The 2008 Advanced Practice Registered Nurse (APRN) Consensus Model, developed by the APRN Consensus Work Group, defined four APRN roles and established that all APRNs must practice under recognized standards of practice. While Certified Nurse Practitioners, Certified Nurse Midwives, and Certified Registered Nurse Anesthetists have developed comprehensive Standards of Practice through their professional organizations, the Clinical Nurse Specialist (CNS) operates solely under competency frameworks organized within the Three Spheres of Impact model. This absence of formal Standards of Practice creates a critical gap that undermines professional legitimacy, regulatory compliance, and public safety protections. Concurrently, the CNS role faces challenges including role confusion, inconsistent utilization, and declining educational programs. In this article, we examine the urgent need for CNS standards of practice by analyzing the current regulatory landscape, comparing the CNS model with other APRN roles, and exploring the multifaceted implications of this professional deficit. Our analysis revealed five critical areas of concern: compromised quality and safety oversight, regulatory compliance challenges, diminished professional recognition and utilization, educational inconsistencies, and workforce sustainability threats. The conclusion presents a compelling call to action for the immediate development of professional Standards of Practice to preserve the CNS role and ensure optimal patient outcomes. Without swift action to establish authoritative Standards of Practice, the CNS role risks continued marginalization in an increasingly regulated healthcare environment that demands clear professional accountability and evidence-based standards of practice.
Key Words: Advanced Practice Nurse, APRN, Clinical Nurse Specialist, CNS, Nursing, Standards of Practice, Competencies, LACE, Consensus Model
The Clinical Nurse Specialist (CNS) remains the only Advanced Practice Registered Nurse (APRN) role in the United States (U.S.) without comprehensive Standards of Practice. Standards of Practice are authoritative guidelines that inform professional practice and provide the profession and the public with well-defined performance expectations, serving as criteria for assessing clinical quality and effectiveness (Yoos et al., 1997; American Nurses Association [ANA], 2010; Evans, 2024). However, research has revealed that even when nursing standards exist, significant barriers to awareness, diffusion, and adoption persist in practice settings (Sitzer et al., 2023). This highlights the critical importance of not only having standards but ensuring their effective implementation.
The APRN Consensus Model (2008) defines advanced practice registered nurses (APRNs) and recognizes the CNS as one of the four APRN roles. This model explicitly states that all APRNs are licensed independent practitioners who are expected to practice within standards established or recognized by a licensing body. It establishes that APRNs maintain accountability to patients, the nursing profession, and the licensing boards for adhering to state nurse practice act requirements and deliver quality advanced nursing care. The framework also emphasizes responsibilities of APRNs to recognize professional limitations and consult with or refer patients to other healthcare providers when appropriate (APRN Joint Dialogue Group, 2008).
While the National Association of Clinical Nurse Specialists (NACNS) has developed and refined core CNS competencies for three decades (NACNS, 2019), the lack of corresponding Standards of Practice creates a fundamental inconsistency within the APRN Consensus Model. In contrast, the other three APRN roles, Certified Registered Nurse Anesthetists (CRNA), Certified Nurse Practitioners (CNP), and Certified Nurse Midwives (CNM), all have established comprehensive Standards of Practice (American Association of Nurse Anesthesiology [AANA], 2019; American Association of Nurse Practitioners [AANP], 2022; American College of Nurse Midwives [ACNM], 2024).
The lack of Standards of Practice for the CNS role generates multifaceted potential professional consequences. Potential consequences may include diminished public safety oversight and professional accountability, reduced professional legitimacy that impedes APRN recognition, and regulatory compliance deficits that contradict the Consensus Model requirements. Furthermore, the absence of Standards of Practice constrains educational infrastructure development that limits workforce development capacity and compromises professional identity development threatening career sustainability.
In this article, we examine the critical need for CNS Standards of Practice, present the existing professional competencies that guide CNS practice, compare the CNS role with other APRN roles, and analyze the complex implications of the existing deficiency in CNS standards of practice. Additionally, we issue an urgent call to action for immediate development of professional Standards of Practice for the CNS role.
Standards of Practice and Competencies
It is important to understand the distinction between Standards of Practice and competencies—two related but fundamentally different professional constructs that are often conflated in discussions of the CNS role. While NACNS has developed numerous competencies, the absence of corresponding Standards of Practice represents a significant structural deficiency.
