Consensus Model for APRN Regulation:

Licensure, Accreditation, Certification, Education

Reasons for a FutureAPRN Model

• Lack of common definitions related to APRN roles– Regulation– Role– Specialty– Sub-Specialty– Broad-based education– Population foci– Core examination

Reasons for a FutureAPRN Model

• Lack of standardization in programs leading to APRN preparation– Initial accreditation/approval

necessary– Blended programs with variable clinical hours– Inconsistent Master’s Essentials compliance– Programs graduating students that cannot be licensed

Reasons for a Future APRN Model

• Proliferation of specialties and subspecialties– Examples: Palliative Care NP,

Cardiovascular CNS and Homeland Security NP

• Lack of common legal recognition across jurisdictions– Less than 30 states recognize or title protect CNS– Not all states license/authorize CRNA same as NP

Basic Assumptions

• Recommendations must address current issues facing the APRN community

• The ultimate goal of accreditation, education, licensure and certification is to promote patient safety and public protection.

• Goal must be forward looking and do no harm

APRN Working Groups

APRN Consensus Work Group

23 Organizations

NCSBN APRN Committee(formerly Advisory Group)

Joint Dialogue Group

APRN Consensus Process 50 Organizations

Organizations represented at Joint Dialogue Group

• American Academy of Nurse Practitioners Certification Program• American Association of Colleges of Nursing• American Association of Nurse Anesthetists• American College of Nurse-Midwives• American Nurses Association• American Organization of Nurse Executives• Compact Administrators• National Association of Clinical Nurse Specialists• National League for Nursing Accrediting Commission• National Organization of Nurse Practitioner Faculties• National Council of State Boards of Nursing• NCSBN APRN Advisory Committee (5 representatives)

Assumption for the Joint Dialogue Group

• Recommendations must address current issues facing the APRN community but should be future oriented.

• The ultimate goal of licensure, accreditation, certification and education is to promote patient safety and public protection

• The recognition that this document was developed with the participation of the APRN certifiers, accreditors, public regulators, educators, and employers. The intention is that the document will allow for informed decisions made by each of these entities as they address APRN issues.

Definition of Advanced Practice Registered Nurse

The definition includes language that addresses responsibility and accountability for health promotion and the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and non-pharmacologic interventions.

Definition of Advanced Practice Registered Nurse

• An APRN is an individual who has:– Completed an accredited graduate-level educational

program– Passed a national certification examination that matches

the educational preparation– Acquired advanced clinical skills and knowledge– Practice built upon the competencies of a RN– Clinical experience of sufficient depth and breadth to

reflect the intended license– Obtained a license to practice as an APRN in one of the

four roles

APRN Direct Care Component

• Advanced clinical knowledge and skills to provide direct care to patients is a defining component of practice

• All APRNs have a significant component of education and practice focusing on direct care of individuals

Relationship Between Educational Competencies, Licensure and Certification

APRN

Role

Specialty

Competencies

Specialty Certification*

Licensure: based on EducationAnd certification**

Identified by Professional Organizations(e.g. oncology, palliative care, CV)

Measures of competencies

CNP, CRNA, CNM, CNS in Population context

APRN Core Courses: Patho/phys,Pharmacology, Physical/health assess

Population Foci

APRN Direct Care Component

• Advanced clinical knowledge and skills to provide direct care to patients is a defining component of practice

• All APRNs have a significant component of education

and practice focusing on direct care of individuals.

