CNS vs NP?

Identity is one thing, and I also have seen providers who have never given up their identity as a nurse. CRNA and NP. But that had nothing to do with any theoretical foundation, at least they never verbalized anything and in most cases denied any belief in any of the theories they were taught.

Practice on the other had, at least by my definition is the same. You treat the sore throat, the MI, the GI bleed the same, no matter what. The patient in front of you attached to the level one infuser, isn't' in a potentially hypoperfusing secondary to decreased fluid intake, they are bleeding to death from th huge bullet hole in their gut. yes these are meant to be an examples and not specifics, don't go off on my choice of nursing diagnosis or anything.

Without mentioned any of that philosophical or theoretical framework, explain to me the difference, because after 33 years, I can't tell the difference, and I've watched lots of NP' PA and MD's work. Give me specifics, because, I don't get it. Unfortunately I've not had any professors who have been able to explain it either, they kept going of on that theoretical stuff. With the exception of Brenner, (my pet theory) who's theory has been around since before Christ, they are all theories, no facts.

Now here is my perspective as a professional educator. Things like nursing diagnosis, nursing theory, and even care plans can be effective tools to help nurses developer a way of thinking, but it's just that, it's a way of learning how to think. It's a method, just like the Socratic method is used in law schools.

oops hit the submit to fast.

Help me to understand. As a new CNS and as an educator, I need to be educated. It's hard to be one of the unified voices in the wilderness when you don't know what to say.

Once again I find myself agreeing with llg.

But I'm not sure nursing will ever have really tightly defined boundaries. I just see so many other areas that could involve nurses...teaching, counseling, discharge planning, advocacy...that I'm not sure that it would be wise to confine nursing practice. I guess I see nursing as kind of the central factor in patient care, with outreach to many other fields. Nurses kind of like the keystone in the arch of medicine.

And I see theory as helpful in understanding those additional roles. Not all theories...I think the middle range and lower theories are more useful than the grand theories and philosophies...and not all nursing diagnoses. But some of them can prove useful in achieving other goals.

I don't think that nurses will ever be able to match the knowledge of the pathophysiology of disease that the MDs have. But that's because their job is much broader than that.

Aw Craig, Joe and llg - we do have some lively discussions - I would never be offended because anyone disagrees with me - lol.

I guess I just don't think the nursing theories are part of my practice because I use the medical model. However, I do use a more holistic approach then (some) of my physician co-workers; ie I am not fast to give antibiotics for a virus or give meds for things that will go away on their own, given time. So, by being more holistic, I think I have stayed in touch as a nurse., I'm proud to be a nurse and never, ever think any task is beneath me and I do think of myself as a nurse first versus a medical provider.

Also, since Medicare doesn't reimburse for "nursing duties", I find the medical model to be more in line with what I actually do.

[quote=traumaRUs;3510518} So, by being more holistic, I think I have stayed in touch as a nurse., I'm proud to be a nurse and never, ever think any task is beneath me and I do think of myself as a nurse first versus a medical provider.

Also, since Medicare doesn't reimburse for "nursing duties", I find the medical model to be more in line with what I actually do.[/QUOTE]

I think you are probably right. I believe the best NP's are able to rely on the medical perspective for the moment-by-moment assessment and treatment of the patient -- while still retaining the holistic view that has been a strong part of the nursing philosophical tradition.

Also, as for offending you ... Frankly, I was less worried about you, personally than I was about some stranger who might open this thread and think I was attacking you visciously. I didn't want to start a flame war with anyone and was trusting that you would be understanding and help keep this conversation going while simultaneously working to not let it get to "hot." Thank you!

Back to the issues: I think ...

That a lot of knowledge doesn't really "belong" to any discipline. For example, we all know that we should wash our hands to prevent the spread of infection. Does that fact belong to medicine? To nursng? etc. If anyone, it probably belongs to microbiology ... but really, it is just an action based on generic facts. Things are not always clear-cut.

When an NP assesses, diagnoses, and treats a patient with a sore throat ... the knowledge used may come from many disciplines -- but the practice of putting all the relevant facts together and using them in such a manner is most commonly associated with the practice of medicine. So then, the key question becomes, how can we say the NP is practicing in an advanced practice NURSING role if he/she is actually practicing medicine?

The answer is, "We can't." We cannot say the NP is practicing nursing unless that practice includes at least some elements of the philosophical and theoretical perspective that is commonly associated with nursing. The linkages between what the practitioner does and what nursing is must be present for it to qualify as nursing. It is illogical to come to any other conclusion.

So now what ... Well, either we say that NP's are not advanced practice nurses, but are instead "junior physicians" and move responsibility for their education etc. to the medical world. Or, we can expand our nursing philosophies and knowledge base to incorporate NP practice. Nursing has chosen to take the 2nd approach -- but it is a difficult process. The linkages are not obvious and unfortunately, most nurses do not have the advance knowledge and skills of nursing theory and philosophy to do it well or the inclination to learn and/or do it regularly.

But there is no reason why a NP could not base use nursing concepts and theories in her practice. For example, any of the caring theorists would apply. Kristin's Swanson's definition of nursing as being "informed caring for the well-being of others" applies to NP's. Benner's work on caring as the foundation for decision-making is just as applicable to NP practice as to any other type of nursing practice. I don't have the reference here, but Virginia Henderson wrote about NP's as being consistent with her definition of nursing, which says essentially that nurses do for a person what he would do for himself if he could. That "doing for" could just as easily refer to prescribing antibiotics as anything else.

