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Credentialing chaos for nurse practitioners
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Abstract As opportunities for nurse practitioners have increased, the increased exposure has raised concerns for public safety among consumers and regulators. Compounding the problem is the lack of uniformity for credentialing nurse practitioners among the states. Many nurse practitioners do not have sufficient knowledge about the concept of credentialing and its significance to their practice. An accurate knowledge base is essential because credentialing affects the nurse practitioner’s autonomy to practice, prescriptive privileging, and reimbursement for services. The concept of credentialing and implications for nursing practice are presented along with current issues such as telenursing, multistate licensure compacts, and second licensure. By increasing the knowledge of nurse practitioners, the nursing profession can work towards achieving uniformity in credentialing that will provide clarity to the profession and, ultimately, to the public. c 2001 by Copyright W.B. Saunders Company
From Rush Presbyterian St. Luke’s Medical Center and Midwest Neoped Associates, Chicago, IL. Address reprint requests to Amanda Bennett, MS, RNC, NNP, Midwest Neoped Associates, 1653 West Congress Pkwy, Chicago, IL 60612–3864. c 2001 by W.B. Saunders Company Copyright 1527-3369/01/0103-0008$35.00/0 doi:10.1053/nbin.2001.25222
Credentialing Chaos for Nurse Practitioners By Amanda Bennett, MS, RNC, NNP
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hanks to a changing health care environment, the last decade of the 20th century provided a multitude of opportunities for nurse practitioners (NP). The start of the 21st century appears no different in this respect. With the focus of medical education shifted to primary care, residents continue to spend less time in specialty areas.1–3 Neonatal and pediatric intensive care units continue to turn to acute care nurse practitioners to meet their needs of providing quality patient care.4 The predominance of managed care forces physicians to see more patients in less time. Many physicians are turning to primary care nurse practitioners to successfully manage their practice without sacrificing quality of care. Although they are not common, the number of clinics exclusively owned and operated by nurse practitioners is rising.5–8 With greater numbers of nurse practitioners in a variety of practice settings, the practitioner role and the discipline of nursing have achieved a great deal of exposure. There is increased public awareness of the role and capabilities of nurse practitioners. Along with the increased exposure has come intensified scrutiny. Concern for public safety and the assurance that nurse practitioners are competent have become the major focus of consumer groups and regulatory agencies such as state boards of nursing and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO).9,10 There is an added emphasis on quality and cost control of health care that raises concerns for employers and institutions. Specifically, what credentials does an NP need in order to practice? Credentialing or regulation of the profession can be complex and confusing. It seems everyone wants a say in the matter, and it is not unusual to find other disciplines, such as medicine and pharmacy, involved with nurse practitioner credentialing in some states. It is important that the practitioner have a strong knowledge of these concepts in the present health care milieu. Nurse practitioners must know the scope of practice as defined by the state in which they are licensed. This article will provide an overview of credentialing, as well as issues and implications for nurse practitioner practice. In the United States, nurse practitioners are credentialed by the state. The scope of practice for this advanced practice role is determined by the nursing profession but enacted by regulatory agencies at the state and federal levels.11 Often times there is a difference in interpretation between the 2 levels of government. For example, although the federal government provides authority for nurse practitioners to be reimbursed for their services and defines criteria for reimbursement, individual states may limit an NP’s ability to seek reimbursement. The right of individual states is preserved over that of the federal government. Regulatory agencies are concerned about the individual’s preparation for practice, ie, the specialty knowledge and skills obtained in a formal educational program, as well as the competency of the individual.12 Competency is usually evaluated by a variety of factors, such as passing a national certification examination, Newborn and Infant Nursing Reviews, Vol 1, No 3 (September), 2001: pp 169–175
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work experience in the advanced practice role, etc). The level of regulation at the state level determines the degree to which multiple criteria are evaluated for recognition to practice in that state.13
Definition of Terms
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n order to understand the issues of credentialing, it is important to start with a basic definition of the terminology. A review of the literature reveals inconsistencies in how the concepts of regulation and credentialing are defined. Some authorities use the terms interchangeably; others make a distinction between the two. Styles14 differentiates the 2 concepts as follows: “Certification is a form of credentialing and credentialing is a form of regulation.” Credentialing is the process by which individuals, institutions, or agencies are regulated.9,14,15 Credentialing is defined as validation of required education, certification, and licensure. It is the process that is used to determine the appropriateness of one’s qualifications. Credentialing is based on criteria developed by the profession, the employers, and/or the regulatory agents; it is a method to provide evidence that the individual or institution is qualified to perform selected roles or services.16,17 According to Styles, regulation is an umbrella concept synonymous with quality assurance. She further states that regulation serves 3 functions: the setting of standards, the administration of standards, and the promotion of improvement. Regulation can be governmental, professional, or private. Regulation can also occur at the national, state, community, or institutional levels. There are 4 different levels of regulation used by state boards of nursing within the United States. These are recognition, registration, certification, and licensure.18–19 Recognition, the least restrictive level of regulation, provides the public with information about specialty credentials; it does not limit the right to practice. Registration is the next level of regulation and requires the individual to apply to have his or her name added to an official roster of professionals that is maintained by the regulatory agency.18 Within the regulatory arena the third level of regulation, certification, is defined as a mandatory process used to determine whether an individual meets predetermined qualifications in order to use certain professional titles such as nurse practitioner and clinical nurse specialist. Thus, certification equates to title protection.18 The most restrictive level of regulation is licensure.18 Licensure is usually a 2-step process that involves the identification of qualifications necessary to safely perform a unique scope of practice and an evaluation to determine whether an individual meets the qualifications.18 A license is “a legal document that permits a person to offer to the