APRN Regulatory Model

NurseAnesthetist

NurseMidwife

Clinical NurseSpecialist

Adult-Gerontology

Women’s Health/Gender Related

Family/IndividualAcross lifespan Neonatal Pediatrics Psych/Mental

Health

Lic

ensu

re a

t lev

els

of ro

le a

nd

pop

ulat

ion

foci

POPULATION FOCI

APRN ROLES

APRN SpecialtiesFocus of Practice beyond role and population focus

Linked to health care needsExamples include but are not limited to: Oncology, Older Adults,

Orthopedics, Nephrology, Palliative care, Critical Care

Nurse Practitioner

Establish Ongoing Communication: Lace Structure and Processes

• Entities of LACE include– Licensing bodies – Accreditors– Certifiers that offer APRN certification for regulatory

purposes– Educational organizations that set standards for APRN

education• Total participants allow effective discussion• Not duplicative of existing structures• Will obtain consultation on structure

The Future

APRN Titling

• The title of Advanced Practice Registered Nurse (APRN) is the licensing title to be used for the the subset of nurses prepared with advanced, graduate-level nursing knowledge to provide direct patient care in one of the four roles.

• Licensure is based on graduate education in one of the four roles and population foci.

• Verification of licensure will indicate the role and population focus for which the APRN has been licensed.

• The nurse must legally represent themselves, including in a legal signature, as an APRN and by role (e.g. APRN-CNP)

• The title of APRN and role titles are legally protected titles and may not be used by any individual who does not hold the proper credentials.

Requirements of LACE

• Each “leg” of regulation has an unique responsibility

• Responsibilities are interlinked—no one aspect fulfills the mission of protecting the public

• Relationships among the regulatory “legs” continue to evolve

• Communication is the critical component

Requirements for Boards of Nursing

• License in one of four roles with a population focus

• Be solely responsible for licensing (exception for states where boards of midwifery regulate nurse-midwives and midwives)

• Only license graduates of accredited programs• Not issue a temporary license• Only license an APRN when education and

certification are congruent

Requirements for Boards of Nursing (Continued)

• License APRNs as independent practitioners with no regulatory requirements for collaboration, direction or supervision

• Allow for mutual recognition through compact• Have at least one APRN representative on

Board and have an advisory committee including all four roles

• Institute a grandfathering clause

Broad-Based APRN Education

• For entry into APRN practice and for regulatory purpose the APRN education must:

– Be a formal accredited graduate or post-graduate certificate program in an academic institution. The program must be comprehensive and on the graduate level

– Be awarded pre-approval, pre-accreditation or accreditation status prior to admitting students

– Prepare graduates in one of four roles and in at least one of the population foci

Broad-Based APRN Education (cont.)

• For entry into APRN practice and for regulatory purpose the APRN education must:

– Include at least three separate comprehensive graduate level courses in the APRN core

• Advanced Physiology/Pathophysiology• Advanced Health Assessment• Advanced Pharmacology

– Provide basic understanding of decision-making principles– Ensure clinical and didactic coursework is comprehensive to prepare

the graduate to practice in the APRN role and population foci

APRN Specialty

• More focused area of practice than role and population foci• Specialty preparation cannot replace educational preparation in

the role or one of the six population foci• Specialty preparation cannot expand one’s scope of practice

beyond the role and population focus• Addresses a subset of the population-focus

– Definition built on ANA (2004) Criteria for Recognition as a Nursing Specialty

• The title may not be used in lieu of the licensing title, which includes the role and population

• Is developed, recognized and monitored by the profession

APRN Regulatory Model

• APRN regulation includes:– Licensure

• The granting of authority to practice

– Accreditation• Formal review and approval by a recognized agency of educational degree

or certification programs in nursing or nursing related programs

– Certification• The formal recognition of knowledge, skills and experience demonstrated

by the achievement of standards identified by the profession

– Education• The formal preparation of APRNs in graduate or post-graduate programs

Foundational Requirements for Licensure

• The Boards of Nursing (Licensure) will– License APRNs in one of four roles with a population focus– Be solely responsible for licensing (exception for states where

boards of midwifery regulate nurse-midwives and midwives)– Only license graduates of accredited graduate programs– Require successful completion of a national certification

examination that assesses APRN core, role and population competencies.

– Only license an APRN when education and certification are congruent

– Not issue a temporary license

Foundational Requirements for Licensure (cont.)

