1. Goudreau, Kelly A. DSN, RN, ACNS-BC

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Our world is full of acronyms, and LACE is just one more. LACE stands for licensure, accreditation, certification, and education and is identified as the 4 pillars of regulation by Affara and Styles.1 LACE represents a national effort by the advanced practice nursing community to align the 4 pillars for all of the advanced practice nursing roles-clinical nurse specialist, nurse practitioner, nurse midwife, and nurse anesthetist. Here are some things clinical nurse specialists (CNSs) need to know about and monitor regarding this national collaborative effort.



The Advanced Practice Registered Nurse (APRN) Consensus Model was developed over a 4-year period between 2005 and 2008, crafted by stakeholder representatives from all 4 of the APRN roles and professional practice groups such as the American Nurses' Association. Released in July 2008, it received the endorsement of more than 40 nursing organizations. The goal is now to implement the model by a target date of 2015. To that end, LACE has been created. LACE is a collaborative body intending to provide a structure for dialogue, debate, and consensus as implementation of the APRN model proceeds. Placement of the letters in the LACE acronym is not intended to indicate prioritization; each of the elements is as important at the others, and one cannot survive without the others. The elements are codependent. Who are the stakeholders in LACE? All advanced practice nurses, including CNSs, are stakeholders in this effort. In addition to the advanced practice nursing community, there are anchor organizations for each of the pillars. Here is a brief overview of some of the central LACE stakeholders and the interests they represent.


L = Licensure. The licensure stakeholders are represented by the National Council of State Boards of Nursing. The National Council of State Boards of Nursing, although not a regulatory body, is representing the interests of its members and individual state boards of nursing and is addressing needs for state-level legislative actions and subsequent rule making. What's in it for CNSs? Some states do not yet recognize CNSs as advanced practice nurses. Whether a state determines recognition by licensure, certificate to practice, or verification of your credentials, the significant impact for CNSs is recognition in all 50 states. At last count, there were 38 of 52 states and territories that had incorporated recognition of the CNS role (personal communication, J. Rust, June 15, 2010). In some states, only psych/mental health CNSs are recognized, and prescriptive privileges for CNSs are distributed unevenly across the states.


A = Accreditation. To assure the public and consumers (students) that nursing educational programs meet established standards, programs should be accredited. Accreditation has decided advantages for students, graduates, and the schools, including ability of graduates to be admitted to another accredited school, transfer of earned credits among schools, and ability to accept federal funding, to name a few. Nursing has 4 accrediting bodies. The National League for Nursing Accreditation Commission and the Commission on Collegiate Nursing Education both accredit CNS and nurse practitioner programs at both the master's and doctoral levels. In addition, there are separate accrediting bodies for certified nurse midwife and certified registered nurse anesthetist programs. Each accrediting body has met the requirements of the US Department of Education as an accrediting commission within nursing. What's in it for CNSs? The preaccreditation process, similar to what currently exists for certified nurse midwife and certified registered nurse anesthetist programs, will be implemented for CNS and nurse practitioner programs. This process will help CNS programs look more alike and thus prepare graduates with similar clinical competencies. Over the 50-plus years of CNS history, CNS role preparation was inconsistent. Tightening up on educational programs can work to our advantage in today's outcome-focused environment. Additionally, it is expected that members of an accreditation body's on-site accreditation teams will be CNSs or CNS educators where CNS programs are being reviewed for accreditation.


