I was disappointed with the article Perioperative clinical nurse specialist role delineation: a systematic review" (December 2006, vol 84). I am presently a clinical nurse specialist (CNS) in the perioperative setting and know this role from a very personal perspective. I would agree that the role has not been delineated as clearly as I would like and that many people both inside and outside of the perioperative setting do not understand the CNS role. There are some misconceptions that have been portrayed in the article, however, that provide substantiation and validation to incorrect information in the national forum provided by this publication.
There are several areas of inaccurate information to which I take exception. My first and greatest concern is the statement made in the article that CNSs and nurse practitioners (NPs) have similar roles. I am not an NP, but I understand that most NPs define their role as medical diagnosing, prescribing medication, and providing direct patient care. The NP role is clearly needed in order to increase access to the health care system for patients in need, and at times, I feel the role is performed better by an NP than by a physician.
A CNS, however, is very different than an NP. My role as a master's-degree prepared CNS is to be the clinical expert who practices nursing in a specialty area identified in terms of a population, setting, disease, type of care, or type of problem. (1) I find the suggestion of merging the NP and CNS roles to be an affront to both roles. They are different, both are much needed, and both provide strength to the provision of patient care. The authors state that the major benefit of merging the two roles would be an increased validation of the CNS role, but in the same paragraph, they state that the NP works in the medical realm and the CNS works in the nursing realm. How can you merge two practices that work in different realms?
In the results and findings, the authors stated that
the perioperative CNS
was shown to affect the
surgical environment
through activities such as
advocating for patients,
collaborating with surgeons,
consulting for
nursing staff members,
precepting, assessing
patients both physically
and culturally, and offering
clinical insight. (2(p1022))
They then go on to state that this versatility leads to ambiguity. It is my opinion that this versatility leads to good patient outcomes through the provision of advanced practice nursing care.
The authors also state that regulatory inconsistency from state to state leads to confusion and varying roles for CNSs. Of note is the fact that state boards of nursing also have inconsistent regulations for NPs. It is my opinion that this problem would not be solved by combining the two roles, it would just be exacerbated. In that same paragraph, the authors say that several states fail to recognize a CNS as an advanced practice nurse (APN). Oregon is listed as a state that fails to recognize the CNS. I practice in Oregon, and I am recognized and title-protected because I have a separate certificate as a CNS. The Oregon State Board of Nursing, Nurse Practice Act, Division 54, defines a CNS as an advanced practice nurse. (3)
Not all of my comments about the article are negative. I agree with the authors that the current health care climate is ready for growth and that the perioperative CNS provides a needed dimension of advanced practice nursing. I also agree that CNSs need to work with the National Association of Clinical Nurse Specialists and AORN to develop clear expectations of the role of the perioperative CNS. AORN has APN competency statements that, unfortunately, blend the two roles. (4) I would be a strong advocate of supporting the American Nurses Credentialing Center in the creation of a certification examination for all CNSs.
In closing, I want to say that although there are problems with the role delineation of the perioperative CNS, the best way to solve the problem is not to combine the CNS role with the NP role but to define the two roles and clearly delineate the differences. A CNS provides expert nursing care as defined by and through nursing terms and not as defined by medical terms. Yes, there will be some crossover in the roles, but the differences are what define the two roles not the similarities.
(4.) Perioperative advanced practice nurse competency statements. In: Standards, Recommended Practices, and Guidelines. Denver, Colo: AORN, Inc; 2007: 97-124.
Authors' response. We would like to say a few words that may help to clarify this issue. Let us begin by stating that this article was, as it is titled, a systematic review of the literature comprised of 859 articles. The information presented is the published fact and opinion of many other authors over the years and in various regions without the current authors' personal perspective. We forced ourselves to step back and present not what we may have personally thought but what the literature holds for nursing on this topic. This article should serve as a basis for research to go forward and either support or contest the statements about the relationship between the CNS and NP roles. Evidence-based research is needed to clear the air.
Role confusion was clearly evident in the articles about the CNS and NP. We found the sides of the debate were clearly defined even though the roles were not. Although you see a clear distinction between the roles and competencies, the literature revealed that many people do not. In the literature, the similar educational preparation as well as the extreme versatility of the CNS and NP have led organizations to blend the roles or let the individual person define the role in his or her position. Organizations may have an NP seeing patients three days a week and working on system-oriented problems on other days. They also may have the same NP act as the office manager and fulfill CNS functions. In the name of patient safety and patient advocacy, these nurses fulfill the position that the organization has defined, a blended role of an NP and CNS utilizing both realms of practice. We do not deny that the versatility of the CNS and NP has offered improved patient outcomes, but it also has led to ambiguity by organizations about these roles. We as authors are not condoning this action, only stating that it is happening.
We are grateful that the state of Oregon has recognized the CNS as an APN. Our search revealed the American Nurses Association (ANA) documentation of APNs and the states that recognize them. Unfortunately, the three references in our article showed that Oregon did not recognize the CNS as an APN. The search criteria described in the article did not provide the Oregon State Board of Nursing web site in our results. Thank you for this information update, and we hope the ANA has or will publish an updated roster as well.
We hope that we have clarified how our article was presented. It is the opinion of the authors that the CNS and NP roles should not be blended, and additional research needs to be performed to facilitate evidence-based decisions and role definition. This reader has demonstrated that he has clearly defined his role and separated it from the perceived NP role. This supports our statement that "CNSs must define their roles in an organization or risk having their roles defined for them."
LCDR DENNIS E. GLOVER
RN, MSN, MBA/HCM,
CNOR, NC, USN
DEPARTMENT HEAD OF PERIOPERATIVE SERVICES
NAVAL HOSPITAL OAK HARBOR
OAK HARBOR, WASH
LTC LAURA E. NEWKIRK
RN, MSN, CNOR, AN, USA
CHIEF OF PERIOPERATIVE NURSING SERVICES
WINN ARMY COMMUNITY HOSPITAL
FT STEWART, GA
MAJ LISA M. COLE
RN, MSN, CNOR, USAF, NC
PERIOPERATIVE CNS
96TH MEDICAL GROUP
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