public his or her skills and knowledge in a particular jurisdiction in which such practice would be unlawful without a license.”15 A license to practice is a property right and cannot be revoked without due process. Licensure is a form of external regulation through which the state determines whether an individual has met the minimal requirements to practice safely in the profession. Licensure permits the use of a particular title and defines a scope of practice for the profession. Two important functions of licensure are restriction of the number of people entering the profession and determination of eligibility for reimbursement.9 As the highest level of regulation, licensure is used when regulated activities are complex and require specialized knowledge and skill and independent decision-making. The licensing body has authority to take disciplinary action should individuals violate the defined scope of practice.20 Medicine was the first health care profession to require state licensure in the 19th century. It was not until 1938 that the state of New York first required licensure for nurses and defined a scope of nursing practice. Unfortunately, the practice of nursing was defined to be “the performance of certain functions ‘under the supervision of a physician.’”17 Subsequently, other states developed similar scopes of practice that limited nursing to a subordinate role in health care. With the evolution of the advanced practice nurse, the ability to diagnose and treat patients remained exclusive to the domain of medicine. This explains the slow progress nurse practitioners have made in becoming recognized as sharing certain aspects of medicine’s scope of practice.20–21 Certification is defined by the profession as a voluntary process by which a nongovernmental agency or association recognizes the professional competence of an individual who has met predetermined qualifications or standards specified by that agency or association.9 The purpose of certification within nursing has varied over time. Originally, certification was a mechanism to recognize excellence in practice. Over time, the purpose of nursing certification has evolved into recognition of specialty knowledge beyond the entry-level basic nursing knowledge measured by the registered nurse (RN) examination and recognition of entry-level specialty knowledge. More recently, certification for nurse practitioners has changed from a voluntary to a mandatory process. Because employers and regulatory agencies are requiring national certification for entry into NP practice, the voluntary nature of these exams has become a de facto mandatory process in most states. This has forced the professional nursing certification organizations to change their examinations to meet the criteria of regulatory sufficiency; ie, nurse practitioner certification exams must be geared toward entrylevel, minimum competencies rather than recognition of specialty knowledge.17,22 As previously mentioned, certification means title protection within the regulatory arena.
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The distinction between these 2 very different meanings for the same word is often confused within the profession and its published literature.
Why Regulate and License Nurse Practitioners?
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he simple answer is protection of the public. With the emergence of the Industrial Age, the economy shifted to manufacturing and the development of technology. Societal organization shifted from rural farms to the cities, where people found lucrative employment in factories and industrial plants.23 The intimate relationship once experienced between patient and small-town health care provider dissolved as a variety of individuals were available to provide similar services. It was difficult for patients to evaluate the quality of care they were receiving. By the end of the 19th century, federal, state and local governments began enacting laws to protect the consumer. A law may be defined as “a standard or rule of conduct established and enforced by the government of a society.”15 Civil laws regulate the relationships among people and include the practice of nursing. The Tenth Amendment reserves for the states all powers not delegated by the constitution of the United States. A state constitution forms the framework for state government. The state legislature enacts a nurse practice act to regulate nursing. This nurse practice act defines the legal scope of practice for the profession. This is an example of a statutory law—a law enacted by a legislative body. The state legislature delegates authority to the state board of nursing, an administrative agency at the state level, to enforce the nurse practice act. The state board of nursing has the power to establish administrative rules and regulations in accordance with the laws in existence that must be enforced. The rules and regulations that a state board of nursing adopts are examples of administrative laws.15,20 The first nurse practice act was from the state of North Carolina in 1903. This signified the foundation for the first of 3 phases in the development of nurse practice acts.24–25 Within the next 35 years, the majority of states had enacted similar “nurse registration acts,” as they were initially titled. They were modeled after the first medical practice acts. The goal of the nurse registration acts was to organize and promote nursing as a profession. Two important organizations, The National League for Nursing (NLN) and the American Nurses’ Association (ANA), were used to fulfill this goal. The second phase began in 1938 and was marked by passage of the first mandatory nurse practice act in the state of New York. Two levels of nurses were established: registered professional and practical. The scope of nursing practice and title protection were both established during this phase. The ANA defined professional nursing practice for the first time in 1955. By 1971, the third phase in the history
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Table 1. Titles for Nurse Practitioners Found in Nurse Practice Acts NP APRN APNP ANP APN ARNP CNP RNP
Nurse Practitioner Advanced Practice Registered Nurse Advanced Practice Nurse Practitioner Advanced Nurse Practitioner Advanced Practice Nurse Advanced Registered Nurse Practitioner Certified Nurse Practitioner Registered Nurse Practitioner
of nurse practice acts began and continues to this day. Significant for this phase is the state recognition of expanded roles, advanced practice nurses, and registered nurse specialization. During this phase, state nurse practice acts were revised to include advanced nurse practice language. By the end of the 20th century all 50 states, including the District of Columbia, had completed this task. This random progress led to inconsistent advanced practice legislation among states. The current credentialing chaos for nurse practitioners is a consequence of this random process. Table 1 illustrates the various titles used in state nurse practice acts to refer to nurse practitioners. These inconsistencies limit professional practice and mobility, confuse the public, and limit access to high-quality, affordable care. Faced with these challenges, policy makers have analyzed current regulatory practices.5,16,26 The Pew Health Professions Commission Report, “Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century” makes 10 recommendations for reform of current regulatory systems.26 Table 2 lists those regulations most pertinent to the nursing profession. The overall flavor is elimination of the unnecessary boundaries and limitations that have been placed on certain health care providers, many by unjust political or professional motivation, so that regulation of practice is based on demonstrated competencies.
