This letter is in response to the articles in the "Online Journal of Issues in Nursing" addressing the debate over advanced practice nursing. I am currently enrolled as a graduate student to become a Community Health Clinical Specialist with a maternal child focus. Therefore, this debate is informative as well as having an impact on my career following graduation.
I am in total agreement with Marie-Annette Brown's article titled, "Primary care nurse practitioners: Don't blend the colors in the rainbow of advanced practice." Her opinion that the health care system would be better served by "creating and supporting" a variety of advanced practice roles based on the needs of the present health care system, legislation to empower those in advanced practice roles that have successfully provided primary care and "design incentives and strategies to create a rainbow coalition" to enhance collaboration among all the advanced practice nursing specialties is the way to go. Stop the debate of merging the two diverse, but equally valuable, advanced practice roles of Nurse Practitioner and Clinical Specialist into one, and broaden our horizons as a profession, to serve those areas of health care best served by the skills of these two areas of practice.
In maturing in my role as a nurse, later educator, and now as a student, I have come to a crossroads in my career. First, I have undertaken the task of working toward a degree in advanced practice nursing. Second, I chose this path primarily because I no longer felt I had a significant influence on patients' health care choices in the acute care hospital setting; by then it was often too little too late. Further, I felt I had no influence whatsoever on health care policy or reform. Finally, I felt my purpose as a nurse devoted to improving maternal child health would be better served by furthering my education and gaining a better understanding of what influences maternal/child health policy, program development and evaluation, community assessment and research. My eyes have been opened to the politics and economics of health care in this country by way of my education. In some ways it is frustrating, but by the same token, it is extremely liberating to feel I may be able to influence change in some way. With knowledge comes power, with power comes responsibility, the responsibility to apply your knowledge and power effectively, efficiently and thoughtfully. In my opinion this can be done very effectively by utilizing the unique and equally important advanced practice roles in nursing.
The struggle for autonomy and recognition of advanced practice roles persists. My school has chosen, like so many graduate schools of nursing have, to focus on advanced practice roles such as the Family Nurse Practitioner and the Clinical Specialist in Community Health roles in an effort to better meet the needs of its students, but more importantly the health care needs of a large rural state. The advanced practice role of Family Nurse Practitioner in Wyoming has been a widely accepted position in underserved areas of the state. The Community Health Clinical Specialist role is relatively new here, but potentially effective in managing public health programs, home health case management, and contributing to the creation of more diversification of the acute care setting so that it can serve the community as client.
In a recent article, "Family health care delivery for the 21st century (Cox, 1997), the issues of the changing demographics of the population as we near the year 2000, and how those changes will effect the delivery of health care, health care policy and research were considered. The reality that less than 25 percent of the population will be between the ages of 5 and 23, speaks to a shift in the provision of services to a larger population of older adults, the aging "Baby Boomers." Other factors such as structural diversity in composition of families, more single parent families, women as head of household, and the economic trends in financing health care, captitation and cost shifting, have profound implications for the health care system as well as nursing. A paradigm shift from dealing with acute illness in younger populations, to more chronic conditions in an older population must also be addressed. The need for the distinct abilities and services provided by the Family Nurse Practitioners and Clinical Nurse Specialists will be even more necessary in the future than they are now. Cox (1997) supported this with her statement concerning the "need to develop comprehensive and collaborative family care that includes medical/mental health professionals, schools, the workplace, and government programs" as well as emphasizing health promotion and disease prevention "outside the walls of academic health centers" (p. 115).
The role of the Family Nurse Practitioner focuses on individual client needs regarding health promotion, primary prevention, assessment, diagnosis and application of alternative therapies. The Clinical Nurse Specialist is more specialized and focuses on health promotion and primary prevention in the community as client or customer. Cost reduction through early hospital discharge and home healthcare, cost reduction through case management, cost-benefit analysis via program evaluation, and application of research based nursing care that is provided by the Clinical Nurse Specialist to a more diverse population are also necessary (Lyon, 1996). Obviously these two distinct and highly specialized roles should remain distinct; yet by combining their unique abilities, the needs of the family in the 21st century will be better served.
Esther Ann Gilman-Kehrer, RNC, BS, CLE
Masters Student, Community Health Clinical Specialist
University of Wyoming, School of Nursing