ADVANCED PRACTICE NURSING ROLES: NP vs. CNS Advanced Practice Registered Nurse Roles

The United States is home to nearly a quarter of a million advanced practice registered nurses (APRNs). Of these, the vast majority chose to pursue a Master of Science in Nursing (MSN) leading to licensure as a nurse practitioner (NP). The second most common choice is an MSN program leading to certification or recognition as a clinical nurse specialist (CNS). Both pathways provide the preparation necessary for greater responsibility and autonomy as a medical professional. NPs make the transition from care provider to care prescriber, while CNSs become the best-practice experts for their healthcare organization. The care settings are distinct, as well, with many NPs practicing in underserved rural communities and inner-city neighborhoods and CNSs practicing in hospitals and extended-care facilities. To better understand the similarities and differences in NP and CNS roles this essay will examine in detail what is known about these two professions.

Advanced Practice Nursing Roles: NP vs. CNS

As of March 2008 there were approximately 3 million licensed registered nurses (RNs) living and working within the United States according to the Health Resources and Services Administration (HRSA, 2010, p. xxvii). Of these, the Associate Degree in Nursing (ADN) was the most common academic track into nursing, while another 34% had attained bachelor's or graduate degrees. Diploma programs available through some hospitals were the least common, with approximately 20% of the RN population having attained licensure using this mechanism. Despite the cost and commitment required to complete an advanced degree in nursing, close to 250,000 RNs reported having done so in 2008 (HRSA, 2010, p. 5-1). These Advanced Practice RNs (APRNs) acquired the skills and credentials necessary to transition from providing to prescribing patient care. This shift brings with it a substantial increase in responsibilities, including ordering diagnostic tests, prescribing medications, and performing minor procedures.

The four most common APRN professions are nurse practitioners (NPs), clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), and certified nurse midwife (CNM) (HRSA, 2010, p.5-1, 5.2). The number of RNs in each profession will change from year to year, due in part to need and the availability of academic programs. Between 2004 and 2008, NPs increased in number from 123,000 to 139,000, while CNS declined from 57,000 to 42,000. CRNAs increased slightly from 31,000 to 34,000, but CNM increased substantially from 10,000 to 15,000. These statistics represent the number of APRNs who reported preparation for only one of these professions, but a sizeable proportion had received preparation for both NP and CNS (16,000). This brings the total number of NPs and CNSs in 2008 to 156,000 and 59,000, respectively. A much smaller number reported combined preparation for other APRN professions (< 3,000).

Since NP and/or CNS represent the most common choices among RNs seeking advanced practice preparation this essay will review and contrast the roles for these two professions. A number of different sources will be utilized for this information, including peer-reviewed publications, professional nursing organizations, and government agencies. This strategy is intended to provide a consensus view of these two nursing professions. In addition, the academic requirements and practice settings for each profession will be examined in detail to help with the comparison, with the assumption that the roles of each can be better understood by examining the academic pathways to licensure and practice setting choices.

NP Preparation

The NP profession is probably the oldest of the four common APRN professions, having emerged as doctors and nurses collaborated to provide patient care in underserved communities during the early part of the 20th century (HRSA, 2010, p. 5-1). The first academic program for NPs was established at the University of Colorado in 1965, with a focus on health promotion and pediatric care. Early NPs typically found themselves working in rural health clinics and low-income inner city neighborhoods where physicians were rare and overburdened with patients. The historical roots of the NP profession are still evident in care settings where NPs can be found today, including family, adult, and pediatric medicine (American Association of Nurse Practitioners, n.d.). In addition, close to 18% of licensed NPs practice in small rural communities with populations below 25,000. This is most evident in states having regulations that welcome NPs as primary care providers, including Vermont, Main, Wyoming, South Dakota, and Montana. In these states, an estimated 40 to 60% of licensed NPs practice in rural clinics. By comparison, the State of Texas has restrictive regulations requiring physician supervision and only 13% of licensed NPs practice in the vast rural expanses of this state.