Interstate Compacts
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rofessional mobility is becoming a necessity in today’s changing health care system. Many health care systems are regional or national in scope. Technological advances allow the use of telecommunications to deliver health care—often referred to as telehealth, telepractice or telenursing.16,21,24,25 Telenursing is defined as “the practice of nursing over distance using telecommunications technology.”27,28 Using this technology to interact with a client at a remote site, the nurse can retrieve data, initiate and transmit therapeutic interventions, and monitor and record
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Table 2. Key Recommendations From the Pew Report26 1. States should use standardized and understandable language for health professions’ regulation and its functions to describe them clearly for consumers, provider organizations, businesses, and the professions. 2. States should standardize entry-to-practice requirements and limit them to competence assessments for health professions to facilitate the physical and professional mobility of the health professions. 3. States should base practice acts on demonstrated initial and continuing competence. This process must allow and expect different professions to share overlapping scopes of practice. States should explore pathways to allow all professionals to provide services to the full extent of their current knowledge, training, experience, and skills. 4. States should redesign health professional boards and their functions to reflect the interdisciplinary and public accountability demands of the changing health care delivery system. 5. States should require each board to develop, implement, and evaluate continuing competency requirements to ensure the continuing competence of regulated health care professionals. 6. States should understand the links, overlaps, and conflicts between their health care workforce regulatory systems and other systems that affect the education, regulation, and practice of health care practitioners and work to develop partnerships to streamline regulatory structures and processes.
the patient’s response to the nursing intervention. The nurse may practice in one state although the patient resides in another. Holding a nursing license in one’s state of residence may not be adequate. Practitioners need to be able to practice across state lines without barriers, and the public needs to be assured of access to safe and qualified practitioners. In response to this issue, the National Council of State Boards of Nursing (NCSBN) endorsed the mutual recognition model of nursing regulation in August 1997.21,28–30 This model allows the nurse to have license in his or her state of residency and practice in other states, whether physically or electronically, unless practice is restricted by disciplinary action or monitoring agreement. The method used to implement the mutual recognition model is the interstate compact. The interstate compact is a legal agreement between 2 or more states that enables nursing practice across state lines. As of January 1, 2000, the mutual recognition interstate compact model became reality for RNs and licensed practical nurses/vocational nurses (LPN/VN) professionals. The model is compared with the method of obtaining a driver’s license, ie, nurses who possess a license in a state that has an interstate compact with other states is not required to obtain individual licenses in the compact states to practice in those states. If the same nurse anticipates delivering care to patients in a state that is not part of the interstate compact,
he or she must obtain separate licensure from that state to practice nursing in that state.28 The NCSBN’s objective is to provide “a state nursing license recognized nationally and enforced locally.”28 Although this sounds reasonable, it is not that simple to put into practice. The nurse with multistate licensure privileges agrees to follow each state’s practice laws and regulations when practicing in the respective state. Each state’s nurse practice act remains intact. The compact is another statutory level above the individual state’s nurse practice act. The compact specifies what will be agreed on between states, and its rules and regulations specify how the states will work together. The compact administrators, who are the heads of the nurse licensing authority in each state, establish the rules and regulations.21 The compact provides states with additional authority when granting privileges, taking disciplinary action, or sharing information with other party states. The compact supersedes state laws and may be amended only by agreement of all party states. Although the compact is singular and universal, the nurse practice acts from each party state are not identical. This means the nurse must be accountable to the rules and regulations in the home state of licensure as well as in each party state where nursing is practiced. This may prove cumbersome, for, if disciplinary action is necessary, both the home state and remote state will be involved. A complaint made to the home state concerning a violation in the home state would be processed in the current regulatory system. A complaint to the home state concerning a violation in a remote state would be processed cooperatively. A complaint to the remote state concerning a violation in that remote state would be processed in the remote state and reported to the home state.30,31 The compact requires the home state to investigate the incident in the same manner as it would have if the incident had occurred in the home state. It is not required to take action or enforce the remote state’s laws. The home state may take action against the nurse’s license (home state action), but the remote state may only take action against the nurse’s privilege to practice in that remote state (remote state action). A central database is in place to keep licensure records and disciplinary investigations current and accessible to those state boards of nursing that are members of the compact. According to the NCSBN, mutual recognition simplifies the investigation of an action for this reason, as party states can collaborate and coordinate based on the information from the database. Concerns over confidentiality have been raised regarding the sharing of information between states in the compact. The NCSBN has developed Nursys, the first comprehensive nurse licensure database in the nation.31 Data confidentiality laws already in existence at the state level are maintained in this system. The
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interstate compact authorizes the sharing of data only with other compact states. Information is not available to the public or non–party states. Because the mutual recognition interstate compact model is so new and introduces complex issues, it remains to be seen whether the disciplinary action process will be simplified and whether confidentiality will be maintained. It also remains to be seen whether the regulation of nurse practitioners could be managed through such a model. The present state of chaos that exists for NP regulation raises serious doubts to the success of such a model. One of the reasons for development and implementation of the mutual recognition interstate compact model for RNs and LVNs is that licensure requirement among the states differs very little. The goal for uniform core licensure requirement for RNs and LVNs is not far away. This is certainly not the case for nurse practitioner licensure.32,33 For this reason, many nursing organizations are recommending that uniform standards for advanced practice nursing be developed before an advanced practice nursing interstate compact is created. The argument is that the interstate compact tolerates existing barriers to interstate practice rather than eliminates them.32 As the NCSBN has worked with various organizations addressing the issue of uniform education and certification requirements, its Advanced Practice Task Force continues to pursue strategies and language development for an advanced practice nurse interstate compact.
Second Licensure
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n 1993, the NCSBN released a position statement that called for all advanced practice nurses to have a second license to practice.34 This position statement also called for the master’s degree as the minimum level of education for entry into advanced practice.34 The second licensure proposal was an attempt to bring uniformity to titling and educational preparation. The NCSBN’s argument was that second licensure is the only means to prevent others from practicing or representing themselves as advanced practice nurses. Second licensure also provides recognition for the ability to diagnose and treat illness and simplifies direct reimbursement for services. This proposal resulted in much controversy. The ANA and numerous specialty organizations strongly opposed second licensure on the basis that advanced practice nurses should be self-regulated by the profession and the basic RN license is sufficient as long as the state requirements for the title are fulfilled.35 These groups also pointed out that no other profession requires 2 licenses for the same professional provider. For example, physicians receive their medical license after completing medical school. They do not have to obtain a specialty license after completing their specialty training.