Both NP's and staff nurses (and others) find the nursing theories difficult to use in daily practice. Many never learn to use theory well in school. It is the "throw-away" course you have to take to graduate, taught by someone who doesn't know all that much more than the students. Many nurses NEVER take a theory course, much less a high quality theory course. They never learn it well ... and then don't think much about it after that because they are focused on the tasks of their work, not on the knowledge base that underlies it. We become increasingly a profession of "the blind leading the blind." So we have become a fairly "atheoretical" profession -- which weakens us in the eyes of those who come from strong powerful disciplines.

The "problem" with NP practice is not in the practice itself -- it's that NP's have an alternative discipline handy to fall back on. It's easy for them to think only of the medical model because it is so obviously present in their daily activities. With time, they may start to identify their practice more closely with medicine than with nursing ... and slowly drift away from nursing, weakening our profession further.

Staff nurses do not have such an easily identifiable alternative discipline to "hang their hat on." So, while they don't embrace the nursing academic world, they don't have a handy alternative. They become "homeless" in their intellectual/academic endeavors ... or lean towards the medical model when it seems to apply.

I'll stop now.

Totally agree with what you say llg! (See, I surprized ya!)

BTW - I would never ever get offended at people disagreeing with me. The nature of debate is to learn from others and then incorporate that into something you take away.

When I did my LPN to ADN bridge program, I went to a Catholic college because there was no waiting list. Fortunately, I did come across the theories of Sr. Calista Roy. I still remember some of it but I did feel that I at least got some idea of what a nurse was suposed to do.

I know that now as an APN, I bring a different viewpoint to the table than the physician. I worked in the ER last night and took care of a young lady who, though she had many physical complaints, her main reason for being there was that she needed support and understanding. Now, whether I as a woman or as a nurse honed in on this quickly, am not sure. When she left, she thanked me for listening and providing her with resources.

I do feel that I bring something different to the practice of medicine because I'm a nurse first, then an APN. So...am I using some nursing theory or am just being a nurse?

As an aside, one of the physicians I work with was a nurse before she went to med school. I just love working with her as she is thorough, competent and very, very caring. So...is this due to exposure to a nursing theory or because she is practicing holistic care?

Am not sure. All I know is that she is a dynamite physician.

I think you were being a nurse in that instance. Someone who followed the medical model would have focused primarily on what they were trained, the pathophysiology of disease.

And a nursing theory might have been able to guide your interactions, or provide some insight into the actions/beliefs of that patient.

Going back to what llg said, I'd add that I suspect nursing has long been been as a skilled trade--like an electrician--rather than a profession, and that may explain why there is resistance to learning theoretical stuff. In addition, it's tough to learn all that new material and also take in all that theory on top of it. Even if it's taught well, most students aren't interested in that, they're more concerned about practical skills.

That "something different" is what I mean when I talk about "perspective." Each discipline has its own unique perspective. You bring a nursing perspective to a situation that physicians do not bring (unless they have also been educated as nurses). I am happy to read that you recognize that nursing perspective in your practice: I would have for our profession to lose such a great nurse.

I wish I had the answer to the issue just raised by Joe. I agree that most nurses tend to be atheoretical -- more focused on tasks than anything academic. But I also see the value of academics and hate to see so many nurses content to keep nursing "down" by not supporting efforts to further the discipline of nursing. To advance the discipline of nursing (which would help advance the practice and profession of nursing), we need research and a solid knowledge base. Those trying to develop that, get so little support by those practicing nursing that it is disheartening.

As a nurse with a strong academic tendency who has spent most of my career working in hospitals ... it is a battle I fight every day. How do I bridge that gap betweent the scholarly aspects of the nursing discipline with the "in-the-trenches" practice of nursing by those who have had little exposure to anything academic in their education?

I get weary. .... But I really appreciate this nice discussion we've been having here.

llg - thanks for your very kind words.

One of my best take-a-ways from this forum is that we can all discuss issues in a calm, rational manner.

In this case I don't think I can be offended because I'm still trying to formulate my own opion. It's all still theoretic for me.

Personally, I'm trying to develop my own "theory and philosopy" to develop myself as a nurse. This is what I'm getting.

I have to agree that the vast majority of the nurses I work with are nothing more than higly skilled technicians. Who I might add I would let take care of me if I was sick. Nursing theories are a usefull tool to help identify an indivudual nurses reasons for being a nurse as well as helping to guide them in choosing how they are going to practice their proffesion. Now this is just a short one line summation of what I"m thinking. Persoanlly I'm a guy and a geek, so I personally automaticly discount the touchy feely theories. But as an educator, I believe that the theory of novice to expert isn't a theory, but a fact.

So with this confusion and disagreement, were did we go wrong with the nursing theories. This stuff is harder than the questions asked when I was working on my DDiv.

1. do we recognize the fact that a large number of nurses are only functioning at the skilled worker stage?

2. Do we change how we teach nursing theory. My nursing theory instructor was a Male USAF CRNA, who had been an Army Ranger before going int nursing. Not a big pro theory kind of guy.

3. If we do change, how do we change it. I think I posted earlier, I think we need to chnge the format of how it's taught and focus on using it as a personal tool. what I can't decide is how much weight it should have.

I do like the keystone analogy. That states in one sentence what some people have taken 20+ pages to write about.

As to all this holistic stuff, and the big picture and all that. I think unfortunatly that is something that identifies a better practioner, and not something that anecdotaly can artipute to many NP's that I' work with. My defintion of the Nurse part of NP is the practionter who can write me oders, teach the patient, (and not depend on me to do it), and help me turn the patient and wipe their butt. This is however an individual identifier and not a group identifier. I look at some of my fellow staff nurses who would walk out of the room and call a tech to go clean the patient, whey they could have dont it themselves.

Which in writing that sentences, has helped identify were I need to focus some of my thoughts. I keep thinking about the proffesion, based on my experiences with nurses, and not thinking beyound that to the "ideal" of nursing. Based on my past post's, would you guys agree with that?