• The Boards of Nursing will:– License APRNs as independent practitioners with no regulatory

requirements for collaboration, direction or supervision– Have at least one APRN representative position on the board and

utilize an APRN advisory committee that includes representatives of all four APRN roles

– Institute a grandfathering clause that will exempt those APRNs already practicing in the state from new eligibility requirements

– Have the option for mutual recognition of advanced practice nursing through the APRN Compact

Foundational Requirements for Accreditation of Education Programs

• Accreditors will:– Evaluate APRN graduate degree and post-graduate certification

programs– Through their established accreditation standards and process, assess

APRN education programs in light of the APRN core, role core and population core competencies

– Assess developing APRN education programs and tracks by reviewing them using established accreditation standards and granting pre-approval, pre-accreditation or accreditation prior to student enrollment

– Include an APRN in the visiting team when reviewing an APRN program

– Monitor the APRN education programs throughout the accreditation period

Foundational Requirements for Certification

• Certification programs providing APRN certification used for licensure will:

– Follow established certification testing and psychometrically sound, legally defensible standards for APRN examinations for licensure

– Assess the APRN core and role competencies across at least one population focus of practice

– Assess specialty competencies separately from the APRN core, role and population focused competencies.

– Be accredited by a national certification accreditation body

Foundational Requirements for Certification (cont.)

• Certification programs providing APRN certification used for licensure will:

– Enforce congruence between the education program and the type of certification examination

– Provide a mechanism to ensure ongoing competence and maintenance of certification

– Participate in ongoing relationship which make their processes transparent to BON

– Participate in a mutually agreeable mechanism to ensure communication with the BON

Foundational Requirements for Education

• APRN educational programs/tracks leading to eligibility for a APRN license will:– Follow established educational standards and ensure attainment of the APRN

core, role core and population core competencies– Be accredited by a nursing accrediting organization that is recognized by the

U.S. Department of Education and/or the Council for Higher Education Accreditation

– Be pre-approved, pre-accredited, or accredited prior to the acceptance of students, including all developing APRN education programs and tracks

– Ensure that graduates of the program are eligible for national certification and state licensure

– Ensure that official documentation (e.g. transcripts) specifies the role and population focus of the graduate

APRN Regulatory Model

• APRN regulation includes:– Licensure

• The granting of authority to practice

– Accreditation• Formal review and approval by a recognized agency of educational degree

or certification programs in nursing or nursing related programs

– Certification• The formal recognition of knowledge, skills and experience demonstrated

by the achievement of standards identified by the profession

– Education• The formal preparation of APRNs in graduate or post-graduate programs

Work to be Completed with Endorsement of Model Regulation

• Licensing – Adopt regulatory model- completed in August 2008– Adopt licensure language – completed in August 2008– Implementation by state boards of nursing

• Accreditors– Pre-approval process– Review of post Master’s Programs– Integrate role standards

• Certifiers– Assess extent of testing of 3 Ps for all roles– Assess testing of role competencies, including consensus-based CNS

competencies, within each population.– Integrate adult-older competencies into one assessment mechanism – Review psych/mental health

Work to be Completed with Endorsement of Model Regulation

• Educators– Ensure 3 P’s – Ensure APRN, Role and population focused competencies attained– Integrate adult and older adult—SIGNIFICANT attention to older– Review psych/mental health curriculum

Current Activities

• Endorsement• LACE• CNS National Competencies• National Work Groups• Boards of Nursing• State Work Groups

Continuing Issues

• Acute Care• Psych/Mental Health Combined

Certification• APRN Titling

What is Certification? Validation of an individual nurse’s

qualifications for practice in a defined area

Administered by a nongovernmental agency

Based on predetermined standards

Recognizes knowledge, skills and abilities beyond the scope of RN licensure

A means to recruit and retain good nurses

Knowledge that their nurses have met rigorous national requirements and are role models of professional accountability

Growing evidence links certified nursing practice and positive outcomes

Certification is among the key excellence indicators for programs such as Magnet and Beacon

Why Do Hospitals Support Certification?

