The Future of the Clinical Nurse Specialist Role in Finland

7 OCT 2014
Krista Jokiniemi MSc, RN1,*, Kaisa Haatainen PhD, RN2, Riitta Meretoja PhD, RN3 and Anna-Maija Pietil PhD, RN

Abstract

Purpose
To identify and examine the expert panelists visions on the future implementation of the clinical nurse specialist (CNS) role in
Finland.

Design and Methods

A policy Delphi design was conducted in 2013. A purposive sampling method was used to recognize expert panelists in the areas of
advanced practice nursing (APN), healthcare management, and advanced practice nurse education. Three iterative Web-based
survey rounds were conducted (n = 25, n = 22, n = 19). Both qualitative and quantitative methods were used to analyze the data.

Findings
The expert panelists envisioned the future of the CNS role in Finland. This study portrayed the CNS role in Finland as generally
consistent with the international role. CNS have comprehensive skills and knowledge that they use to guide and develop nursing
practice; however, several threats may affect their role achievement. The existing national consensus, contradiction, and
ambivalence related to CNS roles were revealed through the examination of the results, thus pointing out the areas for consideration
when further developing these roles and role policies.

Conclusions
This is the first national study to examine the implementation of the CNS role in Finland. Expert panelists views regarding the CNS
role will be valuable in the forthcoming national policy formulation process. Although the policy Delphi design is not often utilized,
this study reveals that it is very well suited to guide and inform national and international APN policy development.

Clinical Relevance
This study contributes to CNS role development and describes the methods facilitating the essential policy formulation process.
The increased demands of contemporary health care have created a need for nursing to strengthen the quality and safety of
practice and reexamine its clinical roles (Delamaire & Lafortune, 2010; Sheer & Wong, 2008). In order to respond to these
requirements, advanced practice nursing (APN) roles have evolved over the years and are currently a global trend of the nursing
profession (Delamaire & Lafortune,2010; Kleinpell et al., 2014; Pulcini, Jelic, Gul, & Loke, 2010; Ruel & Motyka, 2009; Sheer &
Wong, 2008). Although the nomenclature and generic definitions of an advanced practice nurse vary between and even within
countries (Baldwin, 2013; Dowling, Beauchesne, Farrelly, & Murphy, 2013; Hutchinson, 2014; International Council of Nurses

