The nurse is an active participant on human resource committees. what does this indicate?

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Abstract

Understanding the ways that perioperative nurses view the acquisition of expertise may provide foundational information for perioperative nurse educators. Our study aimed to evaluate specific types of expertise exhibited by experienced perioperative nurses and identify how nurses perceived these areas of expertise. We interviewed 20 perioperative nurses working in a university hospital in Korea. We extracted six themes regarding perioperative nursing expertise: sticking to principles, using available resources in complex situations, paying close attention to details, seeing the whole picture, prioritizing actions according to patients’ conditions, and organizing a team to maximize efficiency. These findings may help perioperative educators develop practical educational strategies for novice perioperative nurses by providing a common language regarding the areas of expertise exhibited by experienced perioperative nurses.

1 How should intensive care units (ICUs) be organized?

Patient outcomes are best in units that provide care by multidisciplinary teams, including intensivists (physician ICU experts), nurses, respiratory and physical therapists, and clinical pharmacists and nutritionists. Our experience is that optimal team performance is critically dependent on open communication across disciplines, demonstrating respect and a willingness to listen to all. Experienced team leaders (typically provided by an intensivist director partnering with a nursing director) are required to create and maintain this environment while optimizing resource utilization. Important aspects of medical director involvement include bed triage, monitoring the system to ensure patient safety, and creation of a safety culture that promotes best practice. Several studies have shown decreased rates of complications and death and better resource utilization in units where patient care is managed primarily by ICU teams (closed ICUs). This may be due to better care for the critically ill provided by intensivist-led multidisciplinary teams and better coordination and fewer communication errors in closed units. Critical care educational programs should incorporate a management training component that addresses each of these issues.

Hospitals with more than one ICU typically create an infrastructure that promotes better communication, usually in the form of a critical care committee. These committees are composed of ICU medical directors, nursing directors, and representatives from hospital administration, clinical pharmacy, respiratory therapy, physical therapy, and clinical nutrition, all of whom participate in the care of critically ill patients. The critical care committee often provides the necessary venue for multidisciplinary, open dialog to identify threats to patient safety and quality care. The committee also creates a mechanism to improve operations, including creation of guidelines and protocols to decrease unwanted variation in ICU clinical practice. The authority and responsibilities of these committees varies significantly across hospitals: many simply provide a convenient monthly venue to improve communication, whereas others are authorized and funded to plan strategically on behalf of the hospital.

In our largest hospitals with multiple ICUs (e.g., academic medical centers), efficiency and cost pressures motivate evolution of the critical care committee to a hospital-based, center-type infrastructure. Center status within the hospital organization provides the opportunity to support a more robust and mission-specific governance across all ICUs, including standing committees for critical care clinical operations, patient safety, education, research, and outreach. The operational assumption for center leadership is that the center, on behalf of the hospital, has the authority to override directors of individual ICUs when the consensus is that patient safety and quality are at risk. A center without the appropriate level of authority may be ineffective at strategic planning and leading change that best serve the community (for example, lack of ICU care coordination and patient flow can increase waiting times in the emergency department and postanesthesia care units). In addition, resources are typically allocated better with this model, as it is much more efficient to redesign care and patient flow, establish informatics platforms, adhere to care protocols, and buy equipment working collaboratively across ICUs.

Interdisciplinary Management of Pain

When experts from multiple disciplines work together in a highly coordinated team to maximize outcomes in the treatment of pain, the model is referred to as interdisciplinary treatment. Typical interdisciplinary pain programs include physicians, pain psychologists, physical therapists, occupational therapists, vocational rehabilitation experts, nurses, and other professionals, such as biofeedback technicians and movement therapists (e.g., yoga, Alexander technique, tai chi, Feldenkdrais). These professionals meet together regularly to discuss patient progress.

The goals of treatment are patient education and training to allow for independent self-care for pain. Specifically, this means stable and simple medication regimens, improved posture, ergonomic awareness, activity tolerance, independence with aerobic conditioning and regional exercise, a personal practice of relaxation techniques, a firm understanding of relapse prevention and exacerbation management, minimal pain behaviors and cognitions, and a definitive return-to-work status.

Interdisciplinary programs are the most successful interventions for patients with complex psychosocial risk factors. Participants report improved pain scores, improved mood, decreased anxiety and catastrophization, better coping skills, decreased use of medication (including opioids), decreased cost of medical care, fewer disability claims, and high rates of return to work. Many of these positive outcomes persist for years after treatment.

