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Certification and regulation of advanced practice nurses
ITION STATEMENT Certification and Regulation of Advanced Practice Nurses AMERICAN ASSOCIATION OF COLLEGES OF NURSING
Position Statement: The nursing profession must de-
velop a standardized national advanced practice nursing certification process by the year 2000. ';Advancedpractice nurse" is an umbrella term appropriate for a licensed registered nurse prepared at the graduate degree level as either a clinical specialist, nurse anesthetist, nursemidwife, or nurse practitioner. Advanced practice nurses are professionals with specialized knowledge and skills that are applied within a broad range of patient populations in a variety of practice settings (seeAttachment A). All advanced practice nurses should hold a graduate degree in nursing and be certified. Each existing and future professional nursing specialty certifying entity must meet uniform national standards when certifying nurses for advanced practice. Those standards wouM be developed and administered by a separate organization such as the American Board of Nursing Specialties. Professional certification validates and standardizes the qualifications and practice competencies of the advanced practice nurse and is the appropriate mechanism by which the public's health and safety can be protected. There are nursesprepared at the advanced level who have rolesas administrators and educators. Thisposition statement does not addressthose individuals. Ratheg, itfocuses on nurses preparedfor rolesas directcareproviders.
Background Nurses in various advanced practice nurse categories have been providing health care in the United States for more than 50 years. However, neither the educational preparation nor the certification process for these nurses has been standardized. In many Reprinted with permission of the American Association of Collegesof Nursing. 184
instances, nurses without advanced graduate education are functioning in advanced practice roles. Similarly, not all master's-prepared advanced practice nurses are certified. Advanced practice nurses who are certified have achieved this status through myriad processes governed by varying standards. There are more than 30 organizations that grant certifications for nurses with training beyond the entry-to-practice level (Fickeissen, 1990). While only a few of these organizations certify the nurse practitioners, nursemidwives, nurse anesthetists, and clinical nurse specialists who are the focus of this position statement, confusion in the public mind about the meaning of certification suggests that a consistent set of standards must be established for all certifications for advanced practice nurses. Since 1992, the issue of regulating advanced practice nursing has become a topic of increasing concern to the nursing profession (Minarik, 1992). One organization proposed a second license as a means of providing legal authority, defining scope of practice, and protecting the professional title for advanced practice nurses (National Council of State Boards of Nursing, 1993). Others have maintained that regulation should take place through education requirements and a standardized certification process. The need for a second license versus certification as the appropriate regulatory mechanism has been argued in the literature, and various groups have assembled periodically to study the matter (Andreoli & Dvorak, 1993; Havens, 1992; Krauss, 1992; Smereina, 1993). A uniform regulatory process must be established to assure the public of the competency of the advanced practice nurse. A standardized national advanced practice certification process that mandates a graduate
Journal of ProfessionalNursing, Vol 12, No 3 (May-June), 1996: pp 184-186
POSITION STATEMENT
185
A-H-ACHMENTA. Examples of the Role and Scope of Advanced Practice Nurses* Advanced Practice Nurses
Application of Advanced Knowledge and Skills
Certified nurse-midwives Well-women health care, management of pregnancy, childbirth, antepartum and postpartum care. Health promotion. Clinical nurse specialists Management of complex patient health care problems in various clinical specialty areas through direct care, consultation, research educationl and administrative roles. Nurse anesthetist Pre-operative assessment, administration or anesthesia, and management of post anesthesia recovery. Nurse practitioners Management of a wide range of health problems through physical examination diagnosis, treatment, and patient/family education and counseling. Primary care and health promotion.
Patient Population Served
Childbearing women
Individuals with • Physical or psychiatric illness and disability • Maternal and child health problems • Gerontologic problems Individuals in all age groups undergoing surgical procedures
Individuals and families • Women • Infants and children • Elderly • Adults and others
Practice Settings
• • • •
Homes Hospitals Birthing centers Ambulatory care
• • • • • • • •
Tertiary care Ambulatory care Community care Home health care Rehabilitation Hospital operating rooms Ambulatory care Surgical settings
• • • •
Primary care Long-term care Ambulatory and community care Tertiary care
*These are examples and are not intended to be an exhaustive description of knowledge, patient populations, or practice.