[ICN], 2014; Jokiniemi, Pietil, Kylm, & Haatainen, 2012; Lewandowski & Adamle, 2009; Pulcini et al., 2010), it is generally agreed
that APN is carried out by autonomous, experienced practitioners who possess an advanced level of skills and knowledge acquired
through graduate nursing education (ICN, 2014). An APN role is actualized through advanced nursing, specialization, and expansion
of scope of practice, which underpin nurses activities in advanced clinical practice, practice development, education, consultation,
research, and clinical leadership (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004; Dowling et al., 2013; Duke, 2012;
Gardner, 2013; Hanson & Hamric, 2003; Hutchinson, 2014; Jokiniemi et al., 2012; Roche,2013). Role specialization and expansion
provide advanced practice nurses with their secondary title, such as clinical nurse specialist (CNS; Ruel & Motyka, 2009). CNS will
lead change in three impactful areas: direct patient care, nursing practice, and systems (Lewandowski & Adamle, 2009; National
Association of Clinical Nurse Specialists, 2004; Patten & Goudreau, 2012).
Several factors, such as healthcare reform, the requirement for evidence-based practice (EBP), and the proliferation of Magnet
hospital status, offer opportunities for strengthening the CNS role worldwide (Patten & Goudreau, 2012). Although the CNS role has
gained support in recent years, it appears to be, out of all advanced practice nursing roles, the least clearly defined (Dowling
et al., 2013; Kilpatrick et al., 2013). Currently many countries develop or reexamine their CNS roles or educational curricula
(Arslanian-Engoren, 2011; Baldwin,2013; Dias et al., 2013; Doody, 2011; Jokiniemi, Haatainen, & Pietil, in press; Kleinpell
et al., 2014; Livneh, 2011; Roberts, 2011; Wong et al., 2010). However, the pace of and readiness for role implementation vary from
country to country (Bryant-Lukosius & DiCenso, 2004; Delamaire & Lafortune, 2010; Sheer & Wong, 2008); thus, differing
approaches have been taken to develop these roles in various countries. Often the rigidity and slowness of healthcare systems and
regulation to change have led to the ad hoc formulation of advanced nursing roles; hence, many countries are retrospectively
working toward policy formulation to support role implementation (Bryant-Lukosius et al., 2004). Variation in CNS practice and lack
of uniform policies regulating CNS and other APN roles represent barriers to the accurate identification and optimal functioning of
these practitioners (Furlong & Smith, 2005; Kilpatrick et al., 2013; Patten & Goudreau,2012; Rounds, 2013). Therefore, considerable
effort and collaboration of the central healthcare agents, organizations, legislators, educational institutions, and other stakeholders
are required to increase clarity and common understanding related to CNS roles to support policy formulation and role
implementation.
The recognition of APN roles and titles is a rather recent development in Finland; however, the patterns of specialty practice have
existed since the early 1900s and of specialist nurse education since the 1970s (Fagerstrm & Glasberg, 2011; Jokiniemi et al., in
press). The Finnish higher education system consists of two complementary sectors: universities and polytechnic institutions. The
universities mission is to conduct scientific research and provide instruction and postqualification education based on it. Polytechnic
institutions, in turn, train professionals in response to labor market needs. The entry requirement to both APN education systems is
a bachelor's degree in nursing (Ministry of Education and Culture, 2014). Despite the history of specialist level practice and existing
APN educational programs, advanced-level nursing roles have not been nationally conceptualized in a Finnish context, authorized
by the National Supervisory Authority for Welfare and Health, or regulated by the government. The role of the CNS was first
established within hospital care in Finland at the beginning of 2000 (Meretoja, 2002). The goal of the CNS role is to assure quality of
care, support the staff's and organization's strategic work, and implement EBP (Jokiniemi et al., in press). Furthermore, certified
nurse midwife and certified nurse anesthetist roles do exist in Finland (Malin & Hemminki, 1992; Vakkuri, Niskanen, Meretoja, &
Alahuhta, 2006), but educational and other APN requirements of these roles are not equivalent to the international APN role

requirements. Without formal regulation, policies, and protected titles, APN roles, such as the CNS, have been defined by individual
organizations, creating the emergence of unnecessary variation in roles and thus compelling the need for national role
conceptualization and standardization.
The increasing interest in APN roles highlights the importance for nurses and the nursing profession to understand the language and
concepts involved in order to communicate with each other, clients, and stakeholders (Bryant-Lukosius et al., 2004; Ruel &
Motyka, 2009; Spross & Lawson, 2013). Furthermore, national regulation and policies are needed to facilitate role recognition,
curriculum design, and effective role implementation and evaluation, yet there is scarce international research available to inform or
assess APN policy formulation. This article reports on a study utilizing a policy Delphi design (de Loe, 1995; Turoff, 2002). Although
the Delphi method is widely mentioned in the healthcare literature (McKenna, 1994; Powell, 2003), the policy Delphi design has not
been utilized much in APN policy formulation studies.

Aims and Objectives

The aim of this study was to identify and examine the expert panelists visions on future CNS role implementation, and to generate
questions as well as supporting and opposing views for further exploration. The research questions were:

How do the expert panelists define the future CNS role and its competencies?

What are the expert panelists supporting and opposing views regarding the future CNS role attributes and
implementation?

What are the most probable threats for CNS role implementation in the future?