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The American Association of Colleges of Nursing (AACN) released a position statement that recommended certification, rather than second licensure, as the regulatory mechanism of advanced practice nurses.36 The completion of a graduate degree in nursing and demonstrated clinical practice experience in the specialty area should be additional prerequisites to credentialing. The certification process should be the responsibility of each respective specialty nursing organization, based on standardized psychometric requirements. The NCSBN had concerns about using national NP certification examinations for regulatory purposes because some certification agencies stated their NP examinations were not designed for entry-level use. Regulatory sufficiency is based on an examination designed to measure entry-level competencies, exclusive job-related knowledge and skills, pass/fail criteria at the point of minimumessential level for safety and effectiveness, and the use of generally accepted testing practices.22 In the mid 1990s, the NCSBN considered the development of a single core licensure examination for all nurse practitioners. Significant conflict ensued between the NCSBN and the specialty nursing organizations. In lieu of developing a core examination, the NCSBN agreed to collaborate with the certification organizations to ensure that their certification examinations were legally defensible as well as psychometrically sound, thus making them sufficient for regulatory purposes. Subsequently, all of the NP certification organizations provided evidence that their examinations met or exceeded these criteria. A related issue to second licensure is the push toward graduate nursing education for entry into NP practice. Currently, approximately 50% of the states have a requirement for the master’s degree in their nurse practice acts.37 The need to change a state’s nurse practice act to add this requirement is becoming a moot point, as the majority of states require national certification for NPs. At this time, a graduate nursing degree is required to sit for all NP certification examinations except for the Women’s Health NP (WHNP) examination offered by the National Certification Corporation for the Obstetric, Gynecologic, and Neonatal Specialties (NCC). WHNP graduates who complete their programs on and after January 1, 2007, will be required to have a graduate nursing education.38 Because of the push towards graduate nursing education by states and employers, certificate-prepared NPs are seeking graduate study. These individuals need to be aware that not all graduate nursing degrees will be acceptable to some boards of nursing. Although some states will accept any graduate nursing degree, other states require the degree to be in the clinical specialty for which the NP is seeking credentialing. Thus, a nonclinical graduate nursing degree with a major in nursing administration or nursing education may be acceptable in one state but not in another.
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Similarly, clinical nursing degrees with a major outside of the specialty area of NP practice are also not acceptable in some states. For example, a certificate-prepared neonatal nurse practitioner (NNP) who obtains a master’s degree in nursing education or in community health nursing would not be allowed to practice in states such as Illinois.39 It is imperative that certificate-prepared NNPs investigate their state’s requirements for type of graduate nursing education acceptable for credentialing within that state.
deserves access to various types of health care providers, including nurse practitioners. Patients need the assurance that the provider they choose is qualified to provide safe and effective health care. The nurse practitioner deserves the autonomy to practice, prescribe medications, and be reimbursed fairly for services rendered. And this should not be within a state of confusion. Nurse practitioners should be aware of the situation and become involved in the process of clarifying, unifying, and implementing sound methods to achieve uniformity of practice regulation and credentialing.
Conclusion
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he preceding discussion clarified the concept of credentialing for NPs and illustrated the state of chaos that exists within the nursing profession. More importantly, the awareness of these issues should serve as incentive for nurse practitioners to take their professional credentials seriously. As elegantly stated by Lewis and Carson, “credentials are powerful and personal. . . they name us, define our practice, and attest to our qualifications. . . we must see them as property, the most tangible assets we have as career professionals. . . they are hallmarks of achievement that add to our self-esteem and confidence.”17 The task of obtaining an NP credential should not be taken lightly or for granted. It is more than simply being given the right to practice nursing in a specialty area at an advanced level. The nurse practitioner must ask, “How am I allowed to practice in this state?” Depending on the state, the credentialing process can dictate the scope of practice (independent versus physician collaboration or supervision), the level of educational preparation, the scope of prescriptive authority, and the ability to apply for third-party reimbursement for professional services. It is imperative that nurse practitioners be informed about these issues in all states in which they practice. It is also important to realize that the nurse practice acts and rules and regulations are being reviewed and revised on a regular basis to meet the changes in health care delivery. The requirements of today may not be the requirements of tomorrow. During the past several decades, emphasis was placed on the “if we could do it” notion. Could a nurse practitioner assess, diagnose, and treat patients effectively? Could we perform those tasks initially felt to be exclusive to the medical model? Having proven that we could in fact do this, the focus has shifted to how we are allowed to do it. Credentialing must be simplified and standardized among the states. The mission to achieve uniformity for nurse practitioner credentialing is underway, although the exact method for this mission remains unclear. Based on the state of disorder and confusion discussed in this article, it appears that it could take several more decades for any sort of consistency to be achieved. Yet, for the profession and the public, the sooner the better. The public
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22. National Council of State Boards of Nursing: Using nurse practitioner certification for state nursing regulation: An update. Issues 18(1), 1997 23. Kowalski K, MacMullen N, Brundage J, et al: The high touch paradigm. MCN: The American Journal of Maternal-Child Nursing 21(1): 43–51, 1996 24. Hickey JFV, Ouimette RM, Venegoni SL: Advanced Practice Nursing: Changing Roles and Clinical Applications (2nd ed). Philadelphia, PA, Lippincott, 2000 25. Safriet BJ: Still spending dollars, still searching for sense: Advanced practice nursing in an era of regulatory and economic turmoil. Advanced Practice Nursing Quarterly 4(3):24–33, 1998 26. Pew Health Professions Commission: Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century. San Francisco, PHPC, 1995 27. Interim Report: State Initiatives Program Regulatory Reform Grantees. San Francisco, UCSF Center for Health Professions, 1997 28. National Council of State Boards of Nursing: Mutual recognition: Multistate regulation task force communiqu´e. Special Edition. Chicago, NCSBN, 1997 29. Hutcherson C, Sheets VR, Williamson SH: What five regulatory trends mean to nursing practice. Nursing Management 29(11):49–50, 1998 30. National Council of State Boards of Nursing: Mutual recognition: Frequently asked questions. Available: www.ncsbn.org/files/mutual/ mrfaq.asp
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31. National Council of State Boards of Nursing: Mutual Recognition: Response to ANA House of Delegates Regarding Concerns About Mutual Recognition and the Interstate Compact. National Council Paper. 1999 32. Minarik PA, Price LC: Multistate licensure—for advanced practice nurses?: Nursing Outlook 47(2):93–94, 1999 33. Lowe M, Havens DH: Advanced practice nurses saddled with complex nurse licensure compact. J Pediatric Health Care 12(2):94–7, 1998 34. National Council of State Boards of Nursing: What regulation of advanced practice can offer health care reform. Issues 14(3), 1993 35. Spatz DL: Women’s health: The role of advanced practice nurses in the 21st century. Nursing Clinics of North America 31(2):269–277, 1996 36. American Association of Colleges of Nursing: Certification and regulation of advanced practice nurses. Journal of Professional Nursing 15(2):130–132, 1999 37. Pearson L: Annual legislative update: How each state stands on legislative issues affecting advanced nursing practice. Nurse Pract 26(1): 11-18, 21-28 38. National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties (NCC): Guidelines for Nurse Practitioner Articulation Agreements. Chicago, NCC, 1996 39. Illinois compiled statutes, professions, and occupations: Nursing and Advanced Practice Nursing Act 225 ILCS65/Public Act 90-472. Effective date 8-6-99. Titles 5, 10, 15, and 20. State of Illinois General Assembly.