6.4.1 CERITD

The non-profit association, CERITD (Centre d’Études et de Recherches pour l’intensification du Traitment du Diabète, French Center for Diabetes Treatment Intensification Studies and Research), has the objective of improving the life conditions of diabetic patients and relieving them of the burden of their pathology, through support from expert nurses and the provision of modern means facilitating their autonomy. The CERITD, under the leadership of Doctor Charpentier in collaboration with the South Francilien Hospital (CHSF), is engaged in a process of translational research on diabetes to develop new resources, particularly of telemedicine, allowing diabetic patients to self-monitor and to have the information necessary for the adjustment of their treatment. One of the first results of this research is a communicating medical device available on smartphones42.

Clinical Judgment

Clinical judgment, that is, skilled clinical knowledge, use of discretionary judgment, and the ability to integrate complex multisystem data and understand the expected trajectory of illness and human response to critical illness defines competent nursing practice. In critical care, the novice nurse focuses on individual aspects of the patient and the environment. As expertise develops, the nurse develops a global understanding of the situation. The expert nurse anticipates the needs of patients, predicts the patient’s trajectory of illness, and forecasts the patient’s level of recovery. Evolving clinical expertise creates safe passage for patients. The very best nursing care often is invisible, as it should be, because untoward effects and complications are prevented. Nursing’s unique contribution to patients within the health care environment, which encompasses all nursing’s competencies, is that nurses create safe passage for patients and families. Safe passage may include helping the patient and family move toward a greater level of self-awareness, knowledge, or health; transition through the acute care environment or stressful events; and/or a peaceful death.

Current collaborating models of care

As the complexity of the disease increases, access to and continuity of input from expert HD multidisciplinary professionals may decline. Less frequent indepth, in-person assessments delay timely interventions. There are many models of care that attempt to bridge the gap between expert HD community-based care and residential care.

In the United States, care is often fragmented due to the lack of a robust national healthcare system. The only apparent exceptions are seen where formal agreements with HD experts have been established by HD specialty residential care centers. This approach is more proactive and less crisis-driven. The use of tele-medicine might help establish collaborations with residential care centers serving fewer people with HD.

When problems arise in nonspecialty residential care settings, families seek help from HD experts at academic medical centers. Such visits are sporadic, crisis-driven, costly educational sessions, which are time-consuming and usually seen by both staff and HD expert as “too little, too late.” Staff report a lack of pre-admission planning, specialty training, limited or no access to the written care plan, and little influence over changes in the care plan as consensus is not sought before implementation. In such settings, the nursing care plan remains a federally mandated, underutilized official document completed primarily to satisfy national regulators, but not to improve HD care.

In the United States, a unique role of an HD expert nurse practitioner mirrors an earlier model used to gather research data by the HD Center without Walls at Johns Hopkins (personal communication, S. Folstein, 1992) in which people with HD originally seen in an academic outpatient center are then followed for comprehensive in-person assessments or targeted problem-solving visits in residential care centers. Although beyond the scope of this chapter, nurse practitioner roles as primary care practitioners with advance training in neurology and psychiatry in long-term care need extensive documentation (Zingales-Browne et al., 2015).

In the United States, the state of Minnesota has a unique blend of architecturally adapted private residences which four to eight people with HD call “home” in a suburban and rural setting. These small residential care homes are run by family members who initially created a dedicated safe environment for their relative, then expanded to invite others. These homes are fully licensed and able to access HD expert assessments on a regular basis. Meals are family-style in a quiet setting. The routine for each person is highly individualized and respected. Normal life is closely replicated. Communicating change in people with HD is easier because of small numbers of staff. Issues are addressed promptly and solutions implemented after consensus is reached. Certified nursing assistants (CNAs) and care assistants without advanced education have direct access to the managers of small homes and solve problems together. The managers can refer any issues to the visiting clinical nurse specialist or physician expert. People with HD who do not adapt to a large HD residential center often find their “home” in the small private residences. A larger HD specialty residential care center serves as back-up and provides an alternate level of care when the small homes are no longer safe settings.

The USA currently has eight established HD specialty residential care centers, caring for approximately 260 people with HD. A majority of people with HD are not in HD specialty centers, but are cared for in small local centers where staff have learned from family. Most local residential care centers can be successful if staff are willing to be instructed by family carers. There are no data to examine if longevity and quality of life differ in small, local nonspecialty centers when compared to HD specialty center care.

