You may also consider looking into the FNP route. I know that the ACNP route is great for acute care and ER, but in many ERs, they want the NP to be able to see children (there was actually one who had their ACNP certification and was told that they had to get their FNP or Peds NP certification so they could see kids or they would not be allowed to work there anymore). All ERs are different, but where I work, as long as you can get a ER rotation in school (although I didn't. I was just lucky because I was a ER nurse there for five years so they knew and trusted me) that you can work ER. They will not hire a NP with ACNP certification unless they are dual certified because they need them to see children. I'm sure in bigger areas, and possibly where you work, the ER or trauma center is split up into an adult area and has a seperate Peds ER. In that case, ACNP certification would probably be more desirable as ACNPs get more training in acute care, including procedures such as central lines and chest tubes. Still, where I work, the "mid-levels" (that's what they call us) such as the NPs and PAs aren't allowed to be priviledged to do these procedures anyway. Any central lines, chest tubes, intubations, LPs, etc. must be done by the physician. Even conscious sedation with reduction of dislocations must be performed under the supervision of the physician. Therefore, at least in my facility and many others I've heard of from other NPs, the FNP route is perfectly acceptable, if not more desired, in many ERs. Just a thought and something to consider. I would have loved to have the ACNP training, but the FNP route was more accessible to me, and it actually worked out better for my desired area of employment. Just something else for you to consider. Oh, and I have nothing but the utmost respect for CNSs, but as mentioned by many of the others, they are so few and far between these days, and many facilities are phasing them out because they are choosing to find less qualified workers to try to fill their void in order to save money. It doesn't work, I believe the patients suffer, but that's the sad state of things in healthcare right now. Hospitals and other healthcare facilities are cutting corners. NPs aren't going anywhere though, because even if the hospitals don't need us at all times, primary care always will. I love my ER position, it pays well, and is very rewarding (but stressful at times) but as I get up in the years I can definitely see myself going to work in a family practice office, seeing 20-30 patiets a day, and having my evenings, weekends, and holidays off. Right now though, I'm enjoying my acute care. ER is all I've ever done since I because a nurse, and I really don't know anything else. Good luck in your decision. Look into the requirements for the location or setting you're gonna work. Like I said, FNP may not be the choice for you, but it's something to consider!!!