Methods and Materials

Policy Delphi Design

A policy Delphi design (de Loe, 1995; Turoff, 2002), a variant of the conventional Delphi, was selected. It is similar to the full Delphi
in terms of procedure and intent (Keeney, Hasson, & McKenna, 2006). The policy Delphi design is considered a decisionfacilitating tool (Powell, 2003; Turoff, 2002), which seeks all possible viewpoints and explores factors underlying disagreement
(Linstone & Turoff, 2011; Turoff, 2002). Since it does not aim for consensus but explores the various opinions (Powell, 2003;
Turoff, 2002), it is an effective method to inform the decision-making process within the policy formulation process (de Loe, 1995).
Given the newness associated with the CNS roles in Finland, as well as the study aim of aspiring information for the basis of policy
formulation, it was appropriate to use a design that highlights a broad range of options rather than aim for a consensus on one or a
few options (de Loe, 1995).
Participants
A purposive sampling method was used to recruit 10 to 50 participants, which has been suggested as an appropriate number of
experts in a policy Delphi panel (de Loe, 1995; Turoff, 2002). Participant recruitment was planned to ascertain a high level of
expertise on the APN roles and thus aid in miscellaneous information gathering. The inclusion criteria of expert panelists were (a)

being a member in an interest group of APN, APN education, or healthcare management, and (b) having expertise in the area of
APN, APN education, APN management, healthcare workforce development, or international APN.
The nursing practice directors at five university hospitals, the National Institute of Health and Welfare, Ministry of Social Affairs and
Health, nursing trade organization, and universities of applied sciences that have APN programs were contacted to obtain
recommendations. Overall, 35 expert panelists were recommended and asked to participate. The interest groups were evenly
represented. The panelists were asked to self-rate their expertise on a scale of 1 (little expertise) to 4 (a lot of expertise). The
expertise on APN role received the highest mean score of 3.32, with 48% of panelists rating themselves as having a lot of
expertise. The expertise on healthcare workforce development received the second highest mean score of 3.12. The lowest mean
score of 2.44 was found in international APN expertise.
Data Collection Rounds
Three iterative policy Delphi rounds were conducted between June and October 2013 by using Web-based online survey and
analysis software. A time estimate of answering each of the rounds varied between 20 and 40 min. Approximately 2 weeks were
given to answer each questionnaire, and if no response was received, reminders were sent a few days before the due date. To
alleviate response exhaustion, the topics observed were divided between the rounds. The subsequent questionnaires were sent
only to the panelists who had answered the previous questionnaire; thus, the policy Delphi study can be seen as a cumulative
process building on the preceding panelist contribution. The response rate was 71% (n = 25) in the first round, 63% (n = 22) in the
second, and 54% (n = 19) in the third round.
In the first round, open-ended questions following the study questions were used to direct the data gathering. By doing this, the
panelists were allowed to bring in their timely views of the CNS roles, which might be more accurate and precise than items formed
based on the literature. The second and third rounds consisted mainly of 4-point Likert-type questions (de Loe, 1995; Turoff, 2002),
where statements formed based on the first round, thus illustrating the views of the panelists, were presented for rating. In ranking
the statements, the panelists were asked to identify the likelihood or desirability of statements, or judge items in terms of their
importance relative to others. A maximum of two response choices were asked at one time. The response choices ranged from
totally disagree to totally agree, very undesirable to very desirable, very unlikely to very probable, or very unimportant to very
important. In addition to rating each of the statements, panelists were asked to make additional suggestions, comments, or
questions on statements to minimize respondent bias (de Loe, 1995; Keeney, Hasson, & McKenna, 2006) and to expose arguments
behind ratings. The statement ratings were examined in order to measure whether the panel supported, opposed, or was ambivalent
toward an option, or whether no clear picture of support emerged (de Loe, 1995). Based on the measurements, the items that had
high consensus in response were omitted in subsequent rounds. Items that had a low consensus level or generated major opposing
views were further examined in the next round (Rayens,2000).
To ensure content and face validity (Mead & Moseley, 2001), all three questionnaires were pretested with six professionals from
outside the research setting. These professionals were identified by the research team using the same inclusion criterion as the
original study participants. In addition to completing the email questionnaires, the experts in the pretesting phase were asked to give
specific feedback about the policy Delphi process, including the time taken to complete the questionnaires, preferred method of

rating, and question understandability and comprehensibility. Minor alterations were made to the questionnaires according to the
feedback.
Data Analysis
The policy Delphi method includes the careful management and analysis of both qualitative and quantitative data. The data
produced by the open-ended questions were analyzed by qualitative content analysis, and statements significant to study design
were formed for panelist rating. The quantitative data acquired through statement ratings were analyzed by using the Statistical
Package for the Social Sciences (version 19.0; SPSS Inc., Chicago, IL, USA), with the aim of identifying how much the panel agreed
or disagreed with each of the statements. To detect any differences between the respondent categories, the respondent ratings
were also analyzed using the Kruskal-Wallis test.