Among HD specialty centers, little data have been pooled to compare and contrast the extent of pharmacologic and nonpharmacologic interventions, and what works best in daily activity programs. The implementation of measurable outcomes is inconsistently applied or nonexistent. Data are not collected by experienced CNAs and licensed practical nurses who provide direct care. Outside such specialty centers, direct carers are rarely consulted, acknowledged, asked to train others, or involved in care improvement strategies. They have little control over their scheduled assignment and remain disenfranchised, underutilized, and unacknowledged. Professional staff can incrementally change a care plan to become more useful and less restrictive and still provide a safe but stimulating place to live. The ideal is to listen to all staff and establish agreement among direct carers regarding coordinated trial and error (U.S. Senate, 2013).

Defining and Documenting the Specialty of Clinical Research Nursing

It has been a challenge to formally document and support the roles of nurses in clinical research, and there has been no standardization of job titles, scope of practice, or specialty identification. For many years, the most consistent group of nurse leaders focused on developing and defining the roles of clinical staff nurses in support of the care of research participants in dedicated research units across the country was the GCRC Nurse Manager group. This group met once per year, had a regional structure and a website supported by the former NIH National Center for Research Resources (NCRR), which funded the GCRCs. Nurses have emerged as leaders over the past 20 years in industry-focused clinical research organizations such as the Drug Information Association (http://www.diahome.org/DIAHome/Home.aspx), the Association of Clinical Research Professionals (ACRP) (http://www.acrpnet.org/), the Society of Clinical Research Associates (SoCRA) (http://www.socra.org/), and the Association of Clinical Pharmacology Units (http://www.acpu.net), although their voices has often been hidden in the interdisciplinary category of “clinical research coordinator.” In 2009, a new professional association, the IACRN (http://iacrn.memberlodge.org/) was created to focus on developing and communicating the role and impact of clinical research nursing practice globally. Since its inception, the organization has grown to more than 300 nurses with representatives from over 10 countries.

Beginning in 2006, nurses at the NIH Clinical Center capitalized on its critical mass of experience and resources and its diversity of research practice settings to formally undertake national leadership in defining the roles and contributions of nurses practicing in clinical research, as well as the needed clinical practice tools to support development of the specialty. This agenda, coined Clinical Research Nursing2010 (CRN2010), has driven the development of a conceptual framework to support nursing practice in clinical research, as well as consensus around standards and documentation of tools to support clinical research practice across the national and global clinical research enterprise.42 In 2007, this work was linked with efforts of the GCRC Nurse Manager group, as nurses in the GCRCs grappled with the transition to the funding framework for the CTSA consortium, and the National Clinical Research Nursing Consortium was formed. Leaders from the Consortium met as a “think tank” three times at Rockefeller University in 2006–2007 to lay the groundwork for defining clinical research nursing as a specialty.7,8,10 In 2009, the Consortium was formally transitioned into the new association of IACRN. Collaboration of the IACRN and the NIH Clinical Center continued through the first three national meetings, held 2009–2011 in Boston and Bethesda.

Conceptual Framework: The Domain of Practice

Development of a specialty identity that can lead to certification begins with clarification of the domain of practice for the specialty. This conceptual statement describes the overall areas of work, unique contributions, and expected work activities for the specialty. Therefore, defining the unique domain of specialty practice that makes up clinical research nursing was a key first step in documenting that a specialty practice exists. The domain framework creates a conceptual basis for developing specialty practice tools such as job descriptions, practice standards, competency assessment, educational content, and, ultimately, certification. This is similar to the steps taken by various specialty groups ranging from oncology nursing to informatics nursing.

The clinical research nursing domain of practice includes 5 dimensions and 53 individual activities, which make up the full range of practice of both clinical nurses providing research-based patient care and study coordinators managing studies (Fig. 39.6 and Table 39.2). The Clinical Research Nursing Domain of Practice was the first major component of the NIH Clinical Center CRN2010 agenda to come to completion and to be offered for validation and internal and external use. Its five dimensions and associated nursing activities were conceptually validated in a national Delphi study of expert nurses with experience managing or implementing clinical research.6 The domain model was further developed into a survey instrument, which was used in a role delineation study at the NIH Clinical Center designed to profile and compare the roles of clinical research care nurses and research nurse coordinators.43

Figure 39.6. The clinical research nursing domain of practice.