Standards of professional practice are a set of guidelines and expectations that inform and guide professional practice (Yoos et al., 1997). These statements provide the profession and the public with a well-defined set of expectations for performance, serving as criteria by which to assess the quality and effectiveness of clinical performance (ANA, 2010; Evans, 2024). Standards of practice are developed by an authority in practice, such as a professional organization, institution, or recognized expert(s) in the field (ANA, 2010). Other healthcare professions, such as the American Occupational Therapy Association (AOTA, 2021) and the American College of Clinical Pharmacy (ACCP, 2023) as well as the three other APRN roles (AANA, 2019; AANP, 2022; ACNM, 2024), have standards specific to their roles.
The ANA defines standards of professional nursing practice as authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to competently perform (ANA, 2021). These standards are divided into Standards of Practice (focusing on the nursing process) and standards of professional performance (addressing professional role behaviors). For APRNs, these standards provide a foundation upon which role specific standards are built.
Standards of Practice serve several essential purposes, such as: guiding regulatory oversight, informing educational curriculum development, establishing employment expectations, and enabling performance evaluation. Most importantly, Standards of Practice ensure public safety through consistent, high-quality care delivery. Professional organizations develop these standards as part of their responsibility to both their members and the public. Competencies, as defined by the ANA, are “an expected level of performance that integrates knowledge, skills, abilities, and judgment” (ANA, 2021, p. 52).
However, knowledge alone does not validate nursing practice competency; rather, competency requires demonstrate application of knowledge and skills (National League for Nursing, 2024). While individual competency components are observable and measurable, validation requires demonstration of performance to established standards integrated with applied knowledge (American Association of Colleges of Nursing ([AACN], 2021; D’Aoust et al., 2022; Zumstein-Shaha & Grace, 2023). This distinction is crucial for understanding the lack of CNS Standards of Practice. While competencies describe what CNSs should be able to do, Standards of Practice define how they should do it and establish benchmarks against which performance is measured and regulated.
The APRN Consensus Model and LACE Framework
The Consensus Model for APRN Regulation, developed in 2008, introduced a comprehensive framework known as LACE: Licensure, Accreditation, Certification, and Education, to standardize APRN practice and establish a formal mechanism for communication among regulatory bodies (APRN Joint Dialogue Group, 2008). Under the Consensus Model, APRNs achieve formal recognition through national certification, which validates achievement of skills and knowledge in a specific area and demonstrates commitment to professional standards and best practice (Dunn, 2019). The Consensus Model explicitly states that APRNs are expected to practice within standards established or recognized by a licensing body and outlines the process for developing nationally recognized core competencies, education and Standards of Practice for each APRN role (APRN Joint Dialogue Group, 2008).
The LACE framework provides the regulatory infrastructure that supports APRN practice; the acronym represents the following: Licensure grants authority to practice as an APRN in a specific role and population focus. Accreditation ensures educational programs meet established standards. Certification formally recognizes a nurse’s knowledge, skills, and experience, demonstrating that they have met the standards set by a professional organization for a specific APRN role and population focus. Education provides the academic and clinical preparation necessary for advanced practice (APRN Joint Dialogue Group, 2008).
The LACE framework emphasizes that Standards of Practice are not optional components of APRN regulations but rather are essential to ensure consistent, safe, and effective advanced practice nursing care. The absence of CNS Standards of Practice creates a significant gap in aligning with the LACE framework, potentially compromising the ability of CNSs to achieve full integration within the APRN model. Having established the regulatory framework that governs all APRN roles, it becomes essential to examine how the CNS role has developed within, or outside, this structure.
Current State of Professional Guidance and the CNS Statement on Practice and Education
The American Association of Critical Care Nurses has developed “Scope and Standards for Acute Care CNS Practice” (AACN, 2022). However, these solely represent specialty-specific guidance rather than comprehensive standards applicable to all CNS practice. The existence of specialty standards, while valuable, reinforces the argument that the broader CNS role lacks the cohesive professional infrastructure that characterizes other APRN roles.
