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The advanced practice registered nursing (APRN) community in the United States has been engaged in consensus building around APRN practice/roles, education, certification, and licensure since 2004. The result is a set of recommendations contained in the paper known as the Consensus Model for Advanced Practice Registered Nurse (APRN) Regulation: Licensure, Accreditation, Certification, and Education1 released in July 2008. The recommendations were created through a long process of stakeholder negotiations convened by the American Nurses Association (ANA) and the American Association of Colleges of Nursing (AACN) to address divergent-approaches APRN educational regulation. This large stakeholder group, known as the APRN Consensus Group, included the National Association of Clinical Nurse Specialists (NACNS) along with nurse practitioner, nurse midwifery, and nurse anesthesia organizations, nurse executive organizations, certification bodies and regulators. The Consensus Group had been working for 2 years when the National Council of State Boards of Nursing (NCSBN) APRN Task Force released its draft Vision Paper in 2006.2 The recommendations in NCSBN's Vision Paper overlapped and paralleled some recommendations of the APRN Consensus Group, but many of the points in the NSCBN paper diverged from opinions in the Consensus Group. Of most concern to clinical nurse specialists (CNSs), the NCSBN Vision Paper stated that CNSs should not be considered APRNs, sending a shock wave through the CNS community. Although it was heartening to see the subsequent outpouring of support for CNSs, it was clear to the Consensus Group that consensus building needed a more inclusive membership.


The large stakeholder group was difficult to manage, and having independent groups working in parallel was ineffective. A smaller working group, including NCSBN representatives, was identified and charged with creating a model for logically linking practice, education, regulation, and certification. This group became known as the Joint Dialogue Group. The result of the continued dialogue is the document known as the Consensus Model for APRN Regulation. The document and the recommendations it contains are based on the work of Styles et al.3 It contains recommendations for licensure, accreditation, certification, and education for 4 recognized advanced practice roles-CNS, nurse practitioner, certified registered nurse anesthetist, and certified nurse midwife. Here's a brief overview of what's in the document that deserves your consideration.


Licensure. The recommendations outline expectations for legal recognition of CNS practice. Clinical nurse specialists in states with no (or limited) recognition will gain regulatory protection. At present, 35 states have some form of recognition for CNSs (electronic personal communication, JoEllen Rust, March 2008). Consistent regulatory language is needed across all states including those currently without regulation. When a role is not recognized in regulatory language, persons not prepared for the role may represent themselves to the public using the title clinical nurse specialist. Title protection is the least restrictive form of regulation, whereas licensure is the most restrictive. Licensure includes a defined scope of practice. It has long been held that nursing has 1 scope of practice. Creating a second license for APRN practice creates a second scope of practice for nursing. A "second scope" creates a situation that can be particularly problematic for CNSs, who are leaders in nursing practice and role models, teachers, and coaches for bedside nurses. It adds the additional burden to regulation to define what that scope will be and additionally adds the burden to the CNS in practice to maintain their defined scope.


Education. The recommendations suggest tightening the link between education and professional practice role. For CNSs, this recommendation will lead to more clearly defined CNS curricula standards. Preparing CNSs consistent with standards specific for CNS academic programs will help eliminate widely different curricula, resulting in more consistent practice competencies among CNS graduates. However, it should be noted that standards for curricula are not the same as standardized curriculum, the latter being more prescribed. Academic programs should be free to meet curricular standards in the manner that best fits the school's mission and the needs of the public in local and regional geographic areas.


Accreditation. Accreditation is recognition by a professional accrediting body that an educational program prepares nurses according to standards defined by the profession. In nursing, there are 2 professional accrediting bodies for nursing education programs-the National League for Nursing Accreditation Commission and the Commission on Certification of Nursing Education (CCNE). Standards for CNS education exist in the form of recommendations included in the NACNS Statement on CNS Practice and Education (2004).4 The National League for Nursing Accreditation Commission adopted NACNS's CNS curricular recommendations; CCNE has no recommended curricular standards for CNS curricula. At present, both CCNE and the proposed regulatory model are supporting more of a prescribed curricular approach, building in requirements for separate courses for pathophysiology, pharmacology, and physical/health assessment content.


Certification. Certification has long been a voluntary process for obtaining recognition by a profession as an expert in practice in a role and/or specialty. More recently, certification has been required by state regulations for entry into practice in an advanced nursing role, including CNS. The APRN Consensus Model recommendations support including professional certification as proof of minimal knowledge (entry into practice) and a requirement for legal recognition. The recommendations also support including prescribed core curricular content be included in certification examinations. Examinations will be for role (CNS) and not for specialty. Specialty focus will be removed for regulatory purposes. As a result, CNS specialty practice areas are free to respond to social need and public, and yet, CNS curricula may be confined by prescribed curricula requirements. Unforeseen consequences lie in the balancing of these 2 competing directives. Nonetheless, NACNS and the American Nurses Credentialing Center (ANCC) are moving rapidly to provide a certification examination that will meet the immediate needs of CNSs for role certification. Unless monitored carefully by CNS leaders the emerging role focus of certification that assesses the minimal role competencies will potentially negate specialty knowledge, which has long been a core foundational element of CNS practice. This will in effect create a 2-tiered certification, with 1 tier for entry into practice and 1 tier for validation of specialty knowledge.


The recommendations contained in the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education1 are moving forward in regulatory, education, accreditation, and certification bodies and hopefully will result in more consistency across APRN roles. It must be noted that consensus is not absolute, and throughout the process and in the final recommendations, there are divergent stakeholder opinions. The success of the consensus process lies in the extent to which divergent opinions were satisfied and stakeholders are well served by recommendations. You can read the complete APRN Consensus Model document from a link at


Regulation is a public process where stakeholders participate. Clinical nurse specialists are encouraged to monitor the implementation of the recommendations and speak out locally and nationally. Contact NACNS and share what is occurring in the state regulatory arena, local schools, and practice settings. Send a letter to the editor and share your views.




1. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education. 2008. Accessed December 6, 2008. [Context Link]


2. National Council of State Boards of Nursing. The Future of Regulation of Advanced Practice Nursing. Chicago, IL: Author; 2006. [Context Link]


3. Styles MM, Schumann MJ, Bickford CJ, White K. Specializing and Credentialing in Nursing Revisited: Understanding the Issues, Advancing the Profession. Silver Spring, MD: American Nurses Association; 2008. [Context Link]


4. National Association of Clinical Nurse Specialists. Statement on Practice and Education. Harrisburg, PA: Author; 2004. [Context Link]