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Abstract As opportunities for nurse practitioners have increased, the increased exposure has raised concerns for public safety among consumers and regulators. Compounding the problem is the lack of uniformity for credentialing nurse practitioners among the states. Many nurse practitioners do not have sufficient knowledge about the concept of credentialing and its significance to their practice. An accurate knowledge base is essential because credentialing affects the nurse practitioner’s autonomy to practice, prescriptive privileging, and reimbursement for services. The concept of credentialing and implications for nursing practice are presented along with current issues such as telenursing, multistate licensure compacts, and second licensure. By increasing the knowledge of nurse practitioners, the nursing profession can work towards achieving uniformity in credentialing that will provide clarity to the profession and, ultimately, to the public. c 2001 by Copyright W.B. Saunders Company
From Rush Presbyterian St. Luke’s Medical Center and Midwest Neoped Associates, Chicago, IL. Address reprint requests to Amanda Bennett, MS, RNC, NNP, Midwest Neoped Associates, 1653 West Congress Pkwy, Chicago, IL 60612–3864. c 2001 by W.B. Saunders Company Copyright 1527-3369/01/0103-0008$35.00/0 doi:10.1053/nbin.2001.25222
Credentialing Chaos for Nurse Practitioners By Amanda Bennett, MS, RNC, NNP
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hanks to a changing health care environment, the last decade of the 20th century provided a multitude of opportunities for nurse practitioners (NP). The start of the 21st century appears no different in this respect. With the focus of medical education shifted to primary care, residents continue to spend less time in specialty areas.1–3 Neonatal and pediatric intensive care units continue to turn to acute care nurse practitioners to meet their needs of providing quality patient care.4 The predominance of managed care forces physicians to see more patients in less time. Many physicians are turning to primary care nurse practitioners to successfully manage their practice without sacrificing quality of care. Although they are not common, the number of clinics exclusively owned and operated by nurse practitioners is rising.5–8 With greater numbers of nurse practitioners in a variety of practice settings, the practitioner role and the discipline of nursing have achieved a great deal of exposure. There is increased public awareness of the role and capabilities of nurse practitioners. Along with the increased exposure has come intensified scrutiny. Concern for public safety and the assurance that nurse practitioners are competent have become the major focus of consumer groups and regulatory agencies such as state boards of nursing and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO).9,10 There is an added emphasis on quality and cost control of health care that raises concerns for employers and institutions. Specifically, what credentials does an NP need in order to practice? Credentialing or regulation of the profession can be complex and confusing. It seems everyone wants a say in the matter, and it is not unusual to find other disciplines, such as medicine and pharmacy, involved with nurse practitioner credentialing in some states. It is important that the practitioner have a strong knowledge of these concepts in the present health care milieu. Nurse practitioners must know the scope of practice as defined by the state in which they are licensed. This article will provide an overview of credentialing, as well as issues and implications for nurse practitioner practice. In the United States, nurse practitioners are credentialed by the state. The scope of practice for this advanced practice role is determined by the nursing profession but enacted by regulatory agencies at the state and federal levels.11 Often times there is a difference in interpretation between the 2 levels of government. For example, although the federal government provides authority for nurse practitioners to be reimbursed for their services and defines criteria for reimbursement, individual states may limit an NP’s ability to seek reimbursement. The right of individual states is preserved over that of the federal government. Regulatory agencies are concerned about the individual’s preparation for practice, ie, the specialty knowledge and skills obtained in a formal educational program, as well as the competency of the individual.12 Competency is usually evaluated by a variety of factors, such as passing a national certification examination, Newborn and Infant Nursing Reviews, Vol 1, No 3 (September), 2001: pp 169–175
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work experience in the advanced practice role, etc). The level of regulation at the state level determines the degree to which multiple criteria are evaluated for recognition to practice in that state.13
Definition of Terms
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n order to understand the issues of credentialing, it is important to start with a basic definition of the terminology. A review of the literature reveals inconsistencies in how the concepts of regulation and credentialing are defined. Some authorities use the terms interchangeably; others make a distinction between the two. Styles14 differentiates the 2 concepts as follows: “Certification is a form of credentialing and credentialing is a form of regulation.” Credentialing is the process by which individuals, institutions, or agencies are regulated.9,14,15 Credentialing is defined as validation of required education, certification, and licensure. It is the process that is used to determine the appropriateness of one’s qualifications. Credentialing is based on criteria developed by the profession, the employers, and/or the regulatory agents; it is a method to provide evidence that the individual or institution is qualified to perform selected roles or services.16,17 According to Styles, regulation is an umbrella concept synonymous with quality assurance. She further states that regulation serves 3 functions: the setting of standards, the administration of standards, and the promotion of improvement. Regulation can be governmental, professional, or private. Regulation can also occur at the national, state, community, or institutional levels. There are 4 different levels of regulation used by state boards of nursing within the United States. These are recognition, registration, certification, and licensure.18–19 Recognition, the least restrictive level of regulation, provides the public with information about specialty credentials; it does not limit the right to practice. Registration is the next level of regulation and requires the individual to apply to have his or her name added to an official roster of professionals that is maintained by the regulatory agency.18 Within the regulatory arena the third level of regulation, certification, is defined as a mandatory process used to determine whether an individual meets predetermined qualifications in order to use certain professional titles such as nurse practitioner and clinical nurse specialist. Thus, certification equates to title protection.18 The most restrictive level of regulation is licensure.18 Licensure is usually a 2-step process that involves the identification of qualifications necessary to safely perform a unique scope of practice and an evaluation to determine whether an individual meets the qualifications.18 A license is “a legal document that permits a person to offer to the