To analyze the quantitative data, each rating set was examined according to mean, rating distribution, and consensus level (de
Loe, 1995). Mean scores were examined in order to assess the multiple statement preference. Consensus was examined,
according to de Loe's (1995) suggestion, to be high, medium, low, or none, indicating the degree to which the group was able to
agree on a given issue. In addition to consensus examination, further examination of each rating distribution was needed to observe
whether the panelists consensus opposed or supported each statement. An example of the rating distribution and consensus levels
can be seen in Table 1. To interpret Table 1, it can be seen that advanced clinical nursing as a future CNS role domain attained a
low consensus level; thus, just over 60% of the ratings fell into two contiguous categories. Furthermore, the consensus on CNS
leadership domain is medium, with 74% of answers being in two contiguous categories. Nevertheless, when further examining the
leadership ratings, it was noted that the majority of ratings were in scale point 1 or 2; thus, here, medium consensus lay in
opposition, although only weak, for this role domain being included in the future CNS role.

Which domains should CNS

Ratings on scalea

work include in the future?

1 2 3 4

1.

Consensus

Support

1 = very undesirable; 2 = undesirable; 3 = desirable; 4 = very desirable.

2.

Note: CNS = clinical nurse specialist; High = 70% of ratings are in one category or 80% in two contiguous categories; Medium =

60% of ratings are in one category or 70% in two contiguous categories; Low = 50% of ratings are in one category or 60% in two
contiguous categories; None = <60% of ratings are in two contiguous categories; SS = strong support (>75% of ratings on point 3 or 4);
WS = weak support (>5075% ratings on point 3 or 4); WO = weak opposition (<5075% ratings on point 1 or 2).
Advanced clinical nursing

4 4 4 7

None

WS

Education

0 1 8 10

High

SS

Practice development

0 0 2 17

High

SS

Consultation

0 0 7 12

High

SS

Which domains should CNS

Ratings on scalea

work include in the future?

1 2 3 4

1.

Consensus

Support

1 = very undesirable; 2 = undesirable; 3 = desirable; 4 = very desirable.

2.

Note: CNS = clinical nurse specialist; High = 70% of ratings are in one category or 80% in two contiguous categories; Medium =

60% of ratings are in one category or 70% in two contiguous categories; Low = 50% of ratings are in one category or 60% in two
contiguous categories; None = <60% of ratings are in two contiguous categories; SS = strong support (>75% of ratings on point 3 or 4);
WS = weak support (>5075% ratings on point 3 or 4); WO = weak opposition (<5075% ratings on point 1 or 2).
Research

1 1 9 8

High

SS

Clinical leadership

3 9 5 2

Medium

WO

Table 1. Rating Distribution, Level of Consensus, and Support on CNS Role Domains
Ethical Considerations
The study was carried out in accordance with the Code of Ethics of the World Medical Association (2013), and all procedures were
performed in compliance with relevant laws and institutional guidelines. Prior to the study, the participants were sent a cover letter
informing them about the study. Answering the survey was regarded as informed consent. To allow participants an equal voice and
hearing without pressure perceived from senior colleagues (de Loe, 1995), panelists were given reassurance that their individual
responses would be disclosed in an unidentifiable format during the study. However, only quasi-anonymity of their responses could
be guaranteed in the sense that the respondents and their responses were known to the research team (Keeney et al., 2006).
Participation in the study was voluntary, and participants could withdraw from the study at any time.

Results
The expert panelists envisioned future CNS role implementation in Finland. The core defining features of the CNS role and its
attributes, as well as the future threats of role implementation, were explored and described during this study. Using the KruskalWallis test, no statistically significant variation was observed between the interest groups of advanced practice nurses, APN
educators, or healthcare managers.

