Possible new career options

AORN Journal,  May, 2005  by Nancy J. Girard

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The nursing profession continues to confuse itself and the rest of the world with who we are and what we do. Just when we get used to the career options and titles available--and you must admit there are a lot of them--along come two more that presently are being discussed: clinical nurse leader (CNL) and doctor of nursing practice (DNP). The CNL is a new title and role. The DNP is not really a new role, but it has a new focus. These career options are being investigated and promoted by the academic community with buy-in from practicing institutions.

BACKGROUND

Last summer, I attended an invitational meeting in Washington, DC, sponsored by the American Association of Colleges of Nursing (AACN). The purpose of the conference was to hear a presentation and obtain buy-in for partnership pilot programs for the CNL. In addition, some information was shared on career progression from CNL to DNP. Representatives from 75 academic institutions attended along with representatives from their partner health care institutions.

The concerns that prompted development of these new roles are similar to those identified by the recent AORN and National League for Nursing think tank. (1) New types of nurses are needed in today's world. The nursing profession agrees that changing patient populations and treatment methodologies require new ways of practicing nursing and, therefore, new ways of educating nurses. The AACN recognizes that there is national concern about a decline in the quality of health care. Many of us can confirm these concerns with examples from our own experiences and those of our family members and friends. In addition to concerns about the quality of care, nursing has never come together to define the differences in practice between individuals with different educational preparation or agreed on one educational entry level for practice. To answer these concerns, an AACN task force proposed the new CNL master's level degree. This new practitioner will not be an advanced practitioner, and a new license and legal scope of practice will have to be defined for this role. (2) More information about the CNL role can be found on AACN's web site at http://www.aacn/nche.edu.

CLINICAL NURSE LEADER

The AACN defines a CNL as a master's prepared nurse who

   leads evidenced-based
   care for patients and
   families, creates an environment
   of clinical excellence,
   has clinical
   responsibility and authority
   for decisionmaking
   regarding patient
   care, and engages in peer
   practice with other health
   professionals. (3)

This may be an entry-level position, and the CNL will be a unit-based generalist. The CNL role will not include administrative or management duties. It will necessitate new definitions of practice and new legal requirements, such as licensure.

There are many areas of the country where academic institutions already have implemented educational programs for CNLs. These include the University of Virginia, Charlottesville, Va; College of New Jersey, Ewing, NJ; Cleveland State University, Cleveland; University of Florida, Gainesville, Fla; University of San Francisco, San Francisco; and University of Iowa, Iowa City. Information about these and other programs can be found on the web sites of these organizations.

Debate is growing about the CNL role. (4) Some organizations support the concept and others adamantly oppose it. One organization that supports the CNL role is the American Organization of Nurse Executives (AONE). The organization published guidelines with principles for patient care in spring 2004 that are similar to those defining the role of the CNL. (5)

The National Association of Clinical Nurse Specialists (NACNS) has published a strong position statement against the CNL role. They state in part that "the proposed competencies of the new nurse duplicate the competencies of the CNS." (6)

DOCTOR OF NURSING PRACTICE

The DNP is a practice doctorate rather than a research doctorate. (7) The research PhD is considered the "gold standard" of doctoral education. Most national and international organizations recognize this degree and accept it. Other less recognizable doctoral degrees are EdD (ie, doctorate in education), DNS (ie, doctorate in nursing science), and ND (ie, nursing doctorate). The DNP would replace the ND as a practice doctorate. The National Organization of Nurse Practitioner Faculties (NONPF) provides information on the practice doctorate resource center web site at http://www.nonpf.com/cdhome.htm. (8)

Case Western Reserve University, Cleveland, is one university that offers the DNP. A position statement from AACN says that the DNP should be the graduate degree for advanced practice nursing preparation

   including but not limited
   to the four current [advanced
   practice nurse]
   roles: clinical nurse specialist,
   nurse anesthetist,
   nurse midwife, and nurse
   practitioner by 2015. (9)

CONTINUING DEBATE

There will be much discussion and debate in the future about these two new roles, and many questions will need to be answered. The major issues to be determined are whether other health care professionals and administrators will recognize and support these new roles, and whether patients and their family members will understand who these nurses are and what their role is. The following questions also will need to be answered.