1. Horner, Sharon D. PhD, RN, MC-CNS, FAAN
  2. Fulton, Janet S. PhD, RN, ACNS-BC, ANEF, FAAN

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When the Advanced Practice Registered Nurse (APRN) Consensus Model was unveiled by the advanced practice nursing community in 2008, pediatrics was identified as a specialty population for which clinical nurse specialists (CNSs) should be educated and certified. The decision to specify pediatrics as a specialty was recognition of the unique health needs of children for advanced-level nursing services. According to the Henry J. Kiser Foundation, 26% of the world's population is younger than 15 years, and with a worldwide infant mortality rate of 38% (, without question, the public needs nurses, including CNSs, dedicated to caring for infants and children.


More recently, the American Nurses Credentialing Center (ANCC) proposed retiring the pediatric CNS certification option. With the APRN Consensus Model linking education, certification, and regulation, this decision could have a major impact on CNSs' ability to meet the public need for pediatric nursing services. To satisfy state regulatory requirements, pediatric CNSs will have to have graduated from a pediatric CNS academic program and obtained pediatric CNS certification. Eliminating a CNS pediatric certification option threatens existing pediatric CNS programs because schools will not continue educational programs if graduates will be denied certification and, thus, practice opportunities. The APRN Consensus Model has created a profession-centric circular argument-if there is no CNS certification option, CNS programs close; if the program closes, there are no graduates to take and maintain certification test validity. For the model to work, all parties must uphold the consensus decision. Unfortunately, it is the very public the model purports to protect that loses access to CNS services in the absence of certification options.


The public health need for pediatric CNS nursing services is clear. The National Survey of Children's Health data, an overview of the state of children's health in the United States, found that 24% of children younger than 18 years had at least 1 chronic physical or mental health problem, and 41% of these children had more than 1 chronic condition.1 Given the fact that children younger than age of 18 years comprise nearly a quarter (23%) of the US population, these chronic health conditions have a substantial impact on today's healthcare system as well as implications for the long-term health of the nation.2 Among school-aged children, the most common chronic conditions are obesity (18%), asthma (9%), learning disabilities (8%), and attention deficit/hyperactivity disorder (8%).1,3 Among adolescents, the most common chronic conditions are obesity (21%), depression (9% had a major depressive episode in the previous year), and asthma (8%).1,2 Cardiovascular health problems are emerging in children and youth and are associated with obesity and hypertension.4 Diabetes affects "only" 1.3% of children and youth, but this is a 30% increase in the last 10 years alone.1,5 Furthermore, newly diagnosed diabetes among adolescents accounts for 20% to 50% of all new-onset cases.5


Other developed or high-income nations around the world report similar statistics to the United States. However, in low- and middle-income countries, the pressing problem facing most children is not obesity but rather is one of malnutrition. In 141 low- and middle-income countries, malnutrition and serious underweight status (-3 SD from mean) is the major risk factor contributing to increased childhood mortality, susceptibility to infectious diseases, and poor school performance, which in turn leads to poorer health in adulthood.6 The World Health Organization supports efforts to improve the nutritional status of children, including feeding programs (eg, food banks, lunch programs) and community agricultural initiatives (eg, local farming, community gardens).7 The World Health Organization is collaborating with international organizations and local governments to reduce and prevent infectious diseases through community-wide immunization programs.7 Pneumonia and diarrhea remain the leading causes of childhood mortality around the world.7


Strong interrelationships exist among health problems in children. For example, obesity, the leading health problem facing Americans today, also affects physical, emotional, and social health. The lifetime consequences of obesity are severe-obese children become obese adults.4 Obese children are more likely to have asthma, hypertension, atherosclerosis, joint pain, elevated lipids and insulin resistance, poor self-esteem, and distorted body image.1,4 Furthermore, severe obesity reduces life expectancy by 5 to 20 years.8 In other words, chronic health problems are paying negative dividends by evolving into serious comorbidities. In addition, only 70% of poor children have good to excellent health in comparison with 90% of children from middle-income homes.1 In the United States, today's children are the first generation in more than a century to have shorter life expectancies than their parents or grandparents.8


Complex health problems need the careful attention of a healthcare team with the knowledge, skills, and expertise to work with families in the context of their homes and communities to achieve effective behavioral changes. Pediatric CNSs have the education and expertise to lead efforts to coordinate care across disciplines and to provide direct support and guidance to families needing to make sustainable lifestyle behavioral changes.9 But given the limited numbers of CNSs specializing in child health, and the large population of affected children and families, we need more attention to maintaining and expanding pediatric CNS programs in colleges and universities. Pediatric CNSs have been providing advanced level nursing care to children for about 50 years. To the extent that the APRN Consensus Model facilitates CNSs providing care to children, it should be honored by the advanced practice nursing community. Should it fail to produce intended results, it is up to the advanced practice community to either revise or abandon the model in favor of the more important priority of the public need for nursing services.


As this editorial goes to press, ANCC reports retaining the Pediatric CNS certification for the immediate future. Students enrolled in a pediatric CNS program before October 31, 2017, but not graduated by October 31, may apply for and take the pediatric CNS examination after October 31, 2017, but not later than 6 months after graduation. Provided there are adequate applicants to maintain test validity, ANCC should consider retaining the Pediatric CNS certification.


Nursing needs a cadre of expert pediatric nurses prepared at the advanced level, and the pediatric CNS is a role that can provide leadership for children's health. Pediatric CNS is a recognized role and population in the APRN Consensus Model, and therefore, it deserves the support of the advanced practice nursing community across educational accreditation, professional certification, and state regulatory arenas. Schools are challenged to maintain these programs with adequate enrollment when certification options are threatened and, ultimately, the public loses access to nursing services. Pediatric CNS educational and certification options should be supported and grown for the sake of the health of the nation and world's children.




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