Table 39.2. Dimensions and Activities Within the Domain of Clinical Research Nursing Practice

Clinical Practice Dimension (CC)
Provision of direct nursing care and support, using the nursing process, to participants in clinical research, their families and significant others. Care requirements are determined by the scope of study participation, the clinical condition of the patient, and the requirements and clinical effects of research procedures.
CP 1	Provide direct nursing care to research participants (e.g., interaction with research participants to provide nursing care, administration of research interventions, specimen collection)
CP 2	Provide teaching to research participants and family regarding study participation, participant's current clinical condition, and/or disease process
CP 3	Monitor the research participant and report potential adverse events to a member of the research team
CP 4	Record research data (e.g., documenting vital signs, administration of a research compound, participant responses) in approved source document (e.g., the medical record, data collection sheet)
Study Management Dimension (SM)
Management of clinical and research support activities to ensure patient safety, address clinical needs, and ensure protocol integrity and accurate data collection.
SM 1	Participate in study development
SM 2	Participate in research participant recruitment
SM 3	Participate in screening potential research participants for eligibility
SM 4	Coordinate and facilitate the collection of research specimens
SM 5	Develop study-specific materials for research participant education
SM 6	Perform quality assurance activities to assure data integrity
SM 7	Participate in the preparation of reports for appropriate regulatory and monitoring bodies or boards
SM 8	Facilitate accurate communication among research sites
SM 9	Facilitate communication within the research team
SM 10	Contribute to the development of case report forms
SM 11	Participate in the set-up of a study-specific database
SM 12	Comply with International Conference on Harmonization Guideline for Good Clinical Practice
SM 13	Collect data on research participant based on study end points
SM 14	Facilitate scheduling and coordination of study procedures
SM 15	Provide nursing expertise to the research team during study development and implementation
SM 16	Protect research participant data in accordance with regulatory requirements
SM 17	Participate in site visits and/or audits
SM 18	Support study grant and budget development
SM 19	Oversee human resources (people) related to research process
SM 20	Record data on approved study documents (e.g., case report forms, research or study database)
SM 21	Facilitate processing and handling (storage and shipping) of research specimens
SM 22	Identify clinical care implications during study development (e.g., staff competencies and resources, equipment)
SM 23	Participate in the identification and reporting of research trends
Care Coordination and Continuity Dimension (CCC)
Coordination of research and clinical activities to meet clinical needs, complete study requirements, and manage linkage with referring and primary care providers.
CCC 1	Facilitate the education of the interdisciplinary team on study requirements
CCC 2	Collaborate with the interdisciplinary team to create and communicate a plan of care that allows for safe and effective collection of clinical research data
CCC 3	Coordinate research participant study visits
CCC 4	Provide nursing leadership within the interdisciplinary team
CCC 5	Coordinate interdisciplinary meetings and activities in the context of a study
CCC 6	Coordinate referrals to appropriate interdisciplinary services outside the immediate research team
CCC 7	Communicate the impact of study procedures on the research participant
CCC 8	Provide nursing expertise to community-based health care personnel related to study participation
CCC 9	Facilitate research participant inquiries and concerns
CCC 10	Provide indirect nursing care (e.g., participation in clinical, unit, and/or protocol rounds; scheduling study-related test) in the context of research participation
Human Subjects Protection Dimension (HSP)
Facilitation of informed participation by diverse participants in clinical research.
HSP 1	Facilitate the initial and ongoing informed consent or assent process
HSP 2	Support research participant in defining his or her reasons and goals for participating in a study
HSP 3	Collaborate with the interdisciplinary team to address ethical conflicts
HSP 4	Coordinate research activities to minimize subject risk
HSP 5	Serve as institutional review board member
HSP 6	Manage potential ethical and financial conflicts of interest for self
Contributing to Whom It May Concern: The Science (CS)
Contribution as a research team member to the development of new ideas for study and explorations of innovations arising from clinical research findings to practice.
CS 1	Disseminate clinical expertise and best practices related to clinical research through presentations, publications, and interactions with nursing colleagues
CS 2	Serve as an expert in a specialty area (e.g., grant reviewer, editorial board, presenter)
CS 3	Participate in the query and analysis of research data
CS 4	Generate practice questions as a result of a new study procedure or intervention
CS 5	Collaborate with the interdisciplinary team to develop innovations in care delivery that have the potential to improve patient outcomes and accuracy of data collection
CS 6	Identify questions appropriate for clinical nursing research as a result of study team participation
CS 7	Mentor junior staff and students participating as members of the research team
CS 8	Perform secondary data analysis to contribute to the development of new ideas
CS 9	Serve as a resource to new investigators

