The advanced practice nursing community has embarked on an initiative for clarifying and aligning graduate education, educational program accreditation, professional certification, and licensure/regulation for all advanced practice roles. It is called the L-A-C-E initiative for licensure, accreditation, certification, and education.1 It is a voluntary national collaborative including advanced practice nursing professional organizations and certifying bodies. The National Association of Clinical Nurse Specialists has been representing clinical nurse specialist (CNS) interests in the collaborative. This year's annual National Association of Clinical Nurse Specialists conference included a lot of conversation about LACE and the impact on CNS practice and education.

After all the discussion at the conference, it occurred to me that a piece of this intricate puzzle is missing. Where are clinical competencies? Nursing exists to provide services to the public, to meet a public need. Advanced practice nursing roles, CNS included, each provide a unique subset of nursing services to the public. Clinical nurse specialist services are reflected in core practice competencies. Core competencies not only direct CNS practice, but also communicate expectations to the public, telling the public what to expect from CNS practice. So where do clinical competencies fit in the LACE initiative?

Clinical competencies are created by the profession, by professional organizations composed of practicing nurses; the profession determines competencies. Clinical competencies are the outline for educational programs because education provides students opportunities to gain knowledge and skills related to the profession's delineated competencies. At the program level, accreditation helps assure the professional community and public that educational programs are delivering content necessary to achieve competencies. At the individual level, graduates seek validation of knowledge through professional certification and obtain additional confirmation of competence over and above an academic degree. Thus, we have 2 mechanisms standing in evidence of competence. Legislation, through scope of practice, assures the public access to the competencies in the form of direct care services. Regulation contains yet a third mechanism for ensuring competency through a disciplinary process to remove incompetent providers. With 50 state practice acts, hundreds of graduate programs, multiple professional certifying bodies, and 2 national level educational program accreditation entities, we have simply arrived at a place where the elements do not necessarily articulate well across 4 different advanced practice roles-CNS, nurse practitioner, nurse midwife, and nurse anesthetist.

Although all elements are intricately linked, the driving force, the raison d'etre for any of the LACE elements, service to the public, is not visible. In logical order, the initiative is C-E-A-C-L, with a second C for competencies leading the list-competencies, education, accreditation, certification, and licensure. Alas, not as clever, but more inclusive.

Including competencies is critical, whether it fits a clever acronym or not. Why? Healthcare reform is here! After years of talking, posturing, speculating and legislative tinkering, a serious agenda for healthcare reform has arrived. Clinical nurse specialists along with the entire advanced practice nursing community must participate in shaping healthcare reforms. We should enter the reform discussion with our best foot forward-our competencies, our services. At the reform table, our goal is to assure the public access to these services.

As the LACE initiative proceeds, let us not lose sight of our social contract. How we achieve and ensure competencies is our internal professional business, important business, but a supporting role at best to the main event. Let us put our service to the pubic front and center, and let it lead our LACE initiative.

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