88 ■ I: HISTORICAL AND THEORETICAL FOUNDATIONS FOR ROLE DELINEATION
incorporating nursing diagnosis and management, as well as systems assessment and
synthesis of improved approaches to nursing care. Psychiatric–mental health CNS prac-
tice was a forerunner in extending the focus beyond acute care. In 2000, only about one
third of psychiatric– mental health clinical specialists were practicing in hospital- based
settings, while a majority were practicing in other types of settings, providing a vari-
ety of mental health therapies (e.g., in clinics; private or collaborative practices offering
counseling and/ or psychotherapies; and forensic settings) (Delaney, 2009).
During the 1980s and 1990s, CNS and NP education were similar in some domains—
coursework, caseload, practice strategies— although education and scope of practice for
both were rapidly evolving (Lindeke, Canady, & Kay, 1997). Some suggested that both
CNS and NP clinicians had similar competencies and could overlap in roles and functions.
For example, in acute care or psychiatric– mental health care, some graduate programs
established joint curricular pathways for both CNS and NP education (Elder & Bullough,
1990; MacDonald et al., 2006; Page & Arena, 1994). However, regulatory authority over
CNS titling practice is a relatively recent innovation. Clinicians working as CNSs typically
were not required by hiring organizations to have specific preparation in the role until late
in the 20th century. Many nurses functioned as CNSs based on their clinical experience
and expertise, without formal education preparation or certification in the role. In the
1990s, only about half of state nursing boards had statutes or regulations governing CNS
scope of practice (Hudspeth, 2009). There remains wide variation at the state level in title
protection, regulation, and scope of practice for the CNS. The consensus model for APRN
practice, discussed subsequently, clarifies current and future vision for overlap and dif-
ferences in education, licensure, regulation, and scope of practice for the CNS and other
APRN clinicians, and, importantly, provides for uniform treatment and regulation of CNS
scope of practice at the state level.
■ UNIFICATION OF APRN EDUCATION, REGULATION, AND PRACTICE
Professional and regulatory organizations continued to move toward a cohesive
approach relative to the preparation of advanced practice nurses for entry into prac-
tice, and toward a unified vision of the scope of advanced practice nursing in general.
Lewis (2000) notes that, in 1992, both the ANA and the NCSBN took similar positions
regarding the need for advanced practice nursing education (with advanced practice
nursing defined as NP, nurse anesthetist, nurse- midwife, and CNS) to be situated only
at the graduate level, and made an initial effort to create a regulatory model (NCSBN,
1998). As nursing professional organizations began to take similar positions regarding
advanced nursing practice and advanced nursing education, the transition of certificate
programs preparing advanced practice nurse clinicians to formal graduate- level pro-
grams accelerated.
In the 1990s, the AACN convened a national group representing multiple organ-
izations and specialty stakeholders for the development of consensus guidelines for
advanced practice nursing education at the graduate (master’s) level: The Essentials of
Master’s Education for Advanced Practice Nursing (AACN, 1996). This document recog-
nized only four types of clinicians providing direct, advanced patient care as advanced
practice nurses: nurse- midwives, nurse anesthetists, NPs, and CNSs. It specified clearly
that education for advanced nursing roles should occur at the master’s level. The
National Task Force for Quality Nurse Practitioner Education, comprised of represent-
atives from a variety of organizations, including the AACN, National Organization
of Nurse Practitioner Faculties (NONPF), NP certifying bodies, and a variety of other