Thank you for your comments on my editorial of July 2002 (16[4]). In response to your points about CNSs taking on administrative functions, many authors have identified clinical leadership, not administration, as a key competency for clinical nurse specialist (CNS) practice. The administrator component of the CNS role was included in American Nurses Association's (ANA) 1986 document The Role of the Clinical Nurse Specialist-which delineated administrator as a dimension of the CNS role. 1 In that document, ANA stated "Clinical nurse specialists may maximize their opportunities for expert innovation in clinical practice by choosing to be administrators, thus becoming responsible for the design and direction of clinical programs and services" (p. 4).

ANA was an early advocate of credentialing CNS competence. However, credentialing of competence does not automatically translate into certification by examination. For CNSs, an earned master's or doctorate degree with a CNS major or focus was and continues to be the primary credential. Unfortunately, the certification examination is the only nondegree credentialing option that has been extensively explored. Recently, certification for CNSs has shifted focus, moving from recognizing excellence in practice (where practice experience as a CNS is a prerequisite for the examination) to verification of minimum competencies (where the examination is taken before beginning practice in the role).

Verifying competency is important, but many existing certification examinations do not verify specialty competency. Since it is competency, not certification, that is central to the discussion, options other than certification need to be explored if completion of the educational degree is believed to be inadequate. To be clear, NACNS supports specialty certification when specialty examinations are available. However, for too many CNSs, no certification examinations exist and are not likely to exist in the future because small numbers of CNSs in specialties will make exam development economically unfeasible. Generalist examinations for specialty practice beg the question of using certification examinations to credential specialty CNS competency and to protect the public. Regulating specialty practices out of existence by insisting on examinations that don't exist raises serious questions about unfair restraint of trade. In the 17(1) issue of this journal, NACNS published its response to the National Council of State Boards of Nursing (NCSBN) Uniform Advanced Practice Registered Nurse Licensure/Authority to Practice Requirements. NCSBN's position advocates certification for second licensure purposes. NACNS views this approach as creating inappropriate and unnecessary barriers to practice.

The statement "the focus on certification serves to obfuscate CNS practice" addresses the problem that certification requirements can create. Obfuscation of CNS practice occurs when we are lead to believe that if there is no certification examination, there is no specialty practice. CNSs need to evolve practice to meet societal needs-which cannot happen if we are required to develop certification examinations a priori. Historically, certification was important for other advanced practice nurse (APN) groups-nurse practitioners, nurse midwives, nurse anesthetists-because competency was not originally built on a academic foundation. Many early programs for NPs, nurse midwives, and nurse anesthetists did not require a minimum of a bachelor degree in nursing, much less a graduate degree in nursing. CNSs are the only group of APNs for whom all members hold a minimum of a master's degree in nursing. Other groups, through reliance on certification, have grandparented providers who lack academic preparation by today's standards. This practice has given rise to the dubious notion that certification is the great equalizer. It also raises questions about state regulatory boards who are willing to make exceptions for academically underprepared providers with certification while choosing to regulate more academically prepared providers out of practice for lack of an examination.

The evolution of CNSs away from direct practice occurred, in part, because the nature and characteristics of advanced practice nursing were not clearly defined. NACNS, formed in 1995, was the first professional organization solely dedicated to addressing CNS practice and related issues. NACNS supports the advancement of nursing practice-bridging the gap between new knowledge and current nursing practice. Continued evolution of our understanding of the nature of CNS practice, and advanced nursing practice in general, has been distracted by confusing advanced nursing practice with nurses practicing in the medical domain (disease diagnosis and treatment) and the focus on certification as verification of specialty competency. Examinations for specialty competency may be a viable option, but the Oncology Nursing Society (ONS) examination, as it exists now, is not an adequate model. The ONS certification examination does not test for oncology CNS specialty competencies-both CNSs and NPs take the same examination.

CNSs need regulatory title protection. The practice of each APN is uniquely different, and each of the four APN groups needs to negotiate regulatory authority that will facilitate its practice. In this respect, CNSs do stand apart from other advanced practice nurses in the scope of their practice and therefore regulatory requirements. NACNS has a position paper on regulatory credentialing of CNS, which can be obtained by contacting NACNS at http://www.nacns.org.

I invite reader response to this debate about certification requirements for CNSs. Is certification an appropriate requirement for CNSs even if a specialty examination does not exist?

Janet S. Fulton, PhD, RN, Editor

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