Master s level education is the predominate preparation

The Effects of Master s Degree Education on the Role Choices, Role Flexibility, and Practice Settings of Clinical Nurse Specialists and Nurse Practitioners Sharon W. Stark, DNSc, APN-C ABSTRACT Master s degree education that explores advanced practice nursing (APN) roles in multiple settings may increase APN roles and practice viability in ever-changing health care environments. This descriptive, comparative study investigated differences in role choices, role flexibility, and practice settings among master s prepared clinical nurse specialists (CNSs) and nurse practitioners (NPs) educated in specialized and combined programs using multivariate analysis of variance. Role theory delineates activities in specific societal roles that are recognized as activities practiced always, sometimes, or never by all, some, or none of its members. Role specialization is determined by the amount and frequency that activities are performed by others in similar roles. Significant differences were found between groups on actual and preferred percentage of time spent in APN roles. The CNS group spent more time in acute care and mental health settings, and the NP and Combined groups spent more time in clinic and primary care settings. Master s level education is the predominate preparation for nationally certified clinical nurse specialists (CNSs) and nurse practitioners (NPs) in the United States. Educational standards for master s advanced practice nursing (APN) education incorporate a Received: February 13, 2003 Accepted: May 20, 2005 Dr. Stark is Associate Professor, Monmouth University, Marjorie K. Unterberg School of Nursing and Health Studies, West Long Branch, New Jersey. Address correspondence to Sharon W. Stark, DNSc, APN-C, Associate Professor, Monmouth University, Marjorie K. Unterberg School of Nursing and Health Studies, 400 Cedar Avenue, West Long Branch, NJ 07764-1898; e-mail: swstark@monmouth.edu. graduate core that includes research, policy, organization and health care financing, ethics, professional role development, human diversity and social issues, health promotion and disease prevention, and nursing theory, as well as an APN core that includes pathophysiology, advanced health and physical assessment, and advanced pharmacology (American Association of Colleges of Nursing [AACN], 1996). As such, CNS and NP education currently shares core courses previously specific to either CNS or NP education. Some nurses believe practice settings dictate CNS and NP roles more than educational background (Elder & Bullough, 1990; Fenton & Brykczynski, 1993; Forbes, Rafson, Spross, & Kozlowski, 1990; Hawkins & Holcombe, 1995; Williams & Valdivieso, 1994). Therefore, it is essential that education provide a means for APNs to practice efficiently across multiple settings (Elder & Bullough, 1990; Hawkins & Holcombe, 1995). Role flexibility and greater practice opportunities have been linked to a more generalized APN education (McGivern & Mezey, 1999). No studies in the literature have examined evolving APN role choices, role flexibility, and practice settings. Nurse educators cannot design curricula to effectively prepare a highquality APN workforce if they do not understand evolving APN roles and health care settings. Therefore, this study examined the effects of education on CNSs and NPs role choices, role flexibility, and practice settings. THEORETICAL FRAMEWORK According to role theory (Biddle & Thomas, 1979), social behaviors are influenced by societal demands and the rules imposed by them. Role norms evolve from interactions between individuals within those roles. Role socialization regulates the behaviors and functions of members in social groups (Biddle & Thomas, 1979), while role specialization embraces specific behaviors of individuals or social groups, January 2006, Vol. 45, No. 1 7