C = Certification. Certification by a professional nursing organization, long a measure of excellence, has shifted focus to be a measure of minimum competency to practice in an advanced practice role, including CNS. To practice as an APRN, it is expected that state boards of nursing will require evidence of advanced certification by the year 2015, making certification a proxy for a licensure examination. As with any single written examination, it is difficult to determine practice competence, which is leading to dialogue about a sequential or serial assessment of knowledge. What's in it for CNSs? The question of certification of CNS specialty practice will have to be resolved. Clinical nurse specialist certification in the current model presents challenges, given the diversity of specialty practice available to CNSs. Few certification examinations are available, and many do not match the specialties existing in CNS practice. Recently, the American Nurses Credentialing Center and the National Association of Clinical Nurse Specialists (NACNS) collaborated to create a core CNS competencies certification examination. It was an innovative and interesting first step toward building a credible and practical certification option for specialty CNS practice. The American Nurses Credentialing Center shelved this option prematurely. The positive elements of this approach will have to be revisited to build a certification option for CNS specialty-focused certification. It is logically inconsistent to have a specialty practice recognized by a broad, generalist certification mechanism, or to eliminate specialty practices because we, the nursing community, cannot create a workable certification mechanism.


E = Education. Along with educational program accreditation, developing educational standards for CNS programs will help to clarify the role for students, employers, and the public. Master's-level programs have been including recommended core content (AACN Master's Essentials, 1996). The APRN model recommends expanding the core content for advanced practice to include physiology/pathophysiology, health/physical assessment, and pharmacology. Adding this content may be challenging for some CNS programs where additional content may result in deleting other CNS role-specific content. Additionally, NACNS is developing standards for CNS education, which will help provide direction for CNS course revisions. What's in it for CNSs? Delineating clear expectations for CNS education programs will lead to increased ability to monitor CNS practice outcomes and demonstrate the value of CNS practice to the employer and public. A caveat here is to not move too far and allow standards for education to become standardized education. As with certification, CNS education needs to retain the elements of specialty practice. Schools of nursing are expected to meet the needs of the unique sociogeographic areas they serve; maintaining specialty CNS practice is one way of addressing these unique public needs.


Clearly, there are both opportunities and challenges for CNSs related to implementing the APRN consensus model. If LACE is successful, the current "messy house" in the CNS world will be much cleaner. Clinical nurse specialists will retain our historic place in advanced practice, and we will emerge with a clearer picture of our contributions to the health and welfare of the public. The challenges will be in the cost, both financial and intellectual, of moving this work forward, particularly at a time of severe CNS and CNS faculty shortage. So, what's in it for me? Opportunity!


All CNSs must be engaged in this work. Here are some things for your to-do list. First, engage with your state board of nursing. Be a member of the board or an advisory committee. If you cannot be a board member, regularly meet with board members and educate them about the CNS role, core competencies, and practice outcomes. Teach, explain, demonstrate, and most of all repeat the aforementioned as needed. Be the advocate for CNS practice in your state, community, and health care facility. Second, become a site visitor for the National League for Nursing Accreditation Commission or Commission on Collegiate Nursing Education, the two educational accrediting bodies for CNS programs. As a member of a team, you will help shape CNS education in the academic environment. Look for other opportunities to become engaged in the accreditation process, like reviewing standards or serving as an advisor or consultant. Third, be an active participant on the certification boards within your specialty. Opportunities exist to be a test item writer for the examinations and to serve on content expert panels that determine the viability of the examinations for specialty practice. Fourth, help find reasonable mechanisms for CNS certification. Communicate with NACNS; let the organization know how the core examination can be used to build a certification option for all CNSs. Advocate for appropriate specialty certification in your state and with your state board of nursing. Finally, if you are a practicing CNS, get involved with your local educational programs. If no CNS program is available, help to open or reopen a program. Become engaged in the education of future generations of CNSs in whatever manner you can.


If you are not familiar with the APRN consensus model, you can download a copy at I have been NACNS's representative to the APRN Consensus Model meetings, and I am continuing as the NACNS's representative to the LACE implementation. I have stated a blog, located on the revised Web site of this journal-Clinical Nurse Specialist: The Journal for Advanced Nursing Practice. You can find my blog by going to the journal's Web site at I will be discussing what's new with the LACE implementation, answering your questions, and helping find ways for you to be involved. Join the blog. Together we can make a difference; there is a lot in it for CNSs.




1. Affara F, Styles M. Nursing Regulation Guidebook: From Principle to Power. Geneva: International Council of Nurses; 1997. [Context Link]