In September, the American Association of Nurse Practitioners (AANP) achieved not one, but two momentous milestones. First, AANP membership reached and then quickly exceeded 100,000 members. That number represents roughly a third of the nurse practitioners (NPs) licensed in the United States today. The achievement of membership by that proportion of the total would be a great accomplishment for any society, but it is especially noteworthy for a healthcare profession characterized by enormous diversity of specialization, viewpoint, and background. The burgeoning membership of AANP is a testament to its track record of speaking for the benefit of all NPs, everywhere, and with impressive results in advancing our agenda of making healthcare available and accessible.

The second accomplishment was actually achieved a few months ago but was celebrated with a grand opening on September 13. That is the opening of the new AANP headquarters building in Austin, Texas. That's right, we have our own building, and we own it. When you put these two accomplishments together, it's impossible to ignore the fact that AANP as an organization is big and powerful, and it continues to grow by leaps and bounds. That's good news for all of us who teach and/or practice as NPs, as well as those who conduct research about the NP role. There is power in numbers, and we have the numbers to be an enormously powerful positive force for change to improve the health care of our patients.

And what of our millstones? What's holding us back? An examination of this question provides action steps that any one of us can take. A few millstones that most of us seem to agree on are:

* The ongoing need to weed out and overturn antiquated state laws that limit our role and make our status "less than" something or someone else.

* Data and information sources to provide the evidence needed about NP outcomes. As we grow, this information requires frequent updating and expansion. That is a primary purpose of this journal.

* The continued responsibility to educate the public, other healthcare providers, and legislators about the NP role and scope. This can only be done by those who take the time to arm themselves with facts. Critically reading this and other NP journals can provide many of the facts needed to promote yourself and your role.

We each have an important part to play in moving our careers and those of our colleagues forward. What have you done today to ensure that you and other NPs are viewed as leaders? There are great NP role models and mentors available in every state to help. I hope that every NP will critically read the literature, gather the facts, and then step forward as a positive force for change.

In this issue

Deborah Himes and colleagues present a research study to compare breast cancer risk screening tools. The authors provide the sensitivity and specificity of several tools and make a recommendation based on their findings. This is also the continuing education feature this month.

Joan Riordan and colleagues sampled women who are or were active duty military and used a mobile application to encourage physical activity. This study helps to identify what types of fitness apps do and do not enhance physical activity.

Judith Scott and Ann Mayo present a qualitative study of older women adjusting to an assisted living environment. The authors identified phases of the transition and also found modifying factors affecting transition to an assisted living facility.

Courtney Pitts and colleagues present a collaboration between National Organization of Nurse Practitioner Faculties and AANP to design checklists to use during student clinical placements. The authors provide a list of items detailing faculty expectations of preceptors and vice versa. They also note that it is imperative that clinical placements be managed in a structured and standardized fashion and that communicative pathways between NP faculty and clinical preceptors be enhanced. This article should be of much use to both faculty and preceptors.

Kelly Marcoux and her team provide background on fellowship programs as a way for NPs to develop specialty skills. The authors then describe the design, implementation and outcomes of two specialty NP fellowship programs in Developmental-Behavioral Pediatrics and in Pediatric Physical Medicine & Rehabilitation. This information has practical applications for those interested in fellowships in other specialty areas.

Patrick Sherlock and Linda Rounds provide a quality improvement report on an NP-managed transitional care encounter program. Clinicians found benefits with a dedicated transitional care provider NP. The program was also a source of revenue for the facility and improved provider satisfaction. For the many NPs grappling with breakdowns in care between care settings, this article is a valuable source of information.

Sandra Arnold and colleagues also conducted a quality improvement initiative that included use of the HEART score to evaluate patients with chest pain in the emergency setting. The authors found that consistent use of this tool appropriately screened out low risk patients and provided significant cost savings without adverse events. Evaluation for use in other settings is recommended.

Our final feature this month is by Shirin Vellani, who presents a case study of a patient with advanced dementia for whom family and providers faced a decision about enteral versus oral nutrition. The author presents the literature available supporting type of feeding as well as studies of adverse events related to feeding method. Both the evidence and existing guidelines recommend against tube feeding in this population. This article can be used to help support conversations and care decisions about this difficult decision.

I hope you enjoy these new contributions to our science.