APN ROLE CHOICES, ROLE FLEXIBILITY, AND PRACTICE SETTINGS and is governed by the amount of behavior engaged in, compared with others in similar roles. Role behavior ranges from all and many to no behaviors engaged in by members of a social group (Biddle & Thomas, 1979). The more behaviors engaged in, and the more individuals who engage in the same or similar behaviors, the less specialized the behavior is. Conversely, the fewer behaviors engaged in, and the fewer individuals who engage in the same or similar behaviors, the more specialized the behavior is. Role flexibility expands APN role choices and increases opportunities to practice in a variety of health care settings. As such, education may obstruct or facilitate APN practice. LITERATURE REVIEW A literature review revealed the history and evolution of the CNS and NP roles, similarities and differences in CNS and NP education, their practice and practice settings, and support of and opposition to a combined CNS- NP education. Many opinion articles were found, but few research studies regarding similarities and differences in CNS and NP education, practice, and roles were identified. No research studies regarding CNS and NP role choices, role flexibility, or practice settings were found. CNS and NP Education Historically, CNS and NP educational preparation was dictated by areas of practice. The CNS and NP roles originated from different philosophical and educational backgrounds: CNS practice was in tertiary care and the community, and NP practice was in ambulatory and primary care settings (Hawkins & Thibodeau, 1996; Lincoln, 2000; Lindeke, Canedy, & Kay, 1997; Rasch & Frauman, 1996; Ray & Hardin, 1995; Williams & Valdivieso, 1994). Now, primary, tertiary, and community care settings are practice arenas for both CNSs and NPs, and role variations have evolved in response to the practice setting (Donley, 1995; Forbes et al., 1990; Hester & White, 1996; Kitzman, 1989; McGivern, 1993; Williams & Valdivieso, 1994). Opposition to integrating CNS and NP educational and occupational roles is based, in part, on the belief that the goals of patient care differ between CNSs and NPs. There is agreement among some nursing professionals that CNS goals of patient care are specialized and nursing based, while NP goals are broad and medically based (Bullough, 1992; Elder & Bullough, 1990; Forbes et al., 1990; Lyon, 1996; National Association of Clinical Nurse Specialists [NACNS], 1998; Page & Arena, 1994; Rasch & Frauman, 1996; Rogers, 1972). The few differences in CNS and NP education were found in practice settings; greater emphasis on pharmacology, primary care, physical assessment, health promotion, nutrition, and history-taking in NP curricula; and CNS and NP practice requirements mandated by curricula and certification bodies (Forbes et al., 1990). Both CNSs and NPs practice in many settings, and although role diversity exists, NP roles are as rooted in nursing as CNS roles are (Jacobs & Kreamer, 1997). Hupcey s (1990) research findings indicated that during the socialization process, senior-level NP students placed greater importance on technical/medical role behaviors than on nursing role behaviors. As a result, Hupcey recommended that master s NP programs strengthen master s nursing roles in their curricula. Differences in CNS and NP Practice Studies have shown that differences in CNS and NP practice were dictated far more by practice settings than by educational preparation. Research was emphasized more by CNSs, and administrative responsibilities, teaching staff and families, conducting research, and administrative responsibilities were more prevalent among CNSs (Elder & Bullough, 1990; Hawkins & Holcombe, 1995; Rasch & Frauman, 1996; Williams & Valdivieso, 1994). Tertiary practice settings were more common among CNSs than NPs (Fenton & Brykczynski, 1993). Clinical nurse specialists were also involved in case management; staff, patient, and family support and advocacy; role modeling; and policy change. Support from staff, administration, and physicians; peer networking; and access to support services helped implement CNS roles (McFadden & Miller, 1994). In addition, CNSs reported 29% to 91% of their time was spent as expert practitioners, 24% to 89% as educators, 18% to 96% as consultants, 15% to 93% in research, and 34% to 85% in administrative duties (Scott, 1999). Nurse practitioner roles included a higher degree of direct patient care, prescribing medications, treatment planning, and patient teaching; NPs were also involved in management of patient health/illness status, consultation, safe care issues, and patient referral to medical specialists. Primary and ambulatory care were the predominant practice settings for NPs (Elder & Bullough, 1990; Rasch & Frauman, 1996; Sawyers, 1993; Williams & Valdivieso, 1994). Acute care NPs performed patient care; therapeutic, interpretive, and pharmacological management; discharge