The Definition and Competencies of Clinical Nurse Specialist

Based on the findings of this research, Finnish CNS work at the unit, clinic, or organizational level in a primary care or hospital care
setting utilizing a wide range of work experience and advanced knowledge attained through master's-level education. They have a
comprehensive vision and knowledge of the healthcare system, which they use to guide and develop nursing practice while working
in collaboration with multidisciplinary teams. The Finnish CNS's EBP and independent role are actualized through practice
development, advanced clinical nursing, education, consultation, and leadership, as well as research.

Sixty-seven competency descriptions of CNS practice were extracted from the expert panelists first round of texts. These
competency descriptions were rated in the second round based on their relativity to CNS practice, and the panelists were also
asked to comment on the competencies and provide additional competencies if required. In the third round, the newly provided
competencies and competencies receiving less than 80% support were clarified based on panelists comments and rerated. Out of
the final 75 competency descriptions, 88% were supported with a high level of consensus.

Expert Panelists Views on Future CNS Role Attributes and Implementation

On clarifying future CNS role attributes and implementation, the CNS role domains, work area, education, and regulatory issues
were queried further. The CNS domains of practice development, education, clinical research, consultation, advanced clinical
nursing, and leadership were rated on desirability (see Table 1) and probability. There was medium to high consensus supporting
practice development, education, clinical research, and consultation aspects as desirable and probable domains of CNS future
practice; however, the leadership aspect was seen as an improbable and undesirable part of the role. The support was lowest in the
domain of advanced clinical nursing, where CNS operate in advanced direct patient care in a specialty area, coordinating care and
implementing EBP in cooperation with a multidisciplinary team. The reasoning behind opposing this domain included, for example,
that the clinical work snatches too big of an amount of the CNS's time and hinders the overall perception of the work. The reasoning,
in favor of advanced clinical nursing, included the arguments of clinical work being the core of CNS practice, advanced clinical skill
preservation, and the enablement of international comparisons and CNS role evaluation, inter alia.
The panelists agreed that the CNS work areas should include several units and not be built around the medical specialties, but
rather bound to some specialty area of nursing, such as mental health nursing. The statements that divided the opinions most were
whether or not the CNS should be specialized within some area of nursing, although it was recognized that specializing in an area of
nursing would help CNS to govern and maintain expertise in their area of work. The work areas may be constituted according to the
needs or goals of varying organizations or posts. The opinions were most polarized on whether the CNS work area should be joined
with primary and specialized health care and whether the post should be organization wide or unit wide.

According to the panelists, the dual educational system within Finland, where both universities and polytechnic institutions prepare
CNS with distinct curricula, causes difficulties with the planning and specification of the CNS's educational requirements. Although
the regulation equates these degrees in Finland, due to their differences there was a high level of support that there should be a
clear distinction between these two degrees and they should also prepare practitioners for different APN subroles. Additionally, there
was a high level of support that the CNS's education should be close to the international level but that the curriculum should be built
onto the national core competency descriptions.

Finally, the statements formed on the CNS regulatory issues are outlined in Table 2. Many of these issues appear to be important,
but they nevertheless receive low support on probability. CNS title protection, national registration, regular competency evaluation,
and defining continued educational requirements were regarded as desirable, but support on probability was low. The temporary
registration by the National Supervisory Authority for Welfare and Health was the only aspect rated both undesirable and improbable
out of the eight regulatory items.

Support on probability
Support on desirability

SS

WS

WO

SO

Note
1.

CNS = clinical nurse specialist; SS = strong support; WS = weak support; WO = weak opposition; SO = strong opposition; 1= CN

title and subsequent core competencies are combined nationally; 2 = registered nursing degree and national guidelines form a base for CN

practice; 3 = nursing managers define the CNS practice requirements; 4 = CNS title will be protected/legalized; 5 = CNS will be registere

by the nursing registration body; 6 = CNS registration will be contemporary; 7 = CNS continued educational requirements will be defined
nationally; 8 = CNS competency will be evaluated regularly.
SS