public his or her skills and knowledge in a particular jurisdiction in which such practice would be unlawful without a license.”15 A license to practice is a property right and cannot be revoked without due process. Licensure is a form of external regulation through which the state determines whether an individual has met the minimal requirements to practice safely in the profession. Licensure permits the use of a particular title and defines a scope of practice for the profession. Two important functions of licensure are restriction of the number of people entering the profession and determination of eligibility for reimbursement.9 As the highest level of regulation, licensure is used when regulated activities are complex and require specialized knowledge and skill and independent decision-making. The licensing body has authority to take disciplinary action should individuals violate the defined scope of practice.20 Medicine was the first health care profession to require state licensure in the 19th century. It was not until 1938 that the state of New York first required licensure for nurses and defined a scope of nursing practice. Unfortunately, the practice of nursing was defined to be “the performance of certain functions ‘under the supervision of a physician.’”17 Subsequently, other states developed similar scopes of practice that limited nursing to a subordinate role in health care. With the evolution of the advanced practice nurse, the ability to diagnose and treat patients remained exclusive to the domain of medicine. This explains the slow progress nurse practitioners have made in becoming recognized as sharing certain aspects of medicine’s scope of practice.20–21 Certification is defined by the profession as a voluntary process by which a nongovernmental agency or association recognizes the professional competence of an individual who has met predetermined qualifications or standards specified by that agency or association.9 The purpose of certification within nursing has varied over time. Originally, certification was a mechanism to recognize excellence in practice. Over time, the purpose of nursing certification has evolved into recognition of specialty knowledge beyond the entry-level basic nursing knowledge measured by the registered nurse (RN) examination and recognition of entry-level specialty knowledge. More recently, certification for nurse practitioners has changed from a voluntary to a mandatory process. Because employers and regulatory agencies are requiring national certification for entry into NP practice, the voluntary nature of these exams has become a de facto mandatory process in most states. This has forced the professional nursing certification organizations to change their examinations to meet the criteria of regulatory sufficiency; ie, nurse practitioner certification exams must be geared toward entrylevel, minimum competencies rather than recognition of specialty knowledge.17,22 As previously mentioned, certification means title protection within the regulatory arena.
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The distinction between these 2 very different meanings for the same word is often confused within the profession and its published literature.
Why Regulate and License Nurse Practitioners?
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he simple answer is protection of the public. With the emergence of the Industrial Age, the economy shifted to manufacturing and the development of technology. Societal organization shifted from rural farms to the cities, where people found lucrative employment in factories and industrial plants.23 The intimate relationship once experienced between patient and small-town health care provider dissolved as a variety of individuals were available to provide similar services. It was difficult for patients to evaluate the quality of care they were receiving. By the end of the 19th century, federal, state and local governments began enacting laws to protect the consumer. A law may be defined as “a standard or rule of conduct established and enforced by the government of a society.”15 Civil laws regulate the relationships among people and include the practice of nursing. The Tenth Amendment reserves for the states all powers not delegated by the constitution of the United States. A state constitution forms the framework for state government. The state legislature enacts a nurse practice act to regulate nursing. This nurse practice act defines the legal scope of practice for the profession. This is an example of a statutory law—a law enacted by a legislative body. The state legislature delegates authority to the state board of nursing, an administrative agency at the state level, to enforce the nurse practice act. The state board of nursing has the power to establish administrative rules and regulations in accordance with the laws in existence that must be enforced. The rules and regulations that a state board of nursing adopts are examples of administrative laws.15,20 The first nurse practice act was from the state of North Carolina in 1903. This signified the foundation for the first of 3 phases in the development of nurse practice acts.24–25 Within the next 35 years, the majority of states had enacted similar “nurse registration acts,” as they were initially titled. They were modeled after the first medical practice acts. The goal of the nurse registration acts was to organize and promote nursing as a profession. Two important organizations, The National League for Nursing (NLN) and the American Nurses’ Association (ANA), were used to fulfill this goal. The second phase began in 1938 and was marked by passage of the first mandatory nurse practice act in the state of New York. Two levels of nurses were established: registered professional and practical. The scope of nursing practice and title protection were both established during this phase. The ANA defined professional nursing practice for the first time in 1955. By 1971, the third phase in the history
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Table 1. Titles for Nurse Practitioners Found in Nurse Practice Acts NP APRN APNP ANP APN ARNP CNP RNP
Nurse Practitioner Advanced Practice Registered Nurse Advanced Practice Nurse Practitioner Advanced Nurse Practitioner Advanced Practice Nurse Advanced Registered Nurse Practitioner Certified Nurse Practitioner Registered Nurse Practitioner
of nurse practice acts began and continues to this day. Significant for this phase is the state recognition of expanded roles, advanced practice nurses, and registered nurse specialization. During this phase, state nurse practice acts were revised to include advanced nurse practice language. By the end of the 20th century all 50 states, including the District of Columbia, had completed this task. This random progress led to inconsistent advanced practice legislation among states. The current credentialing chaos for nurse practitioners is a consequence of this random process. Table 1 illustrates the various titles used in state nurse practice acts to refer to nurse practitioners. These inconsistencies limit professional practice and mobility, confuse the public, and limit access to high-quality, affordable care. Faced with these challenges, policy makers have analyzed current regulatory practices.5,16,26 The Pew Health Professions Commission Report, “Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century” makes 10 recommendations for reform of current regulatory systems.26 Table 2 lists those regulations most pertinent to the nursing profession. The overall flavor is elimination of the unnecessary boundaries and limitations that have been placed on certain health care providers, many by unjust political or professional motivation, so that regulation of practice is based on demonstrated competencies.