degree in nursing is the appropriate mechanism. AACN supports advanced practice nurse certification that requires completion of a graduate program in nursing for advanced practice as well as demonstration of clinical practice experience in the specialty. Completion of a graduate program in nursing prepares nurses to function as practitioners, case managers, change agents, clinical teachers, consultants, and health and social policy advocates. These graduates utilize nursing and health care research in modifying nursing practice. More specifically, nurses prepared at the graduate level function in a variety of roles as advanced practice nurses in specialty areas of practice. For example, advanced practice nurses plan and coordinate multidisciplinary interventions within a variety of health care systems with diverse populations, initiate and facilitate organizational change and continuous quality improvement programs in the area of practice, facilitate the conduct and utilization of research, develop educational materials and strategies and evaluate their effectiveness within a specialty area of practice, participate in the formulation of health and social policies, provide clinical consultation in a specialty area of practice, and apply ethical and legal principles to complex health care circumstances (seeAttachment A). The first step in ordering advanced practice nurse practice is to assure the public that the preparation of these nursing professionals is at a level reflective of its advanced knowledge base, that is, graduate preparation accomplished with a curriculum that incorporates
professional standards and clearly defined core competencies. AACN has been conducting meetings nationwide to involve participants in identifying the essentials of advanced practice nursing education. This educational quafification must be required for graduates of advanced nursing programs to sit for a national certifying examination in their respective specialties. The Certification of advanced practice nurses by professional specialty nursing organizations incorporates professional assessment of necessary skills and measurement of a licensed registered nurse's competence with regard to established criteria. For example, advanced practice nurses certified by the American Nurses Credentialing Center must have master's degrees and demonstrate successful completion of an 8-hour written examination composed of in-depth questions prepared by and :reviewed by practitioners. For certain specialties, advanced practice nurses also must show evidence of specified clinical practice experience. Once granted, certification is effective for 5 years, whereupon the individual must apply for recertification based on either a retest or demonstration of continuing education credits. The current system for recognizing advanced nursing practice through certification was established and is operated by professional nursing specialty organizations. In response to a need to be more formally organized as a national peer review program for advanced practice nursing certification bodies, the American Nurses Credentialing Center and more than a dozen certification boards joined the American
186
AACN
Board of Nursing Specialties (ABNS). This umbrella board established in 1991 approves membership of those advanced practice nursing certifying bodies that have met the standards and principles of ABNS. One of the 12 standards that must be met is a requirement for uniform educational preparation, ie, a graduate degree in nursing. The ABNS resembles the American Board of Medical Specialties whose mission is to maintain and improve the quality Of medical care by assisting member boards in their efforts t O develop and Utilize professional and educational standards for the evaluation and certification of physician specialists. Not unique to nursing and medicine, this approach also parallels the means used to board certify dentists, pharmacists, and attorneys to specialize in a particular practice area. All of the professions require a license to commence practice but rely on professional certifications as a basis for specialization. AACN is not suggesting that there be one examination for all advanced practice nurses; ratherl its position is that all advanced practice nursing certification procedures must meet a recognized and uniform national certification standard, integral to which is a requirement for a graduate degree in nursing. Certification has national precedence and respect and adheres to the principles of regulation promulgated by the International Council of Nursing and
adopted by major nursing organizations and regulators. Moreover, certification assures national consistency of professional standards, imposes standard titles, helps the public understand the professional's scope of practice, and provides a venue for the public to raise practice grievances. The professional certification process meets the objectives of greater professional autonomy and provides recognition of a nationally uniform measure of competence that can be relied upon by the public in making health care provider choices with confidence. Certification and licensure are both forms of regulation of a profession. State Boards of Nursing guided by Nurse Practice Acts regulate the practice of nursing through enabling legislation that authorizes Boards to test graduates of accredited nursing schools for licensure as registered nurses. This process has a long and successful history. With a standardized approved certification process for advanced practice nursing, a second license is not necessary to regulate nursing practice in the public's interest. With certification as the regulatory mechanism for advanced practice nursing, nursing can pool resources and move forward expeditiously on the process of regulation in the interest of public safety. (Approved by Membership--October 31, 1994)
References
Andreoli,'K. G., & Dvorak, E. (1993). Regulation-When it is appropriate and when it is not. Journal of
ProfessionalNursing, 9, 310. Fickeissen, J. L. (1990). Fifty-six ways to get certified. AmericanJournal of Nursing, ,90(3), 50-57. Havens, D. H. (1992). Licensure of advanced practice nurses. Journal of PediatricHealth Care, 6(6), 378-380. Kranss, J. (1992). Regulation of advanced practice
nursing--The cog in the health policy machine. Journal of
ProfessionalNursing, 8, 200. Minarik, E A. (1992). Second license for advanced nursing practice. ClinicalSpecialist, 6(4), 221-222. National Council of State Boards of Nursing, Inc. (July, 1993). National councilfact sheet. Chicago: Author. Smereina, C. (1993). Licensure of advanced practice nursing. OrthopedicNursing, 12(1), 13.