The evolution of the CNS Statement on Practice and Education (NACNS, 2019) spans over three decades, beginning with the formation of NACNS in 1994 and followed by the publication of the first NACNS Statement on Clinical Nurse Specialist Practice and Education in 1998 (Lyon, 1998). This foundational document established the first validated core competencies and outcomes of CNS practice and defined educational recommendations for CNS preparation.
These first CNS competencies were validated through a content analysis process using expert consensus of a competency task force as well as input from practicing CNSs together with 50 selected external reviewers (Baldwin et al., 2007). In 2004, The Statement underwent significant revision visualizing CNS practice competencies across three spheres of influence: patient/client care, nurses and nursing practice, and healthcare organizations/systems. This model provided a visual representation of the scope and interconnectedness of CNS practice competencies (NACNS, 2010).
In response to the 2008 APRN Consensus Model call for core competencies, a National CNS Competency Task Force was convened, resulting in the 2010 publication of CNS Core Competencies (NACNS, 2010). The recent NACNS 2019 Statement on Clinical Nurse Specialist Practice and Education revision refined the conceptual model to incorporate external practice influences and consolidated competencies to 16 patient-focused, 14 nurse/nursing practice, and 14 organization/systems competencies, organized around "spheres of impact" to emphasize outcomes (NACNS, 2019).
Despite these efforts towards competency development, NACNS has not established Standards of Practice for the CNS role. This absence is concerning, as competencies should be grounded in clearly defined Standards of Practice. Without such Standards of Practice to guide clinical work, the development and implementation of competencies risk being misaligned with actual practice. The existence of competencies without corresponding Standards of Practice represents a critical gap and poses a significant risk to the integrity and effectiveness of the CNS role.
Comparison with Other APRN Roles
A stark contrast emerges when examining the professional infrastructure supporting the other three APRN roles. The American Association of Nurse Anesthesiology (2019), American Association of Nurse Practitioners (2022), and American College of Nurse Midwives (2024) and have all developed, published, and revised comprehensive scope of practice statements and standards of practice for their respective roles. These organizations recognized early in their professional development that Standards of Practice were essential to establish professional credibility, regulatory recognition, and public accountability.
Certified Registered Nurse Anesthetists follow standards developed, published, and revised by AANA (2019), that have created detailed expectations for anesthesia practice that address patient assessment, anesthesia planning and implementation, and post-anesthesia care. These standards have supported CRNAs in achieving recognition as independent practitioners in many U.S. states.
Certified Nurse Practitioners follow Standards of Practice established, published, and revised by the AANP (2022), which outline expectations, responsibilities, and accountabilities for NP practice across all settings and populations. These standards address qualifications, care processes, patient advocacy, quality assurance, collaboration, and professional development, creating a framework that supports NP practice autonomy.
Certified Nurse Midwives follow standards developed, published and revised by ACNM (2024) that specifically address the unique scope of midwifery practice, including normal physiological processes, collaborative care for complications, and emergency management. These standards have supported legislative recognition and practice authority across states In contrast, Clinical Nurse Specialists operate with numerous competencies but without corresponding Standards of Practice. This absence places the CNS at a significant disadvantage in achieving regulatory recognition, practice authority, and professional visibility.
While CNS competencies outline the knowledge and skills required for the role, the absence of Standards of Practice leads to a lack of authoritative definition and understanding of how CNSs should practice or how their practice should be evaluated. This gap becomes particularly problematic when U.S. states consider APRN legislation or when healthcare organizations develop policies for advanced practice roles. Without clear Standards of Practice, the CNS role lacks the professional infrastructure that other APRN roles use to demonstrate their value, secure recognition, and (AUTHORS: it seems like you’re missing a verb here? You have demonstrate value, secure recognition, and what for credentialing? Not sure would be the best choice, but I think it would read better with something. Thanks, Jackie) credentialing.
The Absence of CNS Standards of Practice
The absence of CNS Standards of Practice exposes the role to wide-ranging consequences for healthcare systems, professional development, and patient care delivery. This challenge is not limited to the United States. A recent study examining various advanced practice roles across 35 European countries revealed that inconsistent definitions and regulatory frameworks create risks to safe, quality care while restricting practitioners' ability to move between countries and share their specialized knowledge (De Raeve et al., 2024). Through systematic analysis of the literature, five recurring themes illustrate the critical need for CNS Standards of Practice: (1) quality and safety, (2) regulatory challenges, (3) professional recognition and visibility, (4) educational inconsistencies and career development, and (5) workforce issues. These interconnected challenges demonstrate why establishing clear CNS Standards of Practice is essential for the profession.