3.1 Simulation design considerations to optimize cognitive load

Most educators believe previous work experience makes expert nurses proficient, however many expert nurses have less experience in simulation-based learning experiences. As such, it is possible that being simulation naïve increases nurses' cognitive load. Theoretically, expert nurses use long-term memory to recognize salient information and implement appropriate interventions with less mental effort in most situations (Fraser et al., 2015). Researchers do not routinely report cognitive load findings in the context of previous experience that may confound results. Most studies comparing novice and expert performance used dichotomous measures and blinded (Cabrera-Mino et al., 2019; Shinnick, 2016) or non-blinded raters (Al-Moteri et al., 2019; Romero-Hall et al., 2016; Yang et al., 2012). Additional studies awarding partial credit for task performance and using blinded raters could more precisely describe the relationship between cognitive load and experience.

Existing literature demonstrates pre-briefing increases familiarity with the simulation environment and scenario. Orientation before simulation-based learning experiences removes the risk an unknown environment adds to intrinsic load (Fraser et al., 2015) which positively affects simulation outcomes (Tyerman et al., 2019). However, no studies measured nurses' cognitive load during or following pre-briefing. Further studies investigating pre-briefing are needed to understand how pre-briefing influences cognitive load.

Using and integrating knowledge increases nurses' cognitive load (Fraser et al., 2015), so educators use repeated simulation-based learning experiences to decrease cognitive load. Several researchers manipulated levels of complexity in repeated simulation-based learning experiences with the goal of understanding how familiarity with scenario content impacts cognitive load. These results operationalize the hypothesized benefit that expert nurses' repeated exposure with skill performance and situational decision-making optimizes intrinsic load (Pawar et al., 2018). Future research should use longitudinal designs to investigate whether repeated simulation-based learning experiences similarly impacts novice nurses' intrinsic load.

Future studies should use repeated simulation-based learning experiences requiring holistic care to measure changes in cognitive load over time for active participants and observers. Because extant literature supports increasing simulation since novice nurses practice decision-making independently (Cabrera-Mino et al., 2019), it seems prudent to measure their cognitive load alongside holistic behavioral performance and other outcomes over time. Using repeated simulation-based learning experiences should decrease stress (Schommer et al., 2003) by enhancing knowledge synthesis and improving clinical judgment (Lawrence et al., 2018). There is a gap in the literature, however, for evidence of cognitive load change over time.

Worked-out modeling involves demonstrating skills and procedures while verbalizing thoughts and standards of practice. Providing partial or completely worked-out examples reduce cognitive load (Fraser et al., 2015; Josephsen, 2015). Josephsen (2018) was the first to investigate worked-out modeling's effect on nurses' cognitive load, though medical educators recommend its use (Leppink and van den Heuvel, 2015). Surprisingly, Josephsen (2018) found providing worked-out models did not significantly reduce intrinsic or germane loads but did reduce extraneous loads. Though study findings were limited by research design (e.g., pilot study, small sample, convenience sample, poor internal consistency with a researcher-adapted tool). Worked-out modeling theoretically reduces cognitive load by developing cognitive schema, minimizing germane load, and decreasing intrinsic load (Jalani and Sern, 2015; Josephsen, 2018). Josephsen (2018) provides a start to investigating how worked-out modeling impacts novice nurses' cognitive load, and the body of literature could be strengthened if further research involved larger samples with reliable measures.

The past

The role of the CNS presents a unique combination: a CNS is a nurse who is an expert nurse clinician who functions within a nursing specialty. This APRN operates in 3 distinct yet overlapping spheres of influence.5 Within these spheres, the patient, nurse/nursing practice, and systems, the CNS uses evidence to develop or improve nursing practice, thus, improving patient outcomes. The foundations of the role are firmly centered in the essence of nursing practice and clinical expertise. Truly, the beginnings of this role reach as far back as Florence Nightingale’s work during the Crimean War.6 Nightingale, as an expert nurse clinician, worked within a specialty (trauma/combat) and used evidence to improve patient outcomes.