The most common academic pathway to licensure is a Master of Science in Nursing (MSN), although...

Completion of an MSN can take anywhere from 1.5 to 3 years, depending on whether the APRN student had attained an ADN or BAN/BSN previously. Post-graduate clinical training, however, will extend the time required for meeting NP licensure requirements p to 7 years. Compared to physicians, however, NP preparation does not have a residency requirement. Of those who complete NP preparation and become licensed to practice in their respective state, 70% will reenter the workforce as NPs (HRSA, 2010, p. 5-8, 5-9, 5-12). Another 11.4% will become staff nurses, while 13.7 will hold either management or teaching positions. Of those who reenter the workforce as NPs, 64% work in primary care. Of these, 84, 60, 47, and 34% work in ambulatory care, school health, public health, and hospital settings, respectively, with considerable overlap between these settings. Some of the other specialties within which NPs practice include critical care, trauma, surgical, gynecology, obstetrics, mental health, and chronic care.
The transition from RN to NP provides some insight into NP roles. Probably the most obvious is the transition from care provider to care prescriber (Barnes, 2014). While this transition is a prominent rationale for pursuing NP credentials, the additional autonomy and responsibilities associated with the role of NP can sometimes cause newly-minted NPs to question the wisdom of their choice (Barnes, 2014; American Association of Family Physicians, n.d.). Unfortunately, a few NPs will never fully transition to the role of NP for a variety of reasons, including insufficient moral and structural support from colleagues, mentors, and employers.

Rural NP Roles

The needs of rural patient populations are somewhat distinct compared to their urban counterparts (Schmidt, Brandt, & Norris, 1995). The rural elderly tend to live longer, but longevity brings higher levels of chronic disease. Injury and death due to accidents is more common and rural residents tend to ignore health issues during peak periods of seasonal work. The value of industriousness is so prevalent in rural communities that NPs seeking to establish a successful rural practice must take this into consideration. The other considerations that define rural NP practices are isolation, geographic distance, increased autonomy, patient autonomy, patient frugality, reimbursement difficulties, and barriers related to provider 'outsider' status. Accordingly, NPs are encouraged to foster a positive public image through civic engagement and promote a public health agenda that seeks to improve the quality of prenatal and elderly care, in addition to reducing transportation-related injuries and death.

NPs working in rural settings must also find a balance between providing medical services for family members and friends, while at the same time protecting patient confidentiality (Schmidt et al., 1995). Studies that have examined the roles of NPs in rural settings have found that disease detection, chronic disease management, disease prevention, health promotion, patient teaching, and lifestyle counseling figure prominently. Although NPs are not physicians, between 50 and 90% of the primary care services typically provided by a physician are available from NPs. Collaborative arrangements with area physicians, clinics, and hospitals allow most NPs to provide complete primary care services within the practice setting and through referrals.

Hospital-Based NPs

Over half of all the registered NPs in Canada work within the Ontario Province (Van Soeren, Hurlock-Chorostecki, & Reeves, 2011). A study using a focus group design examined the roles of NPs within hospital settings and found that 46, 30, 8 and 7% of an NPs' time was spent in clinical practice, engaging in collaborative care teams, fulfilling leadership roles, and conducting research, respectively. The relative contribution from each of these activities was influenced to some extent by the nature of the hospital setting. For example, NPs working in adult community hospitals spent more time in clinical practice, whereas NPs staffing university teaching hospitals tended to allocate more time for research. A few of the clinical activities NPs engaged in included charting, patient assessment, ordering diagnostic tests, prescribing medications, performing special procedures, discussing care plans with patient and family members, making referrals, and conducting patient follow-ups. Care team participation involved making referrals, conducting rounds, developing care plans, improving care quality, teaching, and responding to communications from team members. The leadership roles included patient advocacy, mentoring nurses, evaluating programs, organizing rounds, and acting as professional representatives within and outside the organization. The research activities included poring through the research literature, writing grant proposals, conducting clinical research, implementing best practice guidelines, and data collection/analysis.

CNS Preparation

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