planning; education; and consultation. Primary activities of acute care NPs were history and physical examinations, discussing care with families, ordering and interpreting tests, discharge planning, consultation, and conducting nursing inservice programs (Kleinpell, 1998). In a comparative study of CNSs in tertiary care settings and NPs in ambulatory care settings, Lincoln (2000) found that CNSs spent more time than NPs in education (CNSs: 21% versus NPs: 13%), consultation (CNSs: 23% versus NPs: 7%), and administration (CNSs: 14% versus NPs: 5%). Nurse practitioners spent more time than CNSs as expert practitioners (NPs: 74% versus CNSs: 35%). Finally, neither spent a great deal of time in research (CNSs: 7%; NPs: 2%) (Lincoln, 2000). Combined CNS and NP Roles Lindeke et al. s (1997) survey revealed that CNSs knowledge was specialized in an area of practice, while NPs knowledge was broad based and focused on primary care. Nurse-client relationships were long term for NPs and short term for CNSs. Teaching-coaching for NPs in- 8 Journal of Nursing Education

STARK volved general health promotion and condition-specific patient teaching, while for CNSs, it involved nursing interventions and body systems. Both NPs and CNSs practices were limited to their area of certification and practice setting. Professional autonomy differed in CNSs focus on client issues, nursing process, and organizational structure, and NPs focus on direct patient care and patient satisfaction measures. Management and negotiation of health care delivery systems occurred within tertiary health care systems for CNSs, and between health care systems and health care professionals for NPs. In addition, NPs focused on monitoring and ensuring quality of health care through patient outcomes and cost effectiveness, while CNSs focused on patient outcomes, new technology, cost analysis, interventions, research, quality assurance, and staff development. Finally, participants in Lindeke et al s (1997) study believed NP education included clinical decision making that was not included in CNS education. Summary Although CNS and NP education originated from different applications of nursing, the same core and specialized clinical courses that are shared in master s degree education facilitate greater role choices, flexibility in role activities, and opportunities for practice in a variety of settings. If practice settings also guide CNS and NP roles and activities, it is necessary for APN educators to prepare students to practice the roles and activities of both CNSs and NPs in order to contribute to the advancement of nursing practice. Therefore, this investigation of the effects of specialized or combined CNS-NP master s degree education on role choices, role flexibility, and practice settings will help determine whether changes should occur in CNS and NP curricula. RESEARCH QUESTION AND HYPOTHESIS The research question that guided this study was: Do CNSs and NPs educated in a specialized CNS or NP curriculum differ from CNSs and NPs educated in a combined curriculum regarding role choices, role flexibility, and practice settings? The hypothesis was that CNSs and NPs educated in specialized curricula would differ from CNSs and NPs educated in combined curricula in role choices, role flexibility, and practice settings. METHOD Design This quantitative study used a descriptive, comparative design to describe and compare the differences in role choices, role flexibility, and practice settings of CNSs and NPs educated in specialized or combined curricula. Data were collected by a mailed survey. Participants completed a demographic questionnaire and a self-report Role Choices, Role Flexibility, and Practice Settings Survey (CFPS) (Stark, 2001). Sample Participants were recruited through a stratified, random sampling method from NACNS and American Academy of Nurse Practitioners (AANP) membership lists and a published directory of CNSs and NPs certified by the American Nurses Credentialing Center (ANCC) that represented each National League for Nursing Accrediting Commission (NLNAC) region and who graduated from nursing master s programs accredited by the NLNAC or the Certification Center for Nursing Education (CCNE) between 1990 and 1998. Participants were required to have a minimum of 3 years of experience in an APN role to ensure they had sufficiently developed confidence and competence in their