Position Statement: The nursing profession must de-
velop a standardized national advanced practice nursing certification process by the year 2000. ';Advancedpractice nurse" is an umbrella term appropriate for a licensed registered nurse prepared at the graduate degree level as either a clinical specialist, nurse anesthetist, nursemidwife, or nurse practitioner. Advanced practice nurses are professionals with specialized knowledge and skills that are applied within a broad range of patient populations in a variety of practice settings (seeAttachment A). All advanced practice nurses should hold a graduate degree in nursing and be certified. Each existing and future professional nursing specialty certifying entity must meet uniform national standards when certifying nurses for advanced practice. Those standards wouM be developed and administered by a separate organization such as the American Board of Nursing Specialties. Professional certification validates and standardizes the qualifications and practice competencies of the advanced practice nurse and is the appropriate mechanism by which the public's health and safety can be protected. There are nursesprepared at the advanced level who have rolesas administrators and educators. Thisposition statement does not addressthose individuals. Ratheg, itfocuses on nurses preparedfor rolesas directcareproviders.
Background Nurses in various advanced practice nurse categories have been providing health care in the United States for more than 50 years. However, neither the educational preparation nor the certification process for these nurses has been standardized. In many Reprinted with permission of the American Association of Collegesof Nursing. 184
instances, nurses without advanced graduate education are functioning in advanced practice roles. Similarly, not all master's-prepared advanced practice nurses are certified. Advanced practice nurses who are certified have achieved this status through myriad processes governed by varying standards. There are more than 30 organizations that grant certifications for nurses with training beyond the entry-to-practice level (Fickeissen, 1990). While only a few of these organizations certify the nurse practitioners, nursemidwives, nurse anesthetists, and clinical nurse specialists who are the focus of this position statement, confusion in the public mind about the meaning of certification suggests that a consistent set of standards must be established for all certifications for advanced practice nurses. Since 1992, the issue of regulating advanced practice nursing has become a topic of increasing concern to the nursing profession (Minarik, 1992). One organization proposed a second license as a means of providing legal authority, defining scope of practice, and protecting the professional title for advanced practice nurses (National Council of State Boards of Nursing, 1993). Others have maintained that regulation should take place through education requirements and a standardized certification process. The need for a second license versus certification as the appropriate regulatory mechanism has been argued in the literature, and various groups have assembled periodically to study the matter (Andreoli & Dvorak, 1993; Havens, 1992; Krauss, 1992; Smereina, 1993). A uniform regulatory process must be established to assure the public of the competency of the advanced practice nurse. A standardized national advanced practice certification process that mandates a graduate
Journal of ProfessionalNursing, Vol 12, No 3 (May-June), 1996: pp 184-186
POSITION STATEMENT
185
A-H-ACHMENTA. Examples of the Role and Scope of Advanced Practice Nurses* Advanced Practice Nurses
Application of Advanced Knowledge and Skills
Certified nurse-midwives Well-women health care, management of pregnancy, childbirth, antepartum and postpartum care. Health promotion. Clinical nurse specialists Management of complex patient health care problems in various clinical specialty areas through direct care, consultation, research educationl and administrative roles. Nurse anesthetist Pre-operative assessment, administration or anesthesia, and management of post anesthesia recovery. Nurse practitioners Management of a wide range of health problems through physical examination diagnosis, treatment, and patient/family education and counseling. Primary care and health promotion.
Patient Population Served
Childbearing women
Individuals with • Physical or psychiatric illness and disability • Maternal and child health problems • Gerontologic problems Individuals in all age groups undergoing surgical procedures
Individuals and families • Women • Infants and children • Elderly • Adults and others
Practice Settings
• • • •
Homes Hospitals Birthing centers Ambulatory care
• • • • • • • •
Tertiary care Ambulatory care Community care Home health care Rehabilitation Hospital operating rooms Ambulatory care Surgical settings
• • • •
Primary care Long-term care Ambulatory and community care Tertiary care
*These are examples and are not intended to be an exhaustive description of knowledge, patient populations, or practice.