Quality and Safety Concerns
The absence of Standards of Practice creates critical gaps in quality assurance and patient safety oversight. The Joint Commission and the Institute of Medicine (now the National Academy of Medicine) have consistently emphasized that clearly defined standards and standardized processes are essential to maintain quality and safety (The Joint Commission, 2024; Centers for Medicare and Medicaid Services [CMS], 2024). In advanced nursing roles, the absence of national role-specific standards leads to inconsistent care delivery, evaluation challenges, and unclear expectations, which impact patient safety and quality monitoring (Foster & Flanders, 2014). The landmark 2011 Future of Nursing report noted that without formal standards of practice, there are no clear expectations for APRN practice, no reliable performance benchmarks for performance appraisal, no unified guidance for educational and role preparation, and no consistent criteria for ensuring safe, ethical, high-quality care; such is the case for the CNS (Institute of Medicine, 2011).
Regulatory Challenges
The 2008 APRN Consensus Model requirement that APRNs practice within established Standards of Practice, places CNSs at a regulatory disadvantage. In the United States, professional Standards of practice and state and federal laws and regulations all contribute to an APRNs scope of practice (Hamric, 2014). Many U.S. states struggle to recognize CNSs as APRNs without clear Standards of Practice to guide licensure and scope of practice determinations. We assert that this regulatory uncertainty has contributed to inconsistent CNS recognition across states and limited CNS access to practice authority granted to other APRN roles.
Professional Recognition, Visibility and Utilization
Without Standards of Practice, CNSs remain largely invisible to healthcare executives, policymakers, and the public. This challenge is compounded by evidence that even established nursing standards face significant diffusion barriers, with awareness being identified as both a primary obstacle and essential strategy for professional recognition (Sitzer et al., 2023). The invisibility is reflected in the U.S. Bureau of Labor Statistics 2024 occupational employment and wage statistics report which categorizes CNSs under registered nurses rather than as distinct advanced practitioners—like the other APRN roles of CNM, CNP, and CRNA (U.S. Bureau of Labor Statistics, 2024). Consequently, leaders in healthcare organizations often struggle to define appropriate job descriptions and role expectations for CNSs, resulting in inconsistent CNS utilization and sometimes elimination of CNS positions. The lack of standards hinders evaluation of CNS performance and/or demonstration of return on investment.
Educational Inconsistencies
The absence of Standards of Practice creates challenges for CNS education programs in developing curricula that adequately prepare graduates for contemporary practice. While competencies provide learning objectives, Standards of Practice would offer the framework for demonstrating competency achievement and ensuring consistent educational outcomes across programs. This gap may contribute to the decrease in CNS programs from 217 to 57 (a 73% decrease) over the past twenty years, as academic institutions struggle to articulate clear practice expectations for graduates (Saunders, 2025).
Career Development and Workforce Issues
The 2022 CNS Census revealed that almost 30% of CNS respondents planned to retire within five years, raising concerns about workforce sustainability (NACNS, 2022). The absence of clear Standards of Practice may discourage nurses from pursuing CNS education and careers, as the role lacks the professional clarity and recognition achieved by other APRN roles. This challenge is reflected in workforce data: according to Reed et al. (2021), while an estimated 89,122 CNSs practice in the United States, only 10,000 have obtained National Provider Identifier (NPI) numbers—suggesting many may not be actively practicing in CNS roles. Of those with NPI numbers, 1,932 (19.3%) report working in dual CNS/NP roles, indicating that approximately 20% of CNSs have pursued NP credentials to expand their practice opportunities (Reed et al., 2021).
Call to Action: The Imperative for CNS Standards
The evidence is overwhelming that CNS Standards of Practice represent more than professional convenience: they are an essential foundation for the survival and advancement of the CNS role within the healthcare system. The development of these Standards of Practice is not merely advisable but imperative for the following critical reasons: public safety and professional accountability, professional legitimacy and APRN regulation, regulatory compliance with the APRN Consensus Model, educational infrastructure and workforce development, and professional identity and career sustainability.