roles (Brown & Olshansky, 1997; Cooper & Sparacino, 1990; Hamric & Taylor, 1989). A power analysis was calculated to estimate the minimum sample needed to obtain statistically significant results. A total sample of 165 participants was required, with a minimum of 55 APNs from each of the three groups (p = 0.05, power = 0.80, effect size = 0.15) (Cohen, 1988). Of the total number of packets mailed (N = 1,086), 135 packets were undeliverable, and 545 potential participants never responded. A total of 406 participants returned complete, usable surveys (return rate = 37.4%); however, 121 surveys were incomplete and were not used. The final sample of 285 participants represented each of the NLNAC regions in the United States. Demographic data for the participants is listed in Table 1. Data Collection Data were collected after obtaining appropriate human subjects review. A modified tailored design technique (Dillman, 2000) was used to collect data. The researcher counted the number of APNs identified by the NACNS, AANP, and ANCC in each state within a particular NL- NAC region and calculated 10% of APNs in each state. For example, if there were 100 NPs on a list, every tenth NP was picked until 10 NPs were selected. Postcards were mailed to the 1,086 prospective participants to alert them that a questionnaire would arrive in the mail. One week later, a survey packet with a postage-paid return envelope was mailed (Dillman, 2000). Two weeks later, a follow-up postcard was mailed, thanking participants who returned completed surveys, reminding participants who had not yet responded to complete and return them, and directing those who had misplaced their surveys to e-mail the researcher for a replacement. Data were collected over a 6-week period. The last date for survey return was 6 weeks from the initial mailing. Instruments Two researcher-developed instruments were used to collect data: a 15-item demographic survey (Stark, 2001) and a 93-item, paper-and-pencil, self-report Role Choices, Role Flexibility, and Practice Settings Survey (CFPS) (Stark, 2001). The CFPS lists categories for three subscales: role choices, role flexibility, and practice settings. Item selection was based on a literature review and on recommenda- January 2006, Vol. 45, No. 1 9

APN ROLE CHOICES, ROLE FLEXIBILITY, AND PRACTICE SETTINGS TABLE 1 Demographic Data of Participants (n = 285) Variable n (%) Gender Female 274 (96) Male 11 (4) Race White 271 (95) Black 6 (2) Asian 2 (1) Native American 2 (1) Hispanic 1 (0.4) Pacifi c Islander 1 (0.4) Missing data 2 (1) NLNAC region Northeast 91 (32) Southeast 86 (30) Central 72 (25) West 36 (13) Education Specialized NP 152 (53) Combined CNS-NP 75 (26) Specialized CNS 58 (20) Practice role NP 204 (72) CNS 57 (20) Combined 23 (8) Missing data 1 (0.4) Practice specialization Family 82 (29) Psychiatry 30 (11) Gerontology 22 (8) Adult 21 (7) Other 120 (42) Missing data 10 (4) tions from CNS and NP educators and currently practicing CNSs and NPs. The Role Choices subscale is divided into two parts (10 items). Part I asks participants to indicate the percentage of time spent in five identified APN roles (i.e., expert clinician, consultant, educator, leader, and researcher). Part II asks them to indicate the percentage of time they would like to spend in the identified roles. Percentages can range from 0% (no time) to 100% (all of the time). For each part, the sum of the percentages must equal TABLE 1 (Continued) Demographic Data of Participants (n = 285) Variable n (%) National certifi cations Family NP 95 (33) Adult NP 47 (17) Mental health 22 (8) Gerontological NP 20 (7) Critical care 18 (6) Other 38 (13) Missing data 45 (16) Variable Mean, SD, Range Years as APN Mean = 8, SD = 4.1 range = 3 to 28 Hours worked per week Mean = 37, SD = 11.1 range = 1 to 65 Age (years) Mean = 46, SD = 7.4 range = 27 to 74 Note: NLNAC = National League for Nursing Accrediting Commission, NP = nurse practitioner, CNS = clinical nurse specialist, APN = advanced practice nurse. 