AACN Commentary on “Professional Polarities in Nursing” Response to the article by Elaine S. Scott and Brenda L. Cleary

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As representatives from the American Association of Colleges of Nursing (AACN), we applaud Drs. Scott and Cleary for their desire to bring unity to the nursing profession while recognizing the important need for improving the clinical competency of the workforce. However, we are concerned by the authors’ apparent disregard for the value of innovation and the need for new educational models to further the discipline. While we agree that nurses must work together and harness their collective energy, we must address the challenges posed by the Institute of Medicine (IOM), Robert Wood Johnson Foundation (RWJF), American Hospital Association (AHA), and other authorities to re-envision professional nurse education.

Despite the authors’ attempts to bring harmony to nursing through the application of Polarity Theory, we believe the article actually will cause greater division based on misperceptions and unsubstantiated claims. The central concept that preparing a sufficient nursing workforce can only come at the expense of patient safety is flawed and sends a discordant message to nurse educators at all levels. Further, the idea that academic leaders, which include AACN, have advanced the role of the Clinical Nurse Leader (CNL®) and the movement to the Doctor of Nursing Practice (DNP) in isolation without considering the “full spectrum of nursing interests and issues” or the persistent shortage of nursing simply is not true. Building consensus has been integral to the launch of both initiatives and continues today since the work to advance the profession will only succeed as a collaborative effort.

The concept of polarities in nursing undermines cohesion. The authors believe that preparing an adequate number of nurses and promoting patient safety are mutually exclusive. The AACN would argue strongly that they are not. In practice settings with insufficient numbers of registered nurses (RNs), having the best educated nurses available is imperative. Most of the recent discussions about initial RN preparation have shifted away from limiting entry into practice to moving all nurses further along the educational continuum. Proposals to require new nurses to earn a baccalaureate degree within ten years of initial licensure, community college-based baccalaureate programs, and streamlined articulation models between associate degree (ADN) and baccalaureate (BSN) programs all focus on enhancing the level of RN education. These efforts necessitate the building of stronger bonds between ADN and BSN nurse educators, which will result in greater unity, not division. Given the growing body of research that connects positive patient outcomes to education level, the need to enhance the professional preparation of nurses is clear. Calling for more education does not denigrate those who enter the profession via different routes, but rather sends a message that nursing values education and that education impacts clinical practice. If we do not put a high value on education, employers and practicing nurses most likely will not.

The portrayal of the CNL and Clinical Nurse Specialists (CNSs) as polar opposites reflects a lack of understanding about this emerging role and its unique place in the health care system. The CNL is neither an advanced practice role, nor an administrative position as described by the authors. The CNL is a master’s-prepared advanced generalist charged with overseeing the lateral integration of care for a distinct group of patients. The CNL focuses on improving quality within the microsystem of care. By contrast, CNSs are graduate-prepared experts in evidence-based nursing who practice in distinct specialty areas. Advanced generalists like a CNL do not possess the same expertise and specialty preparation as a CNS. These nurses are prepared differently for different roles. Further, the idea that CNLs and CNSs cannot co-exist in the same healthcare system is inaccurate. In the Veterans Health System and in other practice settings where the CNL role has been integrated into a unit, CNLs and CNSs consult regularly on patient care and complement each other’s distinct scope and practice.

The idea that the CNL role was launched without significant research and input from stakeholders is also untrue. The whole concept of the Clinical Nurse Leader was an outcome of discussions held with practice leaders who identified the need for a new nursing role to fill an existing gap on the healthcare team. These conversations were started based on a number of reports calling for the need to revamp health professions education (i.e. IOM, RWJF), and they continue today with practice leaders and nursing clinicians in care settings across the country.

Consensus-building was also foundational to the movement toward the Doctor of Nursing Practice as the required degree for advanced practice roles and other specialty positions. The adoption of the DNP position statement by AACN in October 2004 was preceded by more than 2 years of focused research, consultation with stakeholder groups, and open calls for input on this innovation in nursing education. Once the collective decision to move to the DNP was made by schools of nursing, 2 AACN task forces spent another 2 years holding forums and soliciting feedback on how these programs should be structured and how a change of this magnitude could be facilitated at the local level. These conversations will no doubt continue into the foreseeable future as awareness and acceptance of the practice doctorate grows.

Finally, to characterize DNP- and PhD-prepared nurses as adversarial rather than complementary misses the point completely. Clinically-focused nurses, prepared at the doctoral level, are natural allies for nurse researchers and the most qualified clinicians to put evidence-based practice into action. In academic institutions where DNP and PhD programs co-exist, enrollments in both programs have increased and scarce resources have been efficiently shared among both types of programs. Concerns that PhD programs will lose ground as DNP programs emerge at schools across the country are overstated.

Though consensus-building has been at the core of all of AACN’s work, we realize that it is impossible to satisfy all stakeholders. The AACN has been managing this distance and working to do what the authors suggest: bring “opposing groups together to identify common interests and clarify areas of positive interdependence.” A range and large number of stakeholders are at the table and have been since the CNL and DNP concepts were first introduced. Debate does not necessarily equal dissention, and it is healthy for the profession to consider all aspects of changing RN roles and the adequacy of educational preparation. It is difficult, however, to see how the recent movements to enhance clinical competency could lead to a devaluation of nursing and more control by “forces outside of the profession” as the authors suggest. Advancing the idea that an artificial distance exists between ADNs and BSNs, CNLs and CNSs, and PhD and DNP is surely not the best way to minimize mistrust and promote unity in the nursing profession.