Professional Documents
Culture Documents
Jurnal Farma PDF
Jurnal Farma PDF
KEYWORDS
Clinical nurse specialist Public health LACE population categories
Advanced practice registered nurse Population-focus
KEY POINTS
Advanced practice community and public health nurse specialists possess specialized
knowledge on the family and individuals across the life span.
It is critical that we retain and promote certification examinations which allow advanced
public health/community/population-focused nurses to be board certified.
Certification of a clinical nurse specialist for the individual/family across the life span and
community with a focus on public health nursing should be explored.
The purpose of this article is to address the need for continued certification of commu-
nity and public health nurses at the advanced practice registered nurse (APRN) level,
and to explore curricular avenues and policy recommendations with regard to certifi-
cation and education of these nurses. The transformation of health care and burgeon-
ing access to information has changed what the public expects and needs from health
professionals. Nursing roles have expanded and transformed, in turn requiring that the
education, licensure, certification, and accreditation of the professional likewise
change. A plethora of policy documents and guiding papers relevant to graduate
education in nursing and to APRN licensure and certification summarize, direct, and
guide nurses and educators. Some of those documents are listed in Table 1.
Since this paper was submitted for publication, the Quad Council has initiated a nationwide
survey of public health nurses related to certification and launched All Out for Excellence:
Certification and Degree completion for PHNs, a campaign to encourage certification.
Findings of that survey and the campaign are not reflected in this article, but the authors
are hopeful that certification options will be retained.
a
College of Nursing, Washington State University, 14204 Northeast Salmon Creek Avenue,
Vancouver, WA 98686, USA
b
College of Nursing, Washington State University, PO Box 1495, Spokane, WA 99210-1495,
USA
* Corresponding author.
E-mail address: Doutrich@vancouver.wsu.edu
DEFINITIONS
Advanced practice implies a higher level of expertise attributable not only to experi-
ence but also to education in a particular field. Advanced practice registered nurses
(APRNs) have been defined as registered nurses who have education beyond a basic
nursing education and who are certified at the national level by a recognized profes-
sional organization in a nursing specialty or at the state level, based on criteria estab-
lished by a state Board of Nursing.1 There is general agreement that recognized APRN
roles are the certified nurse midwife (CNM), the certified registered nurse anesthetist
(CRNA), the certified nurse practitioner (CNP), and the clinical nurse specialist
(CNS).2,3
CNS practice is conceptualized as core competencies in 3 interacting domains
called spheres of influence: those of the patient/client, nurses and nursing practices,
and organizations and systems.4 Advanced practice nursing historically has included
the population-based, community, and public health clinical nurse specialist. Masters
and/or doctorally prepared graduates of public health or advanced population health
nursing whose programs met curricular requirements were eligible to sit for the
national examination and able to be certified as CNSs. The patient/client domain for
the CNS role was considered the population or community.5
Table 1
Policy documents and guiding papers relevant to graduate education in nursing and to ARPN
licensure and certification
not imply a specialty based on where care occurs. Instead, no matter what the label,
they denote an advanced practice based on specialty sciences focused on
improving populations health, and informed by the social justice foundations of
public health.
In the past, nurses with masters degrees in community or public health nursing have
found a niche within the community/public health CNS role.8,9 Logan8 surveyed the
209 CNSs certified in Community Health by the American Nurses Credentialing Center
(ANCC) with a response from 111 of these individuals, and found that 35% described
themselves as educator; 22% defined their roles as administrator/leader; 21% were
clinicians; 14% considered themselves consultants; and 8% described themselves
as researchers. Logan concluded that the Community Health CNS was a viable,
sought after, and satisfying professional certification. Implications were that schools
of nursing should continue to offer the specialty, with more emphasis on the CNSs
3 spheres of influence.
Most of Logans CNS responders were not working in the public health arena;
rather, 41% of these CNSs reported their primary job title to be professor, instructor,
faculty, or administrator of a nursing program. Other titles included disease interven-
tion specialist, executive director of hospice, Community Health nurse epidemiologist,
HIV clinical specialist, home health administrator, public health program manager,
coordinator of cardiac education, health advocate, consultant, occupational health
nurse, school nurse, and diabetes APN.8(p46) It is important to recall that public health
workplaces rarely remunerate for certification, whereas certification may be valued in
an educational or institutional role.
