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From time to time, people have had to revise their ideas about the world because new evidence invalidates past ways of thinking. Newton's theory of gravity toppled the early Greek's notion of two types of matter, heavenly bodies and earthly bodies. Copernicus, Galileo, and Columbus provided evidence that the world is indeed round. These well-recognized examples of scientific discovery remind us that our understanding of the world is subject to change. As social structures and scientific methods advance, so does our ability to collect and analyze evidence, thus modifying our beliefs about our world.


Research, that scientific process of collecting, analyzing, and interpreting evidence, always starts with a belief system-heavenly versus earthly, flat versus round. During the past 20 years there have been multiple research studies examining the practice and roles of clinical nurse specialists (CNSs). Although many of these studies attempted to explore CNS practice, most of the body of work represents role activity studies. Whether implied or stated, the largest percentage of these studies are grounded in a belief system that there are 5 roles of a CNS-practitioner, educator, researcher, consultant, and administrator. This view, articulated by the American Nurses Association (ANA) in 1986, became the dominant belief system, and the 5 roles were viewed to be a description of CNS practice. It follows then that researchers validated CNS work by asking questions about activities related to these roles. There are now data to validate the ANA's belief about CNS roles. But what if that belief system were to be challenged? The world is not flat. The 5 roles do not represent CNS practice.


Try a new view. CNS practice is not a role or a combination of roles. CNS practice is the essence of what characterizes the advanced practice specialty. CNS practice provides the core-it defines CNSs and is based in clinical nursing expertise that is unique among the healthcare services offered by other providers. Unique expertise making unique contributions to the health needs of a specialty population. Unique, not shared. Unique expertise generating unique outcomes.


I was challenged to think about this notion of unique nursing care when a colleague stated that, in her opinion, CNS certification examinations are difficult to develop because CNSs do not have a uniform circumscribed area of practice like nurse practitioner groups-pediatrics or gerontology or such. It seems obvious that other advanced practice nurse groups rely on the tidy world created and articulated by medicine, rooted in disease and the diagnosis and treatment thereof. The work of nurse practitioners, nurse anesthetists, and to a lesser extent, nurse midwives, fits neatly into medicine's world and is easy to describe using medical language. Nursing's unique contributions, grounded in the work of Florence Nightingale, began by focusing on assisting patients in the prevention or resolution of illness. Today there is growing recognition that factors other than disease affect illness and that illness is more likely a state of health that is holistic, experiential, and context dependent. However, over the years, nursing's work has been medicalized so that the language of nursing has put nursing's unique work into the background and substituted nursing's contribution to disease diagnosis and treatment in the foreground. Nursing's unique contributions indeed have language and can be articulated and circumscribed. We do, however, lack skills in articulating our contributions.


We must change our view of the CNS. What is at stake? While other advanced practice nurse groups practice largely as an extension of another discipline, primarily medicine, CNSs are committed to forging ahead on the defined path of nursing. Nursing is concerned with human populations, their health, and their environment. It follows then that expert nursing care would be directed to affect the health and environment of various specialty human populations. Expert nursing interventions direct outcomes by influencing patients and families, their communities, the healthcare delivery system, and those nurses who, in a complex delivery system, also provide nursing care. There are those among us who suggest that the language of nurse work is not tidy-not categorized, coded, and universally understood. Not that tidy is not a noble goal, it is important that nursing's intellectual capital continue efforts to organize and validate the language of our work. But we are not there, and unlike medicine, the language of our work is not codified in public policy and used as a basis for reimbursement.


In the meantime, some CNSs have sought nurse practitioner certification to better capture reimbursement for services. But what is being reimbursed? In most cases, it's the provision of medical care-diagnosis and treatment of disease. This does little to support reimbursement for nursing diagnosis and nursing intervention There are examples of nursing interventions being reimbursed, such as for teaching and counseling patients with diabetes. Expanded reimbursement for nursing interventions will not occur anytime soon if we continue to place our emphasis on reimbursement of nurses for practicing within the medical domain. CNS practice is advanced nursing practice, and indeed, is the flagship for the advancement of nursing itself. CNSs are central to bringing order to the world of nursing practice and ensuring that nursing has a rightful place at the table of healthcare providers-providing unique care not offered by any other profession.


The NACNS Statement on CNS Practice and Education offers a new belief system for CNS practice. The statement is now under revision. In this issue there is a call for comments and general feedback about the statement. Get involved. With revisions of our view will come research based empirical support for CNS practice. CNS practice is real and ultimately a unique circumscribed area. We just need help organizing and tidying up the language. In the mean time, let's remember that most of the previous evidence of CNS practice is a substantiation of a belief system that is now being changed. It's a new era, time for a new point of view.