1, 2

5, 7, 8

WS

WO

SO
Table 2. Support on Desirability and Probability of CNS Regulatory Issues
Threats to Clinical Nurse Specialist Role Implementation in the Future
While a number of important CNS role threats were identified, the major and most probable threat of the future role, recognized by
all participants, was the tight economic situation that could prevent the roles from being implemented. The other probable threats
were that the remuneration is insufficient and that the CNS resource will be directed back to clinical nursing in the tight workforce
and economic situation. The threats dividing the experts opinions the most were whether the healthcare organization would be able
to renew its strategies and job descriptions to include and capitalize on the new CNS roles (50% for, 50% against). Other highly
polarized opinions on threats included the assertion that clinical work is not the core of the CNS practice. According to the experts,
this may turn the CNS post into an office post and diminish the evidence to support the role implementation.

The panelists were also asked to rate the significance of the threats and to point out the ones with the most preponderant
consequences. The most significant threats pointed out by the experts were the economic situation, the problems with the dual
model of nursing education, and the difference of views of CNS role among various professions.

Discussion
The aim of this study was to identify the expert panelists visions of future CNS role implementation in Finland and to generate
questions as well as supporting and opposing views for further exploration. The development of APN roles, such as the CNS,
requires persistent, diligent policy preparation in collaboration with central stakeholders to effectively blueprint and introduce these
roles (Bryant-Lukosius et al., 2010; Jokiniemi et al., in press). The ability of the policy Delphi design to aid in the informed decision-

making process was a significant feature leading to the application of this design in this study. The expert panelists views on future
CNS roles were comprehensive and timely. Several questions were raised for further exploration.
According to this study, the future Finnish CNS role is envisioned as rather consistent with the international role (Dowling
et al., 2013; Gordon, Lorilla, & Lehman, 2012; Kilpatrick et al., 2013; Lewandowski & Adamle 2009). Major polarity of panelists
opinion was found in the area of advanced clinical nursing. Although advanced clinical nursing has been widely perceived
internationally as a core of CNS practice (Bryant-Lukosius & DiCenso, 2004; Gordon et al., 2012; Hanson & Hamric, 2003;
Humphreys, Johnson, Richardson, Stenhouse, & Watkins, 2007; Roche, 2013), the panel debated its necessity as a core domain of
Finnish CNS practice, even though the lack of clinical practice was also seen as a threat to role achievement. Interestingly,
diminishing clinical activity has also been found by international CNS studies (Kilpatrick et al., 2013; Lewandowski & Adamle, 2009),
and determining advanced practice competencies has been found problematic (Furlong & Smith, 2005). Nevertheless, it has been
noted internationally that the perceived lack of impact of the CNS role on the provision of clinical services has been observed as a
fiscal liability, making the role vulnerable to cutbacks (Bryant-Lukosius et al.,2010; Lewandowski & Adamle, 2009), thus highlighting
a rationale for retaining the CNS clinical practice domain.
Another CNS domain causing polarity of opinion was leadership. The cautiousness to include leadership as a domain of the CNS
practice is an issue that may result in the mixing of leadership and management roles. However, it has been argued that there is an
increased need for expert leadership at the bedside with increased patient acuity, decreased hospital stay, and expanded scientific
knowledge (Cronenwett, 2012; Lewandowski & Adamle, 2009). Additionally, the notion of the CNS as a clinical leader may also be
supported by the observation of nurse managers movement further away from clinical surroundings to answer the increased
demands of administrative roles (McWhirter & Scholes, 2009; Shirey, Ebright, & McDaniel, 2008). The CNS leadership and
advanced clinical nursing domains are highlighted as areas needing to be clarified and defined further beyond this study. A
fundamental question is how these CNS practice areas are conceptualized for the basis of further research and policy formulation.
The development of CNS career pathways results in the need to develop national roles and supportive policy, education, and
regulation to standardize and solidify CNS practice (Furlong & Smith, 2005; Hanson & Hamric, 2003). These needs are furthermore
highlighted because the economic situation, questions with CNS education, and divergent views on the CNS role are the most
significant future threats emphasized by the experts. In the current economy there is inevitable value in a policy to guide efficient
APN role development; however, in many countries the absence of policies and regulation has led to insufficiently designed role
introduction (Bryant-Lukosius & DiCenso, 2004; Duke, 2012; Furlong & Smith, 2005; Weaver Moore & Leahy, 2012). Additionally, it
has been noted that regulatory issues may take a long time to actualize (Arslanian-Engoren, 2011; Bryant-Lukosius et al., 2010);
therefore, prioritizing the issues on which to focus can be informed through the Delphi process. In examining the study results, it is
noted that the regulatory issues with low consensus levels on probability and desirability highlight areas needing less attention;
however, the statements rated as desirable but not probable should be scrutinized carefully. If title protection, national registration,
regular competency evaluation, and defining continuing education requirements are perceived as important but improbable, what
procedures are needed to foster actualization of these regulatory issues?
The expert panelist views on future national CNS role are invaluable and will inform the policy formulation process of the CNS role in
Finland. A further policy Delphi study could explore the experts views on future international CNS and other APN subroles.
Furthermore, several issues indicated within this study, such as competency descriptions, conceptualization of advanced clinical