Acknowledging nurses with masters degrees in community/public health nursing
have advanced knowledge and skills to manage the health of populations and com-
munities,(p250) Robertson and Baldwin9 conducted a qualitative study designed to
describe the role of the advanced practice community/public health nurse specialist
(C/PHNS). Their purposive sample of 10 nurses were working in a variety of commu-
nity health settings, and were both interviewed and observed. Practice settings for
their sample included local and state health departments, visiting nurses associa-
tions, schools, and charitable health-related associations. Job positions included
school nurse, case manager, consultant, program manager, and administrator.9(p251)
Robertsons and Baldwins participants, like Logans, described a variety of prac-
tice sites that were not easily lumped into traditional public health settings. Their
findings included 6 advanced practice role characteristics for these participants
including leadership, management, consultation, partnership building, large-scale
program planning, and advocacy and policy setting. In addition, a big-picture
perspective of practice was an overarching theme in all role categories. One of their
participants put it this way:
.Having advanced practice nurses in the community is a role that nursing cannot
value enough. I dont think that nurses appreciate how important [this role is]
after all, nursing began in the community. .The impact that an [advanced prac-
tice] community health nurse makes in the community is not episodic. Its popu-
lation based and I dont think we value enough the fact that if you stop disease
transmission in 4 people youve affected 25,000 lives.9(p254)
There have been numerous efforts to clarify the education, designation, and roles of
APRNs. One of the most extensive and far reaching was a consensus process, which
was designed initially with funding from the Division of Nursing in the Bureau of Health
Professions, Health Resources and Services Administration, US Department of Health
and Human Services; the consensus process is described in the final report. The
process was used to assure broad and meaningful input by nursing organizations
and partner organizations, and included a series of meetings beginning in 2003. The
process culminated in a proposal titled The Consensus Model for APRN: Licensure,
Accreditation, Certification & Education, which was published in July 2008.2 The
model defines advanced nursing practice, describes specialty areas and titles, and
proposes a regulatory model for advanced practice registered nurses, linking the
efforts of state licensing boards, accrediting and certifying bodies, and educational
organizations.2 The Licensure, Accreditation, Certification and Education (LACE)
model requires that in addition to receiving education for a particular role (CNM,
CRNA, CNS, and CNP), APRN students must also receive education focusing on at
Future of Public Health CNS 309
.cannot get hot and bothered about whether the so called 3 Ps are required.
Nurses are nurses, even if they practice at the population level. The public expects
us to know anatomy and physiology; they have every right to expect us to
Future of Public Health CNS 311
This statement comes at a time when the IOM Future of Nursing is emphasizing the
importance of population-based health promotion and disease prevention, and when
the United States is struggling to reform the health care system and emphasize
prevention. The ACHNE Crossroads report identified critical content areas for
advanced practice nurses including, but not limited to, those in the public health
arena.6 The IOM report and the AACNs Essentials for Masters and Doctoral Educa-
tion also state that advanced practice nursing education includes the same critical
content areas identified in the Crossroads report, including population-centered
nursing theory, interdisciplinary practice, leadership and systems thinking, biostatis-
tics, epidemiology, and health policy for all advanced practice nurses, not just public
health.11 Acknowledging those specialized role characteristics, knowledge, and skill
sets identified by Robertson and Baldwin, public and community health nurses
need to be able to continue to pursue advanced practice degrees to develop
a wide-ranging and thorough depth of knowledge regarding systems theory, epidemi-
ology, biostatistics, and health policy development aimed at reinventing the health
care system.9
Nursing and nurse leaders must assume responsibility to implement the LACE model
while also assuring that graduate nurses enter the workforce able to address the
health care needs of the population. The LACE document allows that new specialties
emerge based on health needs of the population.2(p11) Although the advanced pop-
ulation and public health specialist is not a new role, it is one geared to well address
the needs of the population.2
The Future of Nursing report emphasizes the importance of using nurses to the full
extent of their education and the importance of integrating population-based informa-
tion in all curricula. The complex and sophisticated specialist knowledge and experi-
ence held by advanced practice population-focused, community, and public health
nurses must be honored.
The distinction between direct and indirect nursing does not serve the profession or
the nations health needs well. The Masters Essentials document distinguishes
between the provision of direct and indirect care by nurses, defining direct care as
. nursing care provided to individuals or families that is intended to achieve specific
health goals12(p33) or outcomes that can be delivered in a variety of settings. Indirect
312 Doutrich & Dotson
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