Seasoned educators offer reassurance. “Personally, I’m optimistic about the future need for advanced practice nurses, not just nurse practitioners [NPs], but [also] clinical nurse specialists [CNSs] and educators,” says Sister Mary Jean Flaherty, RN, PhD, FAAN, dean of the school of nursing at Catholic University of America in Washington, DC. “It’s a time when we can demonstrate to the public that nurses deliver cost-effective care with respect for the individual.”

Patricia Munhall, RN, ARNP, EdD, PsyA, FAAN, associate dean of the graduate nursing programs of Barry University in Miami, agrees: “Many, many doors will open to nurses with a graduate degree.”

NP programs currently generate the greatest interest. NPs act as primary care providers addressing acute, chronic, and preventive healthcare needs within an area of clinical specialization. By 1992, there were approximately 30,000 nationally certified or state-recognized NPs. Many nurses long for the NPs seeming independence. In 49 states, NPs have authority to prescribe medication, and in 14 states, prescriptive authority is independent of physician involvement. In 24 states, NPs can practice without physician oversight.

NP spells success

As managed care organizations tighten their financial belts, NPs should become more competitive than other kinds of providers. “Advanced practice nurses have marketable skills, especially the assessment of the individual, family, or community within a primary care setting and the management of the patient over time,” says Linda Simunek, RN, ARNP, PhD, JD, dean and professor of nursing at Florida International University’s school of nursing in Miami, and chair of the education committee of the Florida Board of Nursing. “It’s necessary to promote wellness because the current paradigm is less is more and prevention is important.”

Across the country, there are 480 individual NP programs on the master’s level, and many have waiting lists for admission. In the fall of 1995, students in NP programs accounted for 42 percent of all graduate nursing students, according to the American Association of Colleges of Nursing (AACN). Of the NP students, about 46 percent want to be family NPs, 21 percent adult NPs, and 12 percent pediatric NPs.

In the past, NPs were educated in a variety of academic settings, some outside of graduate nursing programs. But those days are ending. The AACN, as well as other nursing organizations, support graduate education for all advanced practice nurses – NPs, CNSs, nurse anesthetists, and nurse-midwives – by the year 2000. “It’s better to keep NP programs in graduate nursing schools so that NPs don’t lose a nursing identity and to ensure that they have exposure to nursing research and theory,” says Munhall.

Chicago’s Rush University is typical of the strong growth of NP programs. Last year approximately two-thirds of the graduate students were CNSs, and the remainder were NPs. This year, the ratio reversed – two-thirds are NP candidates. The number of clinical specialties also is growing. The acute care NP program – managing the critically ill as inpatients – has grown the fastest, doubling within the past year. NPs manage patients and perform therapeutic procedures that in the past were handled by medical residents. Most candidates are already CNSs who are retooling their skills to expand their clinical expertise. They usually are rehired by the hospitals where they work. And interest in acute care NPs is expanding from medical centers to community hospitals.

But no one knows how many NPs the market can absorb, or if graduates will be forced to move to find jobs. “Practitioner programs are proliferating at an astonishing rate, and the market will be saturated soon,” says James Vail, RN, PhD, associate dean, graduate programs and research, George Mason University, college of nursing and health sciences, in Fairfax, Virginia. “We’re not having a wide enough vision of the future. Schools are starting to phase out other kinds of programs and that’s a mistake.” Munhall agrees: “As educators, we need to protect the integrity of the MSN (master of science in nursing) in the educator, the executive, and the CNS role.”

CNS, MBA tracks good choices also

Kathleen Scharer, RN, MS, CS, FAAN, care manager, Lutheran General Hospital in Chicago, and chair of the American Nurses Association Task Force for Advanced Nursing Practice Scope and Standards, advises students to seriously consider CNS tracks. “In some ways, the CNS education program gives you more flexibility and a broader base in terms of research, consultation, patient education, and teaching. But people want a guarantee of employment, and there aren’t any guarantees anymore. In truth, staff nurses and the institutions they work for still need nurses with a high level of proficiency to guide and model improvements in patient care.”

Nurses also return to graduate school to learn business and administration skills. But what kind of degree suits them best, an MSN, a master’s in business administration (MBA), or a master’s in health services administration? “Clearly there’s a need for nurses with degrees within and outside of nursing,” says Jeanne Michaels, RN, MSN, supervisor of the utilization management program of BlueCross BlueShield of Illinois. “Nurses should seek the type of degree that will provide the breadth of knowledge to support marketable skills in a fast-changing market.” Although she has a degree in nursing education, Michaels now needs a broader focus. “Today I would consider a business degree to build on my nursing expertise and to broaden my skills in the larger business arena,” she says. Michaels sees colleagues with clinical nursing degrees go through “a challenging transition when they enter the business world.”

DD White, RN, MSN, director of quality management, Columbia/HCA Health-care Corp., also advocates graduate education for administrators. “Overall, it doesn’t make a difference what kind of degree as long as it’s a graduate degree,” she says. “In a large, complex hospital, you need a master’s degree starting at the nurse manager level.” She tells students to pursue a business-related master’s or a nursing master’s coupled with a business degree. “It allows a nurse executive to communicate on a level playing field because most other players have master’s degrees or greater,” she says. “A greater depth of education also gives nurse executives a broader view of healthcare outside of nursing.”

Dual degrees gain popularity

The number of dual degrees has almost doubled in the last five years, according to AACN. Jackie Dienemann, RN, PhD, CNAA, FAAN, associate professor, school of nursing, The Johns Hopkins University, Baltimore, advocates dual degrees. “It’s vital to understand the business of healthcare, as well as nursing on a deeper and more complex level than is possible on the baccalaureate level.” Dual degrees save time and make graduates far more competitive, she adds.

North Park College in Chicago offers dual degrees, MS-MBA and MS-master of art in theological studies (MATS), besides NP programs. But Alma Labunski, RN, MS, EdD, chairperson and professor of the division of nursing, advises students to seek broad-based skills, regardless of the program. “We can’t afford to be specialty focused any more,” she says. “We need cross-prepared, advanced generalists who are well prepared in a clinical area, as well as in a broad way in a functional role of administration or education.”