The CNS is an RN with a graduate degree (master’s or doctoral degree) leading to preparation as a CNS. The CNS specializes in a particular care setting (critical care, home care, community care) as well as in a specific disease or health issue (diabetes, medical-surgical, pulmonary, trauma). The CNS is deemed a clinical expert in the application of theoretical principles and research-based knowledge in regard to this chosen area of specialization in setting and practice. The CNS’s scope of practice is generally defined as encompassing three distinct spheres of influence (Lyon, 2005):

Practice is usually designated as within a specified interdisciplinary team (e.g., oncology services) or a particular service within an institutional setting (e.g., nursing services or department of internal medicine). Most often, it is the employer that defines the nature and scope of the CNS’s sphere of influence, provides and funds the position either totally or in part, and determines how specific outcomes are to be evaluated and by whom. The National Association of Clinical Nurse Specialists (NACNS) (2004) statement on clinical nurse specialists practice and education defines the core competencies for the CNS in each of these core spheres. Additional direct and indirect care aspects of the CNS include indirect roles as consultant-liaison, staff advocate, peer educator, change agent, policy analyst, patient educator, product evaluator, researcher (to include contributing scholarship to the literature), supervisor, mentor, and community advanced practice nurse (Hawkins & Thibodeau, 2000). Currently, there is a shortage of CNSs across the country. During the 1990s, many hospitals and academic centers were pressured to downsize or eliminate CNS positions as a result of reductions in reimbursables to hospitals, the increased costs of care, and the “nonreimbursable” nature of many, if not most, CNS roles (Hawkins & Thibodeau, 2000).

Current challenges for APNs who function in CNS roles include the absence of standardized credentialing requirements for CNS practice that allow for uniformity across state lines. This has led to differing philosophies regarding the educational preparation for the CNS, a defined scope of practice (despite the development of core CNS “competencies”), whether a “second” license is needed for an expanded scope of practice to include prescriptive authority in some states, and how to ensure competence in specialty areas of practice where no current examination exists. There is an evolving need for the CNS to continue to contribute to the literature to support advance nursing practice with a focus on specific disease and care settings, outcomes evaluation based on nursing interventions (best practices) in patient care, and the systematic evaluation of evidence-based innovations in nursing practice. These contributions support the valuable role of the CNS and the impact that they can make on patient care (Lyon, 2005).

NPs are usually defined by a specified patient population: family NP (FNP), adult NP (ANP), gerontology NP (GNP), women’s health NP (WHNP), psychiatric-mental health NP (PMHNP), acute care NP (ACNP), and pediatric NP (PNP). NP curricula share certain core content areas (advanced pathophysiology, pharmacotherapeutics, advanced health assessment, research and theory development, role development) and then explore pertinent specialty content according to designated populations of need and interest. It is generally recognized that the primary activities/functions of the NP include screening, physical and psychosocial assessment by means of taking health histories and performing physical examinations, patient care management to include follow-up when deviations from the norm are detected, continuity of care, health promotion, problem-centered services related to diagnosis, identification and mobilization of resources, health education, and patient and group advocacy (Hawkins & Thibodeau, 2000). A key component of these functions is the management of pharmacologic therapeutics in all 50 states across all therapeutic specialties and in all locales (Towers, 1991) (Box 1-1). APN curricula are challenged to emphasize quality of care, financial as well as time-based productivity, evidence-based outcomes, and practice cost outcomes, while contributing to equity of care (Allan, 2005). Current challenges include the need to develop practice models that create effective evidence-based interventions for populations differing in terms of ethnicity, culture, gender, and geographic location.

The historical and positive role that the Macmillan nurse has demonstrated throughout the British communities can easily be applied to that of the American APN providing palliative care. Macmillan nurses are posted throughout the United Kingdom; they are highly respected for their palliative care skills and in many ways are the public face of specialist palliative care in the United Kingdom (Skilbeck & Seymour, 2002).

The Macmillan nurse’s key role is to influence patient care by providing direct and indirect services. Indirect services involve strategic and policy-making activities (e.g., administrative, legislative) that influence patient care. They accomplish this by empowering and supporting primary care providers by advising on and assessing the development of patient care plans and clinical practice and through teaching and education (Macmillan Cancer Support, 2006). Direct care offered by Macmillan nurses is at the request of primary care providers and usually occurs when individual patients present with complex problems that would require specialist nurse intervention in the management and planning of their care (Macmillan Cancer Support, 2006). The focus of this role is clinical expertise, education, research, and management, contributing to multidisciplinary activities in various settings (e.g., hospital, long-term care, community home care) (Jack, Oldham, & Williams, 2003).

The Macmillan nurse is a CNS who is required to demonstrate a range of abilities that include expertise in and knowledge of advanced disease management and clinical leadership skills that enable other health care professionals to develop palliative expertise. Effective and therapeutic communication skills are required to ensure that their knowledge and skills are passed on to primary care providers (Macmillan Cancer Support, 2006).

A study that evaluated Macmillan nursing outcomes in patients with advanced cancer (n = 26) revealed that Macmillan nurses provided important assistance to patients by facilitating clinical discussion between patient and physician during medical consultations. They participated in co-coordinating actions resulting from those discussions and navigating the patient and his or her family through the healthcare system (Corner, Halliday, Haviland et al., 2003). It was pointed out in this study that Macmillan nurses spent more time with patients and their caregivers, answering questions, explaining medical terminology, and assisting patients to feel more secure about their treatment and what was happening to them—along with understanding the rationale behind specific diagnostics and whether further investigations were necessary and/or how to understand the results of these findings. Macmillan nurses often serve as the intermediary between the medical treatment team and the patient (Corner et al., 2003).

The described role of the Macmillan nurse can be easily applied to the role of the APN in various care settings. However, the NP with a distinct medical management role in palliative care could also benefit by applying attributes used to describe the role of the Macmillan general practitioner (GP). The Macmillan GP is a primary care physician specially trained in palliative care (Macmillan Cancer Support, 2006).

The Macmillan GP in the United Kingdom serves as a facilitator to improve the care of patients with cancer by providing collaborative practice with physicians in primary, oncology, and palliative care settings (Macmillan Cancer Support, 2006). Aspects of this role that can be applied to the APN in palliative care include the following (Macmillan Cancer Support, 2006):