Once the Designation is achieved, it is expected that nurses maintain their Designation through the completion of 100 hours or more of continuing educational activities every five years. The requirements include participation in educational activities within the Institute (minimum 30 hours), with some additional activities outside of the Institute. Some of activities include: course/workshop attendance; mentorship; leading workshops or co-facilitate de Souza course; deliver de Souza OTN rounds or presentation at de Souza conferences; submission of article for de Souza newsletter; and, journal publication.