terms of the chosen theory. It is necessary to investigate if the core concepts of the theory are followed if the intervention is implemented. If positive outcomes prevail over losses or challenges and the quality of health care is improved, the intervention is defined as successful.
As well as any research, this intervention has to include a data collection process. It is necessary to gather and measure information about nurses, patients, and the nature of their relationships. The distinctive feature of this project is the analysis of CNS and NP roles and the effects of its merger on the healthcare system, patients, and the medical staff. In addition to surfing the web and studying the history of blended roles in nursing, the task is to find out what stakeholders think about this idea and what expectations are developed. Therefore, communication with CNSs and NPs is used to identify the readiness of the staff for change, and communication with patients or their families shows the results and positive or negative achievements. The core aspect of data collection in the intervention implementation process is attention to multiple sources of information. There is no need to focus either on advantages or disadvantages only. The blended role of CNSs and NPs has a long history and includes the evaluation of the first regulations that occurred in the middle of the 20th century and recent healthcare system standards.
The choice of research instruments determines the way of how the intervention can be implemented. In this project, the main measurement tool is a questionnaire. This method includes the necessity to create a list of questions that could be answered with dichotomous “yes” or “no” and boxes if a personal opinion or an explanation is required (Solans-Domènech et al., 2019). The purpose of this research instrument is to gather information directly from respondents and those who experience or observe the outcomes of the intervention. Questions may be sent to participants via e-mail or asked face-to-face with a possibility to make adjustments or by telephone/ Skype. Although the response rate of this method is not as high as the one of interviews, its advantages such as cost-effectiveness, anonymity, and uniformity attract people’s attention.
Plan for Evaluation
An evaluation plan contains a number of steps that are critical for implementing the intervention, its monitoring, and goals’ analysis:
- A healthcare setting (or several facilities) is chosen for participation;
- Information about nurse roles, the theory of interpersonal relationships, and blended intervention is gathered;
- CNSs and NPs are invited to take a quick course (a training program) to improve their knowledge in both spheres;
- Patients are divided into two groups (one is to work with nurses who perform the blended role of CNSs and NPs, and another is to work with CNSs and NPs separately);
- Questionnaires are posed to nurses to gather their opinions about the role merger and to patients to compare the quality of care and the level of their satisfaction;
- Data analysis is based on the creation of codes to be added to a grid and calculated;
- An overall evaluation of the intervention and its impact on health care is introduced, comparing the goals set at the beginning and the results achieved in the end.
Evaluation and Discussion
The results of this project would show if the idea to merge the roles of CNSs and NPs is effective for a particular setting or not. Nurses get a chance to improve their knowledge and be able to provide patients with a variety of services within a short period. The blended role would result in the possibility to deprive patients of the necessity to cooperate with several nurses and share the same information. NPs provide care in regard to the evaluation of patient health, develop treatment plans, and cooperate with doctors and families to understand the needs of patients (Cooper et al., 2019). The intention of CNSs is to examine and communicate with patients in order to contribute to the research field. According to Cooper et al. (2019), CNSs are specialists, and NPs are generalists. Therefore, the intervention to combine these roles should not provoke many challenges. As soon as one person can perform several roles, not at the expense of personal health or financial aspects, the blended role has to be a successful intervention. The major lesson from this project is that the merger would be effective if clear theoretical boundaries, practical responsibilities, and duties are defined.
The main limitation of the project is the offered sample. Nurses are free to express their ideas about the blended role of CNSs and NPs, paying attention to their personal attitudes and experiences. Therefore, the answers may be prejudiced and biased. In addition, some nurses or patients may not want to participant in the intervention. Therefore, the number of answers can be limited. The researcher cannot control these aspects, even being theoretically prepared. To predict misunderstandings and biases, the questions should be properly developed and measured.
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