Interstate Compacts
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rofessional mobility is becoming a necessity in today’s changing health care system. Many health care systems are regional or national in scope. Technological advances allow the use of telecommunications to deliver health care—often referred to as telehealth, telepractice or telenursing.16,21,24,25 Telenursing is defined as “the practice of nursing over distance using telecommunications technology.”27,28 Using this technology to interact with a client at a remote site, the nurse can retrieve data, initiate and transmit therapeutic interventions, and monitor and record
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Table 2. Key Recommendations From the Pew Report26 1. States should use standardized and understandable language for health professions’ regulation and its functions to describe them clearly for consumers, provider organizations, businesses, and the professions. 2. States should standardize entry-to-practice requirements and limit them to competence assessments for health professions to facilitate the physical and professional mobility of the health professions. 3. States should base practice acts on demonstrated initial and continuing competence. This process must allow and expect different professions to share overlapping scopes of practice. States should explore pathways to allow all professionals to provide services to the full extent of their current knowledge, training, experience, and skills. 4. States should redesign health professional boards and their functions to reflect the interdisciplinary and public accountability demands of the changing health care delivery system. 5. States should require each board to develop, implement, and evaluate continuing competency requirements to ensure the continuing competence of regulated health care professionals. 6. States should understand the links, overlaps, and conflicts between their health care workforce regulatory systems and other systems that affect the education, regulation, and practice of health care practitioners and work to develop partnerships to streamline regulatory structures and processes.
the patient’s response to the nursing intervention. The nurse may practice in one state although the patient resides in another. Holding a nursing license in one’s state of residence may not be adequate. Practitioners need to be able to practice across state lines without barriers, and the public needs to be assured of access to safe and qualified practitioners. In response to this issue, the National Council of State Boards of Nursing (NCSBN) endorsed the mutual recognition model of nursing regulation in August 1997.21,28–30 This model allows the nurse to have license in his or her state of residency and practice in other states, whether physically or electronically, unless practice is restricted by disciplinary action or monitoring agreement. The method used to implement the mutual recognition model is the interstate compact. The interstate compact is a legal agreement between 2 or more states that enables nursing practice across state lines. As of January 1, 2000, the mutual recognition interstate compact model became reality for RNs and licensed practical nurses/vocational nurses (LPN/VN) professionals. The model is compared with the method of obtaining a driver’s license, ie, nurses who possess a license in a state that has an interstate compact with other states is not required to obtain individual licenses in the compact states to practice in those states. If the same nurse anticipates delivering care to patients in a state that is not part of the interstate compact,
he or she must obtain separate licensure from that state to practice nursing in that state.28 The NCSBN’s objective is to provide “a state nursing license recognized nationally and enforced locally.”28 Although this sounds reasonable, it is not that simple to put into practice. The nurse with multistate licensure privileges agrees to follow each state’s practice laws and regulations when practicing in the respective state. Each state’s nurse practice act remains intact. The compact is another statutory level above the individual state’s nurse practice act. The compact specifies what will be agreed on between states, and its rules and regulations specify how the states will work together. The compact administrators, who are the heads of the nurse licensing authority in each state, establish the rules and regulations.21 The compact provides states with additional authority when granting privileges, taking disciplinary action, or sharing information with other party states. The compact supersedes state laws and may be amended only by agreement of all party states. Although the compact is singular and universal, the nurse practice acts from each party state are not identical. This means the nurse must be accountable to the rules and regulations in the home state of licensure as well as in each party state where nursing is practiced. This may prove cumbersome, for, if disciplinary action is necessary, both the home state and remote state will be involved. A complaint made to the home state concerning a violation in the home state would be processed in the current regulatory system. A complaint to the home state concerning a violation in a remote state would be processed cooperatively. A complaint to the remote state concerning a violation in that remote state would be processed in the remote state and reported to the home state.30,31 The compact requires the home state to investigate the incident in the same manner as it would have if the incident had occurred in the home state. It is not required to take action or enforce the remote state’s laws. The home state may take action against the nurse’s license (home state action), but the remote state may only take action against the nurse’s privilege to practice in that remote state (remote state action). A central database is in place to keep licensure records and disciplinary investigations current and accessible to those state boards of nursing that are members of the compact. According to the NCSBN, mutual recognition simplifies the investigation of an action for this reason, as party states can collaborate and coordinate based on the information from the database. Concerns over confidentiality have been raised regarding the sharing of information between states in the compact. The NCSBN has developed Nursys, the first comprehensive nurse licensure database in the nation.31 Data confidentiality laws already in existence at the state level are maintained in this system. The
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interstate compact authorizes the sharing of data only with other compact states. Information is not available to the public or non–party states. Because the mutual recognition interstate compact model is so new and introduces complex issues, it remains to be seen whether the disciplinary action process will be simplified and whether confidentiality will be maintained. It also remains to be seen whether the regulation of nurse practitioners could be managed through such a model. The present state of chaos that exists for NP regulation raises serious doubts to the success of such a model. One of the reasons for development and implementation of the mutual recognition interstate compact model for RNs and LVNs is that licensure requirement among the states differs very little. The goal for uniform core licensure requirement for RNs and LVNs is not far away. This is certainly not the case for nurse practitioner licensure.32,33 For this reason, many nursing organizations are recommending that uniform standards for advanced practice nursing be developed before an advanced practice nursing interstate compact is created. The argument is that the interstate compact tolerates existing barriers to interstate practice rather than eliminates them.32 As the NCSBN has worked with various organizations addressing the issue of uniform education and certification requirements, its Advanced Practice Task Force continues to pursue strategies and language development for an advanced practice nurse interstate compact.
