Nurses talk about specialties constantly. ICU, emergency, oncology, pediatrics, perioperative, labor and delivery, informatics—the specialty someone practices in can become one of the strongest parts of their professional identity.
But who actually decides what constitutes a nursing specialty?
That question caught my attention recently when Patient Blood Management (PBM) nursing received formal recognition as a nursing specialty. PBM nurses have been doing this work for years, yet formal recognition required a deliberate effort to establish that their practice represented something sufficiently distinct within nursing to warrant specialty status.
And that process is far more rigorous than I realized.
A Specialty Doesn't Begin With a Name
The American Nurses Association serves as the formal reviewing body for recognition of nursing specialties, but recognition isn't simply an application asking ANA to acknowledge that a group of nurses performs specialized work.
ANA describes specialty development as a progression.
An emerging specialty may have recognizable characteristics but few formal competencies and relatively few practitioners. An evolving specialty has developed formal competencies, is attracting more practitioners, and is gaining recognition within healthcare. An established specialty has a defined scope and standards, a substantial practitioner base, and a recognized presence within nursing.
That distinction matters because nursing practice evolves constantly. New technologies, treatments, patient populations, care environments, and delivery models create new nursing roles all the time.
But a new role isn't necessarily a new specialty.
The Bar Is Surprisingly High
To receive formal ANA recognition, a proposed specialty must meet 14 criteria demonstrating that it represents a distinct area of nursing practice.
Among those requirements, the specialty must clearly define itself as nursing, establish who practices within it and where that practice occurs, demonstrate a distinct body of knowledge, show evidence of need and demand, identify educational preparation, describe how the specialty has evolved, and establish its contribution to nursing and patient care.
Perhaps most importantly, the specialty has to develop its own Scope and Standards of Practice.
Those standards define the boundaries and expectations of the specialty: who practices it, what those nurses do, where they practice, the populations they serve, what competencies are expected, and how competent practice should be evaluated.
ANA estimates that developing those materials alone can take 12 to 24 months.
The process includes a specialty nursing organization assembling a workgroup, developing the scope and standards, gathering input from its membership, opening the work to public comment, revising it, obtaining organizational approval, submitting it for ANA review, and ultimately going through review by the ANA Committee on Nursing Practice Standards and the ANA Board of Directors.
Recognition, in other words, tends to follow the development of a profession within the profession.
New Specialties Are Relatively Rare
That rigor may help explain why genuinely new nursing specialties don't appear very often.
Travel health nursing and burn nursing received formal ANA recognition in 2020. Cannabis nursing followed in 2023. More recently, men's health nursing and Patient Blood Management nursing have joined the ranks of recognized specialties.
Think about how much nursing practice has changed during roughly that same period.
Telehealth expanded dramatically. Virtual nursing emerged across health systems. Artificial intelligence entered clinical workflows. Hospital-at-home programs grew. New care coordination and navigation roles developed. Genetics and precision medicine continued advancing.
Yet formal specialty recognition remains relatively uncommon.
That isn't necessarily evidence that the process is too slow. It may demonstrate something important about what the word specialty is supposed to mean.
Specialty, Role, Setting and Certification Aren't the Same Thing
This may be where much of the confusion comes from.
Nurses specialize in practice every day without necessarily practicing within a newly recognized nursing specialty. A role can require substantial expertise without being its own specialty. A certification can validate advanced knowledge without creating a specialty. A new care setting can change how nurses practice without necessarily creating a new discipline.
Even precepting provides an interesting example. Preceptors perform highly specialized work requiring distinct competencies, but the Association for Nursing Professional Development explicitly notes that precepting itself is not a recognized nursing specialty.
Telehealth offers another example. Nurses can develop considerable expertise delivering care virtually, yet telehealth has historically been viewed as a method of delivering nursing care rather than a separate specialty.
The distinction forces an interesting question: When has nursing practice changed enough that we're no longer talking about a new role or way of delivering care, but an entirely distinct area of nursing practice?
Recognition Usually Comes After the Practice
Patient Blood Management nursing illustrates how that evolution happens.
The Society for the Advancement of Patient Blood Management began working with ANA in 2021 to formally articulate what made PBM nursing distinct. A volunteer nursing workgroup spent years researching, writing, reviewing, and refining the Scope and Standards of Practice that would eventually become the foundation for recognition.
The nurses came first.
The practice came next.
The professional infrastructure developed around it.
Formal recognition came later.
That sequence may be the most interesting part of how nursing specialties evolve. ANA isn't necessarily creating specialties. In many cases, nursing practice evolves until a community of nurses can demonstrate that a distinct specialty already exists.
What Will Nursing Recognize Next?
That raises an interesting question about where nursing is heading.
Healthcare is changing quickly. Virtual care, artificial intelligence, genomics, precision medicine, remote monitoring, hospital-at-home models, new behavioral health approaches, and entirely new care environments are changing what nurses do and where they do it.
Some of those changes will remain tools, roles, or practice settings within existing specialties.
Others may eventually develop their own bodies of knowledge, competencies, professional communities, research bases, and standards of practice.
And a small number may eventually cross the threshold into something nursing considers a distinct specialty.
Looking at how difficult that threshold is to cross makes every new recognition a little more significant. It isn't simply a new title being added to a list. It represents years of practice evolving to the point where nurses can define what makes their work distinct, demonstrate why it matters, and establish the professional standards necessary for the next generation to follow.
Perhaps the more interesting question isn't how many nursing specialties exist today.
It's which areas of nursing practice are quietly becoming tomorrow's specialties.