Public Safety and Professional Accountability
Standards of Practice serve as the primary mechanism to ensure public safety through consistent, high-quality care delivery. While CNS competencies describe what CNSs should know and be able to do, Standards of Practice define how that knowledge should be applied and measured. Standards for CNS practice would include competencies and measurable outcomes that demonstrate application in practice. Without these standards, there are no authoritative benchmarks to ensure that CNSs practice safely and effectively, creating potential gaps in public protection.
Professional Legitimacy and APRN Recognition
The word "statement" in the current CNS Statement on Practice and Education (NACNS, 2019) diminishes the professional impact of the CNS role compared to other APRN roles that have established formal "standards." This linguistic distinction matters significantly in professional and regulatory contexts. Standards establish quantifiable benchmarks and convey authority, while statements merely communicate facts or opinions. For CNSs to achieve equal standing with other APRN roles, they must move beyond statements to establish authoritative Standards of Practice.
Regulatory Compliance with the APRN Consensus Model
The APRN Consensus Model explicitly requires that APRNs practice within established standards recognized by licensing bodies. CNSs cannot fully comply with this foundational regulatory framework without formal Standards of Practice. This compliance gap threatens CNS recognition as legitimate APRNs and limits their ability to achieve the practice authority and recognition available to other APRN roles.
Educational Infrastructure and Workforce Development
The absence of Standards of Practice threatens the educational infrastructure needed to prepare future CNSs on a global level. International evidence has demonstrated that lack of standardized practice frameworks create systemic problems across global healthcare systems, with researchers noting that inconsistency 'limits professional mobility and sharing of expertise' (De Raeve et al., 2024). Academic programs struggle to develop consistent curricula and evaluation methods without clear Standards of Practice. This lack of role clarity has resulted in organizations eliminating CNS positions during financial constraints, leading to reduced recognition and declining program enrollments. The result of these challenges is the sharp decline in CNS programs, which further contributes to declining numbers of CNSs in practice. Standards of Practice would provide the framework needed to guide curriculum development, clinical preparation, and graduate competency evaluation, helping to reverse these troubling trends.
Professional Identity and Career Sustainability
CNSs face an identity crisis that stems partly from the lack of clear Standards of Practice. Without authoritative statements defining CNS practice expectations, the role remains ambiguous to potential candidates, employers, and healthcare colleagues. This ambiguity undermines recruitment efforts, limits career advancement opportunities, and contributes to the aging CNS workforce documented in recent census data.
Conclusion
The solution is both clear and urgent. NACNS, as the professional organization representing CNSs, must prioritize the development of professional Standards of Practice. Moreover, all Clinical Nurse Specialists should demand that NACNS develop standards of practice to ensure their professional future. These standards must address the full scope of CNS practice across the three spheres of impact, establish measurable performance expectations, and create the professional framework needed for regulatory recognition and practice authority.
The development of CNS Standards of Practice is not merely a professional enhancement—it is a survival imperative. Without these standards, the CNS role will continue to struggle for recognition, relevance, and sustainability in an increasingly complex healthcare environment. The time for action is now, before the absence of standards renders the CNS role obsolete in a healthcare system that demands clarity, accountability, and Standards of Practice.
Authors
Mary Beth Modic, DNP, APRN-CNS, CDCES, FAAN
Email: modicm@ccf.org
ORCID ID: https://orcid.org/0000-0002-3456-6390
Mary Beth Modic earned a DNP from Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. She has been a Clinical Nurse Specialist for 33 years. She is a recognized leader in the care of people with diabetes.
Cherrie L. Pullium, DNP, MJur, APRN, ACNS-BC, FCNS
Email: clpullium@tamu.edu
ORCID ID: https://orcid.org/0000-0002-2550-4016
Cherrie Pullium earned a DNP from the Capstone College of Nursing, University of Alabama in Tuscaloosa, AL, and a Master of Jurisprudence, Health Law and Policy from Texas A & M University School of Law. As an Adult CNS, she has been a primary care Advanced Practice Provider for over 20 years with expertise in managing chronic illness.