A new nursing role is only developed when there is a real or perceived need by society, the nursing profession, or the larger health care system. The role of the CNS grew from the societal and professional need for an expert clinician to guide peer nurses in areas of complex patient care and the reality that specialization was happening within health care and nursing.7,8 The 2 separate phenomena, the need for an expert clinician and specialization, were developing simultaneously but actually developed independently of each other.9 Hildegard Peplau brought the concepts together when she fully developed the psychiatric mental health CNS. The role further matured with the development of specialty competencies and role-specific competencies.10 Evidence of societal and professional acceptance came over time: structured educational preparation that was CNS specific, educational programs became accredited, certification of individual CNSs was possible, and title protection/licensure occurred in some states.

The CNS role has been established as evidenced by discussions in the literature over the last 100 years. In a 1943 speech, Frances Reiter7 talked about the “nurse clinician” as an expert nurse. She continued to refine her definition of this role for the next 40 years.7 By 1966, she described the role as one with direct clinical practice and other indirect practices, such as activities carried out with other nurses and with other professionals but always on behalf of the patient.7 This concept was identified as one of the conceptual beginnings of the 3 spheres of influence later described in the Statement on Clinical Nurse Specialist Practice and Education.11 Reiter went on to further define this role as one that has a wide range of functions, an increased depth of understanding, and a provider of a wide breadth of services. The role of the expert clinician was seen as a part of nursing practice and as such needed to be controlled by nursing.7 Not just any nurse could fill this role. The expert nurse clinician required experience, training, and a graduate-level education.12

Even before the discussion for the need of an expert nurse clinician, the need to specialize within nursing was being discussed. An American Journal of Nursing classic reprint of an October 1900 article by Katherine De Witt13 describes a specialized nurse’s sphere being more limited but patients getting better care now than when a nurse had to know and do it all. Dolores Little8 expressed that specialization was no longer up for debate. She went on to describe a nurse specialist as one with advanced knowledge and skills in nursing practice regarding patients who have similar diseases, conditions, situations, or problems.8

In 1954, the 2 concepts of specialization and expert nursing care came together when Hildegard Peplau created a masters-level educational program for the preparation of psychiatric mental health clinical specialists at Rutgers.14 By 1963, federal funding agencies were funding nurses to be trained as CNSs in a variety of specialties.10 Although the role was fully established, there still existed some confusion. There were many different titles for CNSs with conflicting descriptions and unclear expectations of practice. In 1980, the American Nurses Association made clear their position with the release of their position statement, Nursing: A Social Policy Statement.15 The statement clearly identified that the CNS must be educated at the graduate (masters or doctoral) level. It referred to specialization and expert practice as well as specialty certification. Most of the pieces were now in place to have the CNS role widely accepted in nursing, health care, and by society as a whole.

The National Association of Clinical Nurse Specialists (NACNS) was formed in 1995, and by 1996 the board of directors appointed an expert panel to develop core CNS competencies. After a rigorous multiple-tier process, including a review of the document by 51 nationally recognized nursing leaders and 9 national nursing organizations, the first Statement on Clinical Nurse Specialist Practice and Education was released in 1998.16 The document contained the first set of fully described core CNS competencies and educational standards to be used in academe. The core competencies for all CNSs, regardless of specialty, were widely distributed and accepted. The final, and most recent, piece of the puzzle for recognition of the role was the creation of the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education.4 This model was crafted to specifically spell out the requirements of the 4 roles of APRN: nurse practitioner, nurse midwife, nurse anesthetist, and the CNS. This process included more than 60 different organizations and took 4 years to complete. The document was widely accepted, and action is currently in process to fully implement the proposed regulatory model. Included in the model are title protection and recognition of CNSs as a full APRN role. This final piece has firmly established the role of the CNS in society and completed the process that started more than 100 years ago.

The CNS role, as with many other roles within nursing, had a colorful past that has taken many different turns along the way. The role is now well defined with core competencies that have gone through a third revision. Additional work undertaken by the NACNS includes a further-refined and updated list of specific education criteria that has been published in 2012. The NACNS is an organization that represents all CNSs regardless of specialty and is the steward of the CNS core competencies and the education criteria. The consensus model for APRN regulation has defined the requirements for licensure, accreditation, certification and education. All of the requirements to have a role accepted by nursing, health care, and society have now been met.