Second Licensure
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n 1993, the NCSBN released a position statement that called for all advanced practice nurses to have a second license to practice.34 This position statement also called for the master’s degree as the minimum level of education for entry into advanced practice.34 The second licensure proposal was an attempt to bring uniformity to titling and educational preparation. The NCSBN’s argument was that second licensure is the only means to prevent others from practicing or representing themselves as advanced practice nurses. Second licensure also provides recognition for the ability to diagnose and treat illness and simplifies direct reimbursement for services. This proposal resulted in much controversy. The ANA and numerous specialty organizations strongly opposed second licensure on the basis that advanced practice nurses should be self-regulated by the profession and the basic RN license is sufficient as long as the state requirements for the title are fulfilled.35 These groups also pointed out that no other profession requires 2 licenses for the same professional provider. For example, physicians receive their medical license after completing medical school. They do not have to obtain a specialty license after completing their specialty training.
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The American Association of Colleges of Nursing (AACN) released a position statement that recommended certification, rather than second licensure, as the regulatory mechanism of advanced practice nurses.36 The completion of a graduate degree in nursing and demonstrated clinical practice experience in the specialty area should be additional prerequisites to credentialing. The certification process should be the responsibility of each respective specialty nursing organization, based on standardized psychometric requirements. The NCSBN had concerns about using national NP certification examinations for regulatory purposes because some certification agencies stated their NP examinations were not designed for entry-level use. Regulatory sufficiency is based on an examination designed to measure entry-level competencies, exclusive job-related knowledge and skills, pass/fail criteria at the point of minimumessential level for safety and effectiveness, and the use of generally accepted testing practices.22 In the mid 1990s, the NCSBN considered the development of a single core licensure examination for all nurse practitioners. Significant conflict ensued between the NCSBN and the specialty nursing organizations. In lieu of developing a core examination, the NCSBN agreed to collaborate with the certification organizations to ensure that their certification examinations were legally defensible as well as psychometrically sound, thus making them sufficient for regulatory purposes. Subsequently, all of the NP certification organizations provided evidence that their examinations met or exceeded these criteria. A related issue to second licensure is the push toward graduate nursing education for entry into NP practice. Currently, approximately 50% of the states have a requirement for the master’s degree in their nurse practice acts.37 The need to change a state’s nurse practice act to add this requirement is becoming a moot point, as the majority of states require national certification for NPs. At this time, a graduate nursing degree is required to sit for all NP certification examinations except for the Women’s Health NP (WHNP) examination offered by the National Certification Corporation for the Obstetric, Gynecologic, and Neonatal Specialties (NCC). WHNP graduates who complete their programs on and after January 1, 2007, will be required to have a graduate nursing education.38 Because of the push towards graduate nursing education by states and employers, certificate-prepared NPs are seeking graduate study. These individuals need to be aware that not all graduate nursing degrees will be acceptable to some boards of nursing. Although some states will accept any graduate nursing degree, other states require the degree to be in the clinical specialty for which the NP is seeking credentialing. Thus, a nonclinical graduate nursing degree with a major in nursing administration or nursing education may be acceptable in one state but not in another.
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Similarly, clinical nursing degrees with a major outside of the specialty area of NP practice are also not acceptable in some states. For example, a certificate-prepared neonatal nurse practitioner (NNP) who obtains a master’s degree in nursing education or in community health nursing would not be allowed to practice in states such as Illinois.39 It is imperative that certificate-prepared NNPs investigate their state’s requirements for type of graduate nursing education acceptable for credentialing within that state.
deserves access to various types of health care providers, including nurse practitioners. Patients need the assurance that the provider they choose is qualified to provide safe and effective health care. The nurse practitioner deserves the autonomy to practice, prescribe medications, and be reimbursed fairly for services rendered. And this should not be within a state of confusion. Nurse practitioners should be aware of the situation and become involved in the process of clarifying, unifying, and implementing sound methods to achieve uniformity of practice regulation and credentialing.
Conclusion
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he preceding discussion clarified the concept of credentialing for NPs and illustrated the state of chaos that exists within the nursing profession. More importantly, the awareness of these issues should serve as incentive for nurse practitioners to take their professional credentials seriously. As elegantly stated by Lewis and Carson, “credentials are powerful and personal. . . they name us, define our practice, and attest to our qualifications. . . we must see them as property, the most tangible assets we have as career professionals. . . they are hallmarks of achievement that add to our self-esteem and confidence.”17 The task of obtaining an NP credential should not be taken lightly or for granted. It is more than simply being given the right to practice nursing in a specialty area at an advanced level. The nurse practitioner must ask, “How am I allowed to practice in this state?” Depending on the state, the credentialing process can dictate the scope of practice (independent versus physician collaboration or supervision), the level of educational preparation, the scope of prescriptive authority, and the ability to apply for third-party reimbursement for professional services. It is imperative that nurse practitioners be informed about these issues in all states in which they practice. It is also important to realize that the nurse practice acts and rules and regulations are being reviewed and revised on a regular basis to meet the changes in health care delivery. The requirements of today may not be the requirements of tomorrow. During the past several decades, emphasis was placed on the “if we could do it” notion. Could a nurse practitioner assess, diagnose, and treat patients effectively? Could we perform those tasks initially felt to be exclusive to the medical model? Having proven that we could in fact do this, the focus has shifted to how we are allowed to do it. Credentialing must be simplified and standardized among the states. The mission to achieve uniformity for nurse practitioner credentialing is underway, although the exact method for this mission remains unclear. Based on the state of disorder and confusion discussed in this article, it appears that it could take several more decades for any sort of consistency to be achieved. Yet, for the profession and the public, the sooner the better. The public
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