100% for the combined, identified APN roles. The Role Flexibility subscale consists of 45 items that are divided among expert clinician, consultant, educator, leader, and researcher roles. Participants are asked to indicate how well they perform activities that comprise each role using a 6-point Likert scale ranging from 0 (not at all) to 5 (exceptionally well). A higher score indicates better performance. The range of possible scores on the total activities in the Role Flexibility subscale is 0 to 225. Individual scores were identified for expert clinician (0 to 60), consultant (0 to 65), educator (0 to 35), leader (0 to 35), and researcher (0 to 30). The Practice Settings subscale is divided into two parts (38 items). Part I asks participants to indicate the percentage of time spent each week in any of the 19 identified practice settings. Part II asks them to indicate the percentage of time they would prefer to spend practicing in the identified settings each week. Percentages can range from 0% (no time) to 100% (all of the time). For each part, the sum of the percentages must equal 100% for the combined, identified practice settings. Internal consistency reliability of the CFPS subscales ranged from 0.84 to 0.91 for the pilot study and the full study. Overall Cronbach s alpha was 0.88 for the pilot study and 0.95 for the full study. Data Analysis Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 10. Descriptive statis- 10 Journal of Nursing Education

STARK tics were used for analyses of demographic data, while inferential statistical multivariate analysis of variance (MANOVA) were used to test the hypothesis. Mean scores in each of the five individual role activities categories of the Role Flexibility subscale were used for isolated missing data. If more than 5% of the questions within each category had missing answers, no score was entered for any missing data in that individual role activity category. Hypothesis Testing To measure differences among the three groups regarding data from each of the three CFPS subscales (Role Choices, Role Flexibility, Practice Settings), three separate MANOVAS were computed: one for each dependent variable. Inspection of the Box s M equality of covariance matrix test was significant (p < 0.001) in all groups. Therefore, to ensure robustness of analyses, violations in variances were corrected by reducing the alpha level from 0.05 to 0.01 for this study (Tabachnick & Fidell, 1996). RESULTS TABLE 2 Differences Between Groups on Time Spent in APN Roles (n = 282) Group Dependent Variable Mean Difference p CNS vs. NP Actual time spent in expert clinician role 20.70* < 0.001 CNS vs. Combined Actual time spent in expert clinician role 18.60* 0.001 CNS vs. NP Preferred time spent in expert clinician role 17.90* < 0.001 CNS vs. NP Actual time spent in consultant role 5.70 0.010 CNS vs. NP Preferred time spent in consultant role 8.50* < 0.001 CNS vs. Combined Preferred time spent in consultant role 6.70* < 0.001 * df = 2; p < 0.01. Note: Data are from the Role Choice subscale of the Role Choices, Role Flexibility, and Practice Settings Survey (Stark, 2002). APN = advanced practice nurse, CNS = clinical nurse specialist, NP = nurse practitioner, Combined = Combined CNS-NP education. TABLE 3 Differences Between Groups on Overall APN Role Activities (n = 281) Group Dependent Variable Mean Difference p CNS vs. NP Expert clinician activities 8.00* < 0.001 CNS vs. Combined Expert clinician activities 8.10* < 0.001 CNS vs. NP Consultant activities 5.40* 0.010 CNS vs. NP Educator activities 3.10* 0.010 CNS vs. NP Leader activities 4.00* < 0.001 CNS vs. NP Researcher activities 4.80* < 0.001 NP vs. Combined Researcher activities 3.20* 0.004 * df = 2; p < 0.01. Note: Data are from the Role Flexibility subscale of the Role Choices, Role Flexibility, and Practice Settings Survey (Stark, 2002). APN = advanced practice nurse, CNS = clinical nurse specialist, NP = nurse practitioner, Combined = Combined CNS-NP education. Role Choices Inspection of post-hoc Scheffe analyses identified significant differences between groups on actual and preferred percentage of time spent in APN roles (Table 2). The NP and Combined groups actually spent more time in the expert clinician role that did the CNS group (CNS vs. NP mean difference = 20.70, p < 0.001; CNS vs. Combined mean difference = 18.60, p = 0.001), and the NP group preferred to spend more time in the expert clinician role than did the CNS group (CNS vs. NP mean difference = 17.90, p < 0.001). The CNS group spent more time in the consultant role than did the NP group (CNS vs. NP mean difference = 5.70, p = 0.01), and the CNS group preferred to spend more time in the consultant role than did the NP and Combined groups (CNS vs. NP mean difference = 8.50, p < 0.001; CNS vs. Combined mean difference = 6.70, p < 0.01). Assumptions of the test were not significant (F [20, 282] = 2.89, p = 1.0). Inspection of the results indicated that the groups differed on actual and preferred percentage of time spent in the expert clinician and consultant roles. Role Flexibility The post-hoc Scheffe analyses identified significant differences between the CNS and NP groups, and the CNS and Combined groups on overall expert clinician activities (Table 3). The NP and Combined groups participated in more expert clinician activities than did the CNS group January 2006, Vol. 45, No. 1 11