For personal challenge and self-improvement

To advance knowledge and education

To demonstrate mastery of skills, knowledge and abilities to patients and administration

To distinguish themselves through commitment to lifelong learning and career growth

Improve salary and advancement opportunities

Why Do Nurses Get Certified?

As a vital part of AACN, the recognized leader and standard-setter in acute and critical care nursing, AACN Certification Corporation administers certification programs for nurses to proudly demonstrate the specialized knowledge, skills and abilities necessary for safe and effective acute and critical care nursing practice

AACN certification contributes to improved patient health and safety by establishing and promoting high standards of professional practice

Why AACN Certification?

AACN CertificationsFor nurses who care directly for acutely or critically ill patients at the bedside

For nurses who care for acutely and critically ill adult patients in progressive care settings

For nurses who care for acutely or critically ill adult patients from remote location

For clinical nurse specialists who care for acutely or critically ill patients

For acute care nurse practitioners who care for acutely and critically ill adult patients

For certified nurses who subspecialize in caring for adult cardiology patients

For certified nurses who subspecialize in caring for adult cardiac surgery patients

AACN Certification ExamsAACN Certification Corporation develops and administers the CCRN, PCCN, CCRN-E, CCNS, ACNPC, CMC and CSC exams

These exams are legally defensible and psychometrically sound indicators of the knowledge, skills and abilities necessary for effective nursing practice

Exams are open to nurses caring for acutely and critically ill patients who meet the eligibility requirements, including a specified period of clinical practice in the role being tested

CCRN certification is for RNs working at the bedside of acutely and critically ill patients

The clinical setting may include ICUs, CCUs, Emergency Departments, Trauma Units, Interventional Radiology /Cardiology Units, or Critical Care Transport/Flight Units

There are three separate CCRN exams: adult, neonatal and pediatric

PCCN certification is for nurses working at the bedside of acutely ill adult patients in a progressive care setting

Progressive care is how AACN collectively describes units such as Intermediate Care, Direct Observation, Step-down, Telemetry, and Transitional Care

The PCCN credential is also appropriate for nurses who practice in Cardiac Cath Labs

CCNS advanced practice certification is for clinical nurse specialists working with acutely and critically ill patients

The CCNS may be used by nurses in some states to help qualify for AP nursing licensure

A candidate must document completion of a graduate advanced practice education program meeting specific requirements

There are three separate CCNS exams: adult, neonatal and pediatric

CCRN-E certification is for RNs caring for acutely and critically ill adult patients from a remote location

CCRN-Es work in tele-ICUs (virtual or e-ICUs) monitoring from behind a camera to identify trends in patient data and instability and communicate with patients and bedside nurses

Eligible hours are those worked in a tele-ICU or in a combination of tele-ICU and direct bedside care

ACNPC advanced practice certification is for adult acute care nurse practitioners

A candidate must document completion of a graduate advanced practice education program meeting specific requirements

ACNPC certification is approved on a state-by-state basis - check with your State Board of Nursing to make sure the ACNPC exam meets your state's requirements for advanced practice designation or licensure

Cardiac Medicine subspecialty certification is for nurses who hold a nationally accredited clinical nursing specialty certification such as CCRN, PCCN, CCRN-E, CCNS or ACNPC who subspecialize in caring for adult cardiology patients

The clinical settings may include: CCU, Combined ICU/CCU, Medical Cardiology, Heart Failure Clinics/Home Care, Interventional Cardiology and/or Electrophysiology Units

Cardiac Surgery subspecialty certification is for nurses who hold a nationally accredited clinical nursing specialty certification such as CCRN, PCCN, CCRN-E, CCNS or ACNPC who subspecialize in caring for adult cardiac surgery patients within the first 48 hours postoperatively

The clinical settings may include: Cardiac Surgery, Cardiothoracic Surgery, Cardiovascular Surgery and Post-Anesthesia Recovery Units

For more information about AACN certifications, visit:

www.aacn.org