3: REFLECTIVE RESPONSE 2 ■ 109in response to reduced reimbursements and budget challenges (Barker, 2009). CNS
positions were often threatened or lost. There were also educational programs touting
blended role programs that typically provided minimal attention to developing the
CNS skill set and specialized expertise. Because the CNS role was more vulnerable
to workplace reductions and titling protections were often not provided at the state
level, nurses interested in the CNS role often gravitated to this role after completing
graduate education in a different area of study, including education, administration,
or NP programs.
The authors point out threats related to CNS title protection, regulation, and scope
of practice, and these issues are concerning. The Consensus Model for Advanced Practice
Registered Nurses (APRN Consensus Workgroup and National Council of State Boards
of Nursing [NCSBN] APRN Advisory Committee, 2008) offers both opportunities and
challenges to CNS practitioners, particularly because specialization is a hallmark of the
CNS role and this is an “optional” feature of the model. Limited access to and inad-
equate availability of necessary certification examinations are also priority CNS issues
(Zuzelo, 2010). Many CNSs practice across the life span within a particular specialty. As
an example, a CNS educated as an expert clinician in diabetes care management or a
CNS with specialization in orthopedics or congestive heart failure care may work with
people of varying ages. Their areas of expertise have been developed within a specialty,
and their educational and employment experiences follow a trajectory reflective of this
specialization.
The current “across the life span” population of the APRN Consensus Model
poses challenges to this specialization model, and these challenges are associated with
barriers and opportunities. The 2014 Clinical Nurse Specialists Census reports that
3,370 respondents practice in the population of family/ across the life span (NACNS,
2015a). These particular CNSs ( n = 163) capture only NACNS members who chose to
respond. Data support the fact that the lack of a certification examination for CNSs
practicing in this population is an important concern. NACNS is working to address
this need.
A critical aspect of CNS history that is not noted by the authors relates to the
conceptualization of the CNS role through efforts of the NACNS and the subse-
quent opportunities for a CNS “voice” at important national dialogues. This orga-
nization was formed in 1995 to represent CNSs, regardless of specialty. Its early
work included explicating core competencies for CNS practice (Baldwin, Lyon,
Clark, Fulton, & Dayhoff, 2007). Prior to this time, the CNS role was typically
described in a functional, “laundry list” of sub- roles, including educator, clinician,
consultant, researcher, and expert. Notably, other APRNs could reasonably claim
to have similar expertise and responsibilities. This list did not provide an encom-
passing framework to inform CNS practice.
The essence of CNS practice is recognized as clinical expertise based on advanced
nursing science knowledge (NACNS, 2004). Three interacting spheres of influence,
guided by specialty knowledge and specialty standards, provide the conceptual frame-
work for CNS practice (Figure 3.1). A process that included review of evidence, input
and validation of experts, and public comment was used to develop CNS core practice
competencies actualized in specialty practice (Baldwin et al., 2007). These core com-
petencies were again validated in 2009 via a process that included input from practic-
ing CNSs (Baldwin, Clark, Fulton, & Mayo, 2009). The conceptual framework provides
a meaningful lens through which to explicate clear differences between CNS and NP
practice (Zuzelo, 2003, 2010).