APN ROLE CHOICES, ROLE FLEXIBILITY, AND PRACTICE SETTINGS TABLE 4 Mean Scores on Individual Role Flexibility Categories by Group Mean Scores by Group Role Possible Score Range CNS NP Combined Expert clinician 0 to 60 41.90 49.70 49.70 Consultant 0 to 65 51.10 45.80 49.90 Educator 0 to 35 29.20 25.90 28.30 Leader 0 to 35 28.50 24.50 26.70 Researcher 0 to 30 19.80 15.00 18.00 Total 0 to 265 170.50 160.90 172.60 Note: Data are from the Role Flexibility subscale of the Role Choices, Role Flexibility, and Practice Settings Survey (Stark, 2002). CNS = clinical nurse specialist, NP = nurse practitioner, Combined = Combined CNS-NP education. TABLE 5 Differences in Percentage of Time Spent in Various Practice Settings (n = 284) Group Dependent Variable Mean Difference p CNS vs. NP Actual time spent in acute care setting 31.20* < 0.001 CNS vs. Combined Actual time spent in acute care setting 19.60 0.003 CNS vs. NP Preferred time spent in acute care setting 26.80* < 0.001 CNS vs. NP Preferred time spent in clinic setting 17.20 0.010 CNS vs. NP Actual time spent in mental health setting 16.00* < 0.001 CNS vs. NP Preferred time spent in mental health setting 14.60* < 0.001 CNS vs. NP Actual time spent in primary care setting 22.40* < 0.001 CNS vs. NP Preferred time spent in primary care setting 23.90* < 0.001 * df = 2; p < 0.01. Note: Data are from the Practice Settings subscale of the Role Choices, Role Flexibility, and Practice Settings Survey (Stark, 2002). APN = advanced practice nurse, CNS = clinical nurse specialist, NP = nurse practitioner, Combined = Combined CNS-NP education. (CNS vs. NP mean difference = 8.00, p < 0.001; CNS vs. Combined mean difference = 8.10, p < 0.001). Significant differences were also found between the CNS and NP groups on overall consultant (CNS vs. NP mean difference = 5.40, p = 0.01), educator (CNS vs. NP mean difference = 3.10, p = 0.01), and leader (CNS vs. NP mean difference = 4.00, p < 0.001) activities. The mean scores of the Combined group on individual Role Flexibility categories surpassed those of the CNS and NP groups (Table 4). Assumptions of the test were significant (F [10, 278] = 13.2, p < 0.001). Inspection of the results indicated that the groups differed in performance of expert clinician, consultant, educator, leader, and researcher role activities. Practice Settings Post-hoc Scheffe analyses revealed that the CNS group spent a greater percentage of time in acute care than did the NP and Combined groups (CNS vs. NP mean difference = 31.20, p < 0.001; CNS vs. Combined mean difference = 19.60, p = 0.003). The CNS group also preferred to spend a greater percentage of time in the acute care setting than did the NP group (CNS vs. NP mean difference = 26.80, p < 0.001). The NP group preferred to spend more time in clinic settings than did the CNS group (CNS vs. NP mean difference = 17.20, p = 0.01). The NP group actually spent and preferred to spend a greater percentage of time in primary care settings than did the CNS group (CNS vs. NP mean difference, actual = 22.40, p < 0.001; CNS vs. NP mean difference, preferred = 23.90, p < 0.001) (Table 5). Assumptions of the test were not significant (F [72, 285] = 2.6, p = 0.21). Inspection of the results indicated significant differences among the groups in actual and preferred percentage of time spent in acute care, clinic, mental health, and primary care settings. DISCUSSION AND IMPLICATIONS This study is the first to examine the outcomes of specialized CNS and NP and combined CNS-NP education on perceived role choices, role flexibility, and practice settings. Role theory was useful for examining the results of this study in that specialized roles vary by the amount of behavior engaged in, compared with others in similar roles. The more behaviors engaged in by others in similar roles, the less specialized the role (Biddle & Thomas, 1979). Consequently, CNS and NP roles are not specialized because both perform many APN role behaviors; they are generalist practitioners. 12 Journal of Nursing Education