nursing, and leadership, will need to be researched further. Although the policy Delphi design is not often utilized, this study reveals
that it is very well suited to guide and inform the national and international aspirations of advanced practice nursing policy
development.

Limitations of the policy Delphi technique to consider are the use of experts, response rate, generalizability of the results, and
researcher bias. We attempted to achieve a true and diverse expert panel to represent broad knowledge and points of view to
increase confidence in the validity of the results. Response exhaustion is a commonly recognized issue in Delphi studies
(McKenna, 1994); thus, the final response rate of 54% can be regarded as adequate and is congruent compared to other policy
Delphi research (O'Loughlin, 2004; Picavet, Cassiman, & Simoens, 2012). The aim of the Delphi method is to generate ideas and
hypotheses, not to test them; in this sense, a single piece of a Delphi study may never be replicable and, hence, the body of
knowledge about a topic may be regarded as cumulative (Mead & Moseley, 2001). Although the results of this study may be
ungeneralizable, they nevertheless offer ideas and means worth consideration when developing APN role policies. Additionally, the
formulation of questionnaires and statements as well as comprehension of the reasons behind the arguments may have been
interpreted differently if another researcher had conducted the analysis. The analysis process and questionnaire formulation were
discussed within the research team to increase the validity of these processes. Furthermore, the policy Delphi process was also
described in detail to help the reader to assess the steps taken (Mays & Pope, 2000; Mead & Moseley, 2001; Powell 2003).

Conclusions
The authors have described the findings of a nationwide policy Delphi study examining the CNS role in Finland. The expert panel in
this study was knowledgeable in the area of APN roles, generating considerable data for exploration. The core attributes of the CNS
practiceinformation on advanced practice levels, core competencies, issues on regulation, and role implementation threatswere
explored and described in this study, hence contributing to national and international CNS role development. Although the evolution
of CNS roles varies in different countries, the examination and description of these development processes may be internationally
utilized when introducing these roles.

Although the aim of a policy Delphi design is neither consensus nor policy formulation, it is undoubtedly an effective way to aid
informed decision making. It helps to envision the future of a specific phenomenon, highlighting the main areas of consensus,
contradiction, and ambivalence to be considered. A clear vision of APN roles, such as the CNS, and their attributes precedes policy
formulation supporting role development and implementation. Once the APN policy is formulated, we agree with Furlong and Smith's
(2005) statement that it is crucial that educators adhere to these policies in curricula preparation and that clinicians adhere to the
policy in the development and examination of APN roles to enable the recognizability and standardization of these roles.
This study demonstrated a Web-based policy Delphi design as a cost-effective way to reach experts, even globally, in a process that
permits all possible views of a phenomenon to be examined. The description of the methodologies and processes used in this study
may aid in the application of this design at an international level. Although not often utilized, the policy Delphi design offers
comprehensive, inventive means to address APN policy formulation within the global nursing community.

Acknowledgments
This study was funded by the Finnish Nurses Association, the Finnish Association of Nursing Research, and EVO-funding. The
authors are grateful to the expert panelists who participated in this study, sharing their time and experiences. The authors also thank
statistician Tuomas Selander for his valuable contribution to the study.