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), certified nurse-midwives, and certified registered nurse anesthetists are identified as advanced practice nurses. The nurse who functions 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, rehabilitation, 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 educational preparation of nurses, although functions are less distinct than in previous years. In medical-surgical nursing, the most significant
of these titles are nurse practitioner and clinical nurse specialist, and the more recent title of advanced practice nurse, which encompasses 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 components, 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 provision 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 practice within a circumscribed area of care (eg, cardiovascular CNS, oncology CNS). They define their role as having five major components: 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 background and the clinical expertise to organize and coordinate services 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 previously restricted to the practice of medicine. These functions include diagnosis (nursing), treatment, performance of selected invasive procedures, and prescription of medications and treatments. 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 anticipatory guidance are all becoming increasingly important in nursing practice. Advanced practice roles enable nurses to function interdependently 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, responsibility, and recognition.