The first formally recognized clinical nurse specialist (CNS) programs were created after the 1965 enactment of the Nurse Training Act under Title VIII of the Public Health Service. These programs emphasized graduate nursing education with a focus on advanced clinical practice as opposed to a previous focus on education and supervision. Graduates of these early programs pioneered employment opportunities by convincing nursing and hospital administrators to create CNS jobs. Through their successes, CNSs were hired, job descriptions were created, and CNSs moved into the mainstream of hospital employees as advanced practice nurses (APNs).

What has happened to the focus on advanced practice during the past 37 years? The notion of a CNS as an advanced nurse with a clinical practice was replaced by an emphasis on roles. The shift was reinforced dramatically by the 1986 American Nurses Association publication The Role of the Clinical Nurse Specialist,1 a document that identified dimensions of the CNS role-specialist in clinical practice, educator, consultant, researcher, and administrator. Practice ceased to be the focus. The roles were incorporated into hospital job descriptions, often with distinct responsibilities assigned for each role. In other situations, CNSs were subsumed under a single role, such as staff educator. In effect, CNSs were defined by hospital job descriptions organized by roles.

I offer this history not to criticize. CNSs were conceived as advanced clinicians with graduate education in nursing-a significant step in the development of nursing as an academic discipline with the intellectual power to generate knowledge for professional practice. However, with time, CNS practice has gone into the background while roles, usually imbedded in job descriptions, have taken the foreground. With hospitals as the all but exclusive employers of CNS, constant reinforcement of CNS roles through job descriptions led to the obfuscation of CNS practice.

Why is this history relevant? Because almost 40 years after the creation of CNSs, we are, more or less, back to the original threshold. With CNS programs increasing across the country, graduates will be exploring employment opportunities. Unlike 40 years ago, healthcare has emerged from the hospital and is now delivered in a variety of settings, all of which are appropriate settings for CNS practice. We are in danger of losing these opportunities through emphasis on roles and a failure to recognize that the practice of a CNS is different from other APNs, especially nurse practitioners.

For CNSs, the master's degree is the credential for entry into advanced practice. Other nurse practice groups-nurse practitioners, nurse midwives, and nurse anesthetists-were not conceived originally as having master's preparation as entry into practice. In lieu of an academic credential, the professional credential of certification became the norm. As these other groups moved their preparation within master's education curricula, they brought with them an emphasis on professional certification.

Different from the reinforcement of roles through job descriptions, but with the same effect, the focus on certification serves to obfuscate CNS practice. The nursing profession is charged with meeting, in part, society's healthcare needs. Societal health needs change in response to new knowledge, technological innovation, population migrations, and a host of other factors. In the face of constant change, CNS practice should be evolving to meet healthcare demands. This cannot happen if that practice is constrained by a requirement to become certified when, in too many specialties, no certification examination exists. And, the lack of a certification examination gives the false impression that if there is no certification examination, there is no practice.

Certification examinations that are not specific to the specialty offer little assurance that a CNS is competent in the practice area. Existing certification examinations are often a poor match between test content and specialty practice. Consider the CNS who obtains certification as a Medical-Surgical CNS from the American Nurses Credentialing Center (ANCC). This credential is no assurance that the holder, who practices exclusively in the area of diabetes management, is an expert in the diabetes care. Why take an examination that doesn't match specialty practice? No examination is available for CNSs in diabetes management or many other specialty areas. Requiring CNS to have certification credentials when no examination exists is not only unfair but also has the effect of regulating some specialty practices out of existence in states that have included certification in nurse practice regulations and/or statutes.

At this time, graduate education is the best vehicle for entry into CNS practice and attesting to the knowledge and competencies of CNS. Certification may be viable in assuring knowledge of core content reflected in professional standards, but certification for CNS practice is not developed well enough to be included in legal or statutory requirements. Competency, not certification, is a primary criterion for CNS practice. If there is a need to verify minimal competency beyond educational preparation, it is essential that flexible methods be developed to document competent specialty practice.

Certification has other problems, too. Of the available CNS certifications, professional organizations differ in their conceptualization of CNS practice and consequently do not measure the same competencies. Educational programs should be built on a consensus conceptualization of CNS practice and should prepare students with the requisite knowledge and skill for that practice. Differing conceptualizations of CNS practice by various professional groups creates confusion and places impossible demands on educational programs to prepare graduates to pass certification examinations that do not agree on core concepts. In addition, it is difficult to develop flexible competency documentation when there is little consensus understanding of CNS practice. Consensus is needed for the evaluation of specialty practice to an established set of standards regardless of the documentation method.

There is nothing inherently wrong with certification. All CNSs and all APNs should be required to demonstrate competency. In many situations, certification may be a good option in part or whole. The public deserves access to CNS services and needs to trust in the competency of CNS practice. Reasonable and viable options for documenting competency are needed. The National Association of Clinical Nurse Specialists (NACNS), the professional organization of practicing CNSs, developed a Statement on CNS Practice and Education2 and model regulatory and statutory language. 3 The statement, a consensus document reflecting core competencies for all CNS regardless of specialty, should be used to differentiate CNS practice from other advanced practice and to foster dialogue leading to a consensus conceptualization of CNS practice. Both the statement and the model language should be used to craft flexible competency documentation for use in a variety of practice settings and across differing patient populations, such as portfolios to document competencies when no examination exists. Above all, we must not lose the opportunity to evolve CNS practice by surrendering-to any employer, group, or legal entity-our autonomous professional rights and responsibilities to define that practice.

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