DISTINGUISHING THE CLINICAL NURSE SPECIALIST AND THE NURSE PRACTITIONER

The origins of Advanced Practice Nursing as discussed in Chapters 2 and 3 provide historical backgrounds for the CNS and NP, noting differences in stages of early development. The emergence of Advanced Practice Nursing worldwide and the introduction of the concepts of the CNS and APN have resulted in robust discussions attempting to identify the distinguishing characteristics of these new roles and levels of nursing practice. Since the mid-1990s (Dunn 1997) and with more recent and parallel development internationally, the definitive characteristics of the CNS and NP have become blurred. Despite this, the two roles remain largely distinct, albeit with some overlap (Rushforth 2015; Tracy & Sendelbach 2019). This section endeavours to distinguish and clarify traits representative of the CNS and NP.

The CNS is an expert clinician with a specialised area of practice identified in terms of population, setting, disease or medical subspecialty, type of care or problem that includes a systems perspective to provision of healthcare services (NACNS 2018). The focus of NP practice emphasises a population focus mainly in PHC but that now includes both acute care and PHC (AACN Certification Corporation 2011). Bryant-Lukosius (2004 & 2008) clarified the essential distinctions between the CNS and the NP through an Advanced Practice Nursing continuum model, emphasising how the CNS focuses more on indirect care supporting clinical excellence from a systems approach while the NP focuses more on direct patient care within diverse clinical settings.

Source: Bryant-Lukosius, D. (2004 & 2008). The continuum of Advanced Practice Nursing roles. Unpublished document.

A recent national study comparing CNSs and NPs in Canada lends support to the above illustration (BryantLukosius et al. 2018). Results from this study demonstrated that while there are many common features, the main differences between the CNS and NP is related to greater CNS involvement in non-clinical (indirect) activities related to support of systems, education, publication, professional leadership and research. Involvement in direct clinical care was high for both the CNS and NP, but differences in scope of practice were reflected in greater NP involvement in diagnosing, prescribing and treating various conditions or illness. Similar to these findings, additional studies (Donald et al. 2010; Carryer et al. 2018) highlight that NPs engage in direct care activities to a greater extent than CNSs.

4.1  ICN Position on the Clarification of Advanced Nursing Designations

Increasingly, countries are undergoing healthcare reform with system changes that include introducing advanced roles and advanced levels of practice for nurses. These dynamic changes in the perception of how nurses provide care require the interface between what is identified as ‘traditional’ nursing and the medical profession. In addition, this transformation requires suitable education, policy and regulation supportive of APNs (CNSs and NPs) to practice to the full potential of their education. Although enthusiasm for APNs such as the CNS and NP has increased, the available data to accurately depict APN initiatives still remains limited thus hampering full recognition of APN presence worldwide. Data that is available demonstrates wide variation in numbers of APNs and their practice settings with literature mainly dominated by English language publications originating from economically developed countries.

It is the intent of this guidance paper to promote continued dialogue of the concept of Advanced Practice Nursing while also seeking consistency in how APNs are identified and integrated into healthcare systems internationally. Not only do educational programmes need to be specific to the designated APN (e.g. CNS or NP) but relevant policies and a professional standard are required to promote the inclusion of sustainable advanced nursing roles into routine healthcare service provision.

To support future potential for the CNS and NP, there is a need to continue to:

• promote clarity of CNS and NP practice

• identify how these nurses contribute to the delivery of healthcare services

• guide the development of educational curricula specific to the CNS and NP

• support these nurses in establishing advanced practice (CNS or NP) roles and levels of practice

• offer guidance to employers, organisations and healthcare systems implementing the CNS and NP

• promote appropriate governance in terms of policy, legislation and credentialing

In an effort to offer clarity for these two categories of nursing, ICN offers Tables 3, 4 and 5 to identify similarities and distinguishing characteristics of the CNS and NP.