Lynn Mohr, PhD, APRN, PCNS-BC, CPN, FCNS
Email: Lynn_Mohr@rush.edu
ORCID ID: ORCID https://orcid.org/0000-0001-9390-8787
Lynn D. Mohr holds a PhD in Nursing Science from Rush University College of Nursing, Chicago, IL. She has been a certified pediatric clinical nurse specialist (CNS) for the past 23 years. She is a recognized leader in the care of infants, children and adolescents with wound, ostomy, and continence concerns.
Gail A. Bagwell, DNP, APRN, CNS, FAAN, FNAP
Email: gail.bagwell@nationwidechildrens.org
ORCID ID: https://orcid.org/0000-0001-7785-5777
Gail Bagwell is a clinical nurse specialist for the Perinatal Outreach program at Nationwide Children’s Hospital where she executes the CNS role at hospitals that refer to NCH. Dr. Bagwell is past president of the National Association of Neonatal Nurses and was appointed the CNS representative to the LACE steering committee in 2023, currently serving her first term. She earned a BSN from West Virginia Wesleyan College, an MSN from the University of Cincinnati and a DNP from Chatham University.
Barbara Brunt, MA, MN, RN, NE-BC, NPDA-BC
Email: bruntb1@gmail.com
Barbara Brunt received a Master's Degree in Nursing from the University of Dundee in Scotland. She is certified as a Nurse Executive and in Advanced Nursing Professional Development. Ms. Brunt served as a member of the ANA Task Force that revised the 4th edition of Nursing: Scope and Standards of Practice.
Tracy Campbell, DNP, APRN, PCNS-BC, CCRN
Email: rustic113@gmail.com
ORCID ID: https://orcid.org/0009-0003-9357-1565
Tracy Campbell is a Systems Pediatric Clinical Nurse Specialist in the Nursing Department at Children’s Hospital of Philadelphia, with over 20 years of caring for pediatric patients. She translates evidence. She serves as an Adjunct Faculty in the DNP Program at Villanova University.
Susan C. Dresser, PhD, APRN-CNS, CCRN, FCNS
Email: Susan-dresser@ou.edu
Susan C. Dresser is the Track Coordinator for the AGCNS MSN and DNP programs at the Fran and Earl Ziegler College of Nursing. She has extensive clinical experience in caring for patients with cardiovascular disease, working primarily with patients with coronary artery disease, heart failure and acute coronary syndromes.
Jennifer K. Peterson, PhD, APRN-CNS, CCNS, CNE, FAHA
Email: jpete107@jhu.edu
ORCID ID: 0000-0001-7628-567X
Jennifer K. Peterson is an Assistant Professor and DNP Clinical Nurse Specialist Track Director at Johns Hopkins University School of Nursing in Baltimore, Maryland. She completed a Master of Science in 1999 at the University of Minnesota and is a certified Pediatric Acute and Critical Care Clinical Nurse Specialist. She also completed a PhD in Nursing Science at University of California, Irvine.
Jennie Matays, DNP, APRN-CNS, CCNS, CCRN, EBP-C, FCNS
Email: Jennie.E.Matays@kp.org
Jennie Matays is the Magnet Program Director at Kaiser Permanente in Roseville, California. Prior to this role, she worked as a Critical Care Clinical Nurse Specialist for 12 years, most recently at Kaiser Permanente South Sacramento. Dr. Matays earned a BS in Biological Sciences from the University of California, Davis; a BSN from California State University, Sacramento; an MS in the Critical Care/Trauma CNS program from the University of California, San Francisco; and a DNP from the University of Pittsburgh.
Cynthia Rothenberger
Email: cynthia.rothenberger@alvernia.edu
Cynthia Rothenberger’s background includes roles as an adult health Clinical Nurse Specialist in inpatient and outpatient settings. She is currently an Assistant Professor at Alvernia University, teaching in prelicensure and graduate programs.
Lynn (Marilyn) Schallom, PhD, MSN(R), APRN-BC, CCNS, CCRN, FCCM
Email: Marilyn.schallom@bjc.org
ORCID ID: https://orcid.org/0000-0002-8418-5123
Lynn Schallom has 45 years of experience as a nurse, and 35 years as a clinical nurse specialist, and researcher. She currently conducts interdisciplinary research and implements evidence-based practice and process improvement projects in critical care. Lynn has a BSN and MSN from St. Louis University, and a PhD in Nursing from the University of Kansas.
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