108chapter THREE
Refl ective Response 2
Patti Rager Zuzelo
The authors correctly describe the historical “roots” of the clinical nurse specialist
(CNS), nurse practitioner (NP), nurse- midwife, and nurse- anesthetist roles. However, it
is critical to understand the important contrast between CNS role origins as compared
to the genesis of other roles. Midwifery, anesthetist, and practitioner roles evolved from
unmet public needs often in response to a lack of medical care and, many times, were
birthed in practice models informed by medicine or by other non- nursing influences.
These origins are in sharp contrast to those of the CNS role, a role uniquely grounded in
professional nursing.
The term clinical nurse specialist was first used in 1938 (Peplau, 1965/ 2003), and
the initial role description of CNS as an advanced practice nurse with expertise in
nursing practice in the care of complex patients is credited to Dr. Hildegard Peplau
(National Association of Clinical Nurse Specialists [NACNS], 2004). These under-
pinnings contribute to the significant differences found in the subsequent histories,
practice barriers, regulatory challenges, and practice domains between advanced
practice nursing roles.
Specialization is not unique to the CNS but is a hallmark of this role. The first
edition of the Nursing’s Social Policy Statement (American Nurses Association [ANA],
1980) described a CNS as a registered nurse holding a master’s degree in nursing with
a clinical focus. These clinical foci or areas of specialization often develop along lines
of new knowledge, public needs and demands, nurse interests, and available opportu-
nities (Peplau, 1965/ 2003). Nurse- midwife and nurse anesthetist roles are specialized
fields but areas of expertise are confined to a particular demographic or a specific type
of intervention. CNSs specialize in many practice areas with evidence- based compe-
tencies associated with a particular specialty (NACNS, 2004). CNS specialization tax-
onomy could be organized by population, problem type, setting, care requirement, or
disease/ pathology/ medical specialty (NACNS, 2004). Regardless of the specialty area,
nursing is the center of CNS practice. This observation reinforces the notion that the
CNS is “first of all a generalist, so she [sic] can do what is expected of a staff nurse”
(Peplau, 2003, p. 7).
The authors note that during the 1980s and 1990s, there was much discussion
and published exchange about blending the CNS and NP roles. In part, this discus-
sion was fueled by reduction in workforce decisions made by hospital administrators