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Specialization is a hallmark of clinical nurse specialist (CNS) practice now as it has been the past 50 years. It has been around so long that maybe it is time to revisit the importance of specialization. Let us start with a definition. The National Association of Clinical Nurse Specialists and the American Nurses Association agree in defining specialization as a delimited or concentrated area of expert clinical practice with focused knowledge and competencies. The specialty area may be broadly or narrowly defined; the area may be well established or emerging.1,2 Typically, a CNS specialty is identified in terms of population, such as gerontology or maternal child health; type of problem, such as wound or pain care; setting, such as perioperative or emergency; type of care, such as rehabilitation or palliative care; and disease/pathology, such as oncology, diabetes, and orthopedics.1,2


A characteristic of specialization in a practice discipline such as nursing is a division or partitioning of a more general area of practice along some logical lines. Specialization involves a narrowing and deepening of focus or a recombination of aspects of different areas of knowledge and practice competencies with a simultaneous narrowing and deepening of focus.3 Oncology, cardiology, and neurology are specialties, each with a distinctly narrow, but deep, knowledge focus. Pediatric oncology and cardiac rehabilitation are examples of combining 2 areas of knowledge-pediatrics and oncology, cardiology and rehabilitation-to create a specialty with a depth of focus that allows the study of relationships among specific phenomena.


The impetus for specialization arises from scientific and technological discoveries along with continuously evolving health concerns in a society. Specialties are, therefore, adaptable. Today we need CNSs in HIV/AIDS care, while 50 years ago the need was for CNSs in polio care. Ten, 20, or 50 years from now what specialties will we need and how many in each? Specialization gives the nursing profession at large the ability to address the full scope of the health concerns by expanding and contracting specialties. Thus, we in nursing do not determine specialties. Specialties are determined by the society and reflect nursing's implicit contract with society-our social mandate-to meet the needs of the society that creates and supports our profession. Palliative care is a good example-the knowledge exists and the public is demanding improved palliative care. Clinical nurse specialists are now available with an expertise in palliative care because we serve the needs of the public.


As specialists, CNSs are clinical experts in the diagnosis and treatment of illness and the delivery of evidence-based nursing interventions, possess advanced knowledge of the science of nursing along with a specialty focus, and apply that knowledge to nursing assessments, diagnoses, and interventions and to the design of innovations for clients with similar special needs.1,2 Specialization is built on the generalist practice foundations of baccalaureate nursing education.1 CNS specialty practice results when a nurse moves from the generalist focus of an undergraduate degree to an advanced-level nursing (graduate level) with a specialty focus. Thus, a CNS is first a generalist, who has the ability to understand and appreciate the complexity and compounding nature of the multiple problems that a patient may experience. For example, a CNS with a specialty in wound care would be able to understand the etiology and contributing factors influencing wounds from multiple causes-for example, diabetes, vascular insufficiency, trauma-because the CNS is first a generalist.


CNS specialization ensures that a portion of the profession has in-depth knowledge and advanced competencies about emerging and narrow health concerns. Generalist preparation cannot adequately address specialty competencies; thus a smaller group of advanced practice specialists, CNSs, provide the knowledge and competencies to both deliver and direct care to clients and to translate nursing's phenomena of concern into specialty interests.


State nurse practice acts grant nurses an independent and autonomous scope of practice that differentiates the practice of registered nursing from the practice of other licensed health professions, such as physician, physical therapist, and pharmacist.4 We are just beginning to spread our wings and discover how much of nursing's autonomous terrain (scope of practice) is undeveloped. A graduate degree from a program that prepares CNSs is the way CNSs acquire tools to explore the uncharted terrain. It is our responsibility to develop specialty practice in nursing's autonomous domain and ensure overall professional resources adequate to meet society's need for nursing care. Indeed, CNS specialty practice helps to ensure nursing's viability for now and the future. Specialization is as important now as it has always been.




1. NACNS. Statement on Clinical Nurse Specialist Practice and Education. Harrisburg, Pa: National Association of Clinical Nurse Specialists; 2004. [Context Link]


2. American Nurses Association. Nursing: Scope and Standards of Practice. Washington, DC: American Nurses Association; 2004. [Context Link]


3. Peplau H. Specialization in professional nursing. Clin Nurse Spec. 1965/2003;17:3-9. [Context Link]


4. Lyon BL. The CNS regulatory quagmire: we need clarity about advanced nursing practice. Clin Nurse Spec. 2004;18:9-13. [Context Link]