STARK The findings of this study add empirical support to the researcher s premise that a combined CNS-NP education facilitates broader role choices, role flexibility, and practice settings. As traditional role and practice boundaries continue to overlap, practice options and settings will expand (Grosel, Hamilton, Koyano, & Eastwood, 2000; National Advisory Council on Nurse Education and Practice, 1999). For APNs to be part of the changing health care environment and to care for those who will benefit most from their expertise, it is important to prepare them to perform multiple advanced practice activities and practice in many roles in a variety of settings. A combined CNS-NP education facilitates the expansion of nursing science by standardizing APN education for practice that fosters greater exploration of expanded roles, evidence-based practice, nursing research, and outcome measures. The AACN (1996) standards for APN education support a master s level core. Currently, curricula for master s preparation of CNSs and NPs include core courses shared by both CNS and NP students, as well as specialization courses in which CNS and NP students are separated. It is at this point that CNS and NP students no longer gain the same knowledge for practice. Curricula that separates CNS and NP education divides core knowledge into small factions that narrow APNs expertise and diminish their practice opportunities. In effect, specialized programs do not facilitate a broad, comprehensive education that allows for greater choices as APNs. Combined education can effectively prepare high-quality APNs to meet health care workforce demands by preparing them to practice in a variety of roles and participate in activities not facilitated by specialized education. Combined CNS-NP education is advantageous to both groups because elements of NP education related to proficiency as expert clinicians and elements of CNS education related to proficiency as consultants, educators, leaders, and researchers would be merged in didactic and clinical courses (Forbes et al., 1990; Jacobs & Kreamer, 1997; O Flynn, 1996). In this way, expanded role choices, activities, and practice settings would be reinforced through course offerings that introduce aspects of both CNS and NP roles and activities in a variety of practice settings. As a result, APN graduates would have greater opportunities to practice in a variety of settings and to create new careers (Heller, Oros, & Durney-Crowley, 2001). As more combined CNS-NP program graduates enter the workforce, practice settings may diversify. Health care continues to change due to our aging society, increasing cultural diversity, and new, chronic, catastrophic diseases that affect individuals, society, health care, and the economy. Advanced practice nurses play a vital role in caring for those affected by illness and disease, and APN educators have an opportunity to prepare expert practitioners who can provide the most proficient care. A broad APN education that encompasses both CNS and NP roles is most conducive to providing expert care at a reasonable cost. As a result of educational experiences that encourage practice in a variety of APN roles, activities, and practice settings, role flexibility creates greater practice opportunities. In addition, scholarship of practice may become a focus in academia. Although APN faculty are already burdened with full teaching assignments, they are expected to participate in clinical practice to maintain the nationally recognized certifications required to teach clinical courses (Boyer, 1990; National Organization of Nurse Practitioner Faculties, 1999). Faculty who can demonstrate scholarship through clinical practice research may receive greater Although in the past, specialization expanded practice opportunities, ongoing changes in health care may lead to fewer practice opportunities for APNs who practice in only either the CNS or NP role. recognition for their clinical expertise, for which compensation can be negotiated (AACN, 1999). Diverse clinical proficiencies allow for broad, creative faculty practice opportunities that facilitate practice recognized by certifying bodies and clinical