degree in nursing is the appropriate mechanism. AACN supports advanced practice nurse certification that requires completion of a graduate program in nursing for advanced practice as well as demonstration of clinical practice experience in the specialty. Completion of a graduate program in nursing prepares nurses to function as practitioners, case managers, change agents, clinical teachers, consultants, and health and social policy advocates. These graduates utilize nursing and health care research in modifying nursing practice. More specifically, nurses prepared at the graduate level function in a variety of roles as advanced practice nurses in specialty areas of practice. For example, advanced practice nurses plan and coordinate multidisciplinary interventions within a variety of health care systems with diverse populations, initiate and facilitate organizational change and continuous quality improvement programs in the area of practice, facilitate the conduct and utilization of research, develop educational materials and strategies and evaluate their effectiveness within a specialty area of practice, participate in the formulation of health and social policies, provide clinical consultation in a specialty area of practice, and apply ethical and legal principles to complex health care circumstances (seeAttachment A). The first step in ordering advanced practice nurse practice is to assure the public that the preparation of these nursing professionals is at a level reflective of its advanced knowledge base, that is, graduate preparation accomplished with a curriculum that incorporates
professional standards and clearly defined core competencies. AACN has been conducting meetings nationwide to involve participants in identifying the essentials of advanced practice nursing education. This educational quafification must be required for graduates of advanced nursing programs to sit for a national certifying examination in their respective specialties. The Certification of advanced practice nurses by professional specialty nursing organizations incorporates professional assessment of necessary skills and measurement of a licensed registered nurse's competence with regard to established criteria. For example, advanced practice nurses certified by the American Nurses Credentialing Center must have master's degrees and demonstrate successful completion of an 8-hour written examination composed of in-depth questions prepared by and :reviewed by practitioners. For certain specialties, advanced practice nurses also must show evidence of specified clinical practice experience. Once granted, certification is effective for 5 years, whereupon the individual must apply for recertification based on either a retest or demonstration of continuing education credits. The current system for recognizing advanced nursing practice through certification was established and is operated by professional nursing specialty organizations. In response to a need to be more formally organized as a national peer review program for advanced practice nursing certification bodies, the American Nurses Credentialing Center and more than a dozen certification boards joined the American
186
AACN
Board of Nursing Specialties (ABNS). This umbrella board established in 1991 approves membership of those advanced practice nursing certifying bodies that have met the standards and principles of ABNS. One of the 12 standards that must be met is a requirement for uniform educational preparation, ie, a graduate degree in nursing. The ABNS resembles the American Board of Medical Specialties whose mission is to maintain and improve the quality Of medical care by assisting member boards in their efforts t O develop and Utilize professional and educational standards for the evaluation and certification of physician specialists. Not unique to nursing and medicine, this approach also parallels the means used to board certify dentists, pharmacists, and attorneys to specialize in a particular practice area. All of the professions require a license to commence practice but rely on professional certifications as a basis for specialization. AACN is not suggesting that there be one examination for all advanced practice nurses; ratherl its position is that all advanced practice nursing certification procedures must meet a recognized and uniform national certification standard, integral to which is a requirement for a graduate degree in nursing. Certification has national precedence and respect and adheres to the principles of regulation promulgated by the International Council of Nursing and
adopted by major nursing organizations and regulators. Moreover, certification assures national consistency of professional standards, imposes standard titles, helps the public understand the professional's scope of practice, and provides a venue for the public to raise practice grievances. The professional certification process meets the objectives of greater professional autonomy and provides recognition of a nationally uniform measure of competence that can be relied upon by the public in making health care provider choices with confidence. Certification and licensure are both forms of regulation of a profession. State Boards of Nursing guided by Nurse Practice Acts regulate the practice of nursing through enabling legislation that authorizes Boards to test graduates of accredited nursing schools for licensure as registered nurses. This process has a long and successful history. With a standardized approved certification process for advanced practice nursing, a second license is not necessary to regulate nursing practice in the public's interest. With certification as the regulatory mechanism for advanced practice nursing, nursing can pool resources and move forward expeditiously on the process of regulation in the interest of public safety. (Approved by Membership--October 31, 1994)
References
Andreoli,'K. G., & Dvorak, E. (1993). Regulation-When it is appropriate and when it is not. Journal of
ProfessionalNursing, 9, 310. Fickeissen, J. L. (1990). Fifty-six ways to get certified. AmericanJournal of Nursing, ,90(3), 50-57. Havens, D. H. (1992). Licensure of advanced practice nurses. Journal of PediatricHealth Care, 6(6), 378-380. Kranss, J. (1992). Regulation of advanced practice
nursing--The cog in the health policy machine. Journal of
ProfessionalNursing, 8, 200. Minarik, E A. (1992). Second license for advanced nursing practice. ClinicalSpecialist, 6(4), 221-222. National Council of State Boards of Nursing, Inc. (July, 1993). National councilfact sheet. Chicago: Author. Smereina, C. (1993). Licensure of advanced practice nursing. OrthopedicNursing, 12(1), 13.