research recognized by academia. Role differences between CNSs and NPs continue to decrease, as their practice settings merge. Although in the past, specialization expanded practice opportunities, ongoing changes in health care may lead to fewer practice opportunities for APNs who practice in only either the CNS or an NP role. Clinical nurse specialists who have the clinical proficiency to diagnose, treat, and prescribe for patients, as well as knowledge about consultant, educator, leadership, and researcher roles and activities will be more marketable. Similarly, NPs who can take on greater consultant, educator, leadership, and researcher roles and activities will be prepared to better serve as advocates for their patients and the nursing profession, as well as broaden activities within their practice settings. As health care continues to move away from acute care settings, greater opportunities will be open to APNs who provide quality care in a variety of practice settings (Grosel et al., 2000). Advanced practice nurses should be proactive in creating new, diverse roles to meet the nation s health care needs, gain control over practice, be more visible to consumers and other health care professionals, improve productivity, promote continuity in patient care across care settings, and become politically visible (Busen & Engleman, 1996; Lynch, 1996). As access to health care becomes more stringently controlled, educators must create programs that graduate APNs who can meet the pub- January 2006, Vol. 45, No. 1 13

APN ROLE CHOICES, ROLE FLEXIBILITY, AND PRACTICE SETTINGS lic s health care needs. As health care practice continues to evolve into the community, APNs must be equipped to develop practice expertise outside of traditional settings. Education that provides APNs with multiple skills provides greater role choices, role flexibility, and a broader range of practice opportunities. This study applies role theory in CNS and NP roles, and creates opportunities for further research of role theory in nursing. This study contributes to nursing research through the development of a valid and reliable new instrument for data collection. It contributes to the science of nursing and to the knowledge base for APN education by accumulating research data that may be helpful for developing curricula for combined CNS-NP education. LIMITATIONS One limitation of this study was the use of a mailed survey to collect data. More responses may have been gathered through face-to-face distribution of the survey. Another limitation is that individual data from the CNS, NP, and Combined CNS-NP educational groups were combined, and differences within each group were not calculated. Regarding the respondents, the majority were from the northeast and southeast regions of the United States. Only certified CNSs and NPs were surveyed; noncertified APNs were excluded. There were only 2 male participants; thus, the results are biased toward female APNs. The sample was limited to master s prepared CNSs and NPs; postbaccalaureate certificate NPs were excluded. The sample was also limited to CNSs and NPs who had practiced in their role for a minimum of 3 years, excluding new graduates. The sample did not include APN nurse midwives and nurse anesthetists. Participants were randomly selected, and there is no way to know how those who participated differed from those who did not. Finally, there was potential bias in participant selection, as all of them were selected from professional APN organization mailing lists. APNs not affiliated with these organizations were excluded. CONCLUSIONS AND RECOMMENDATIONS The findings of this study reveal similarities and differences in CNS and NP role choices, role flexibility, and practice settings, and that a combined CNS-NP education enables CNSs and NPs to integrate the roles and activities of both. Although practice settings remain stereotyped as either CNS or NP domains for practice, the type of APN activities performed indicated a mixing of the two roles. The literature is divided concerning combined CNS-NP practice. This study verifies differences in CNS and NP roles, even though there is overlap in CNS and NP role activities. However, it is not conclusive that CNS and NP educational preparation was the definitive factor in participants role choices, role activities, and practice settings. 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