Chapter 4
Nursing Licensure and Certification
After studying this chapter, the reader will be able to:
1. Explain the development of licensure requirements in the United States.
2. Summarize current licensure requirements in the context of historical developments.
3. Analyze the various components of a nurse practice act.
4. Discuss mutual recognition of nursing practice, and identify Nurse Licensure Compact states.
5. Describe the development of certification requirements for advanced practice.
6. Identify requirements for certification for advanced practice in different specialties.
7. Use appropriate resources to obtain current information on licensure and certification.
Voluntary process by which schools of nursing are approved to conduct nursing education programs.
Legal title for nurses prepared by education and competence to perform independent practice.
American Nurses Association (ANA)
Professional organization that represents all registered nurses.
American Nurses Credentialing Center (ANCC)
An independent agency of the American Nurses Association that conducts certification examinations and certifies advanced practice nurses.
Process by which nurses are recognized for advanced education and competence.
Commission on Collegiate Nursing Education (CCNE)
A subsidiary of the American Association of Colleges of Nursing (AACN) with responsibility for accrediting baccalaureate and higher-degree nursing programs.
A term of law. In the context of the Nurse Licensure Compact, a state that has established an agreement with other states allowing nurses to practice within the state without an additional license. The interstate compacts are enacted by the state legislatures.
A variety of initiatives to ensure nurses’ knowledge, skills, and expertise beyond initial licensure.
Statutory process by which previously licensed persons are included without further action in revisions or additions in nurse practice acts.
International Council of Nursing (ICN)
Professional organization that represents nurses in countries around the world.
The original program whereby nurses licensed in one state seek licensure in another state without repeat examinations. The requirements are included in state nurse practice acts or accompanying rules and regulations.
Mandatory continuing education
Educational requirements imposed by individual states for renewal of a license.
Program developed by the National Council of State Boards of Nursing (2012). The Nurse Licensure Compact program establishes interstate compacts so that nurses licensed in one jurisdiction may practice in other compact states without duplicate licensure.
National Council of State Boards of Nursing (NCSBN)
Organization whose membership consists of the board of nursing of each state or territory.
National League for Nursing (NLN)
Professional organization whose members represent multiple disciplines. The National League for Nursing conducts many types of programs, including accrediting nursing education programs.
Statute in each state and territory that regulates the practice of nursing.
Appointed board within each state charged with responsibility to administer the nurse practice act of that state.
Statutes that provide for revocation of laws if not reviewed and renewed within a specified time period.
We thank Janet C. Scherubel, PhD, RN, for her contribution to this chapter in the fourth edition.
Additional resources are available online at:
http://evolve.elsevier.com/Cherry/
Three nurses are discussing their nursing practice licenses. Joe Branch, a senior nursing student, is preparing for initial licensure. Mary Stone’s license is due for renewal. Carmella Larkin has just moved into the state. As the three are talking about these changes in their practice, Giorgio Gonzales, a nurse practitioner, joins the group. Giorgio recently completed a certification examination and is interested in becoming certified for advanced practice. All the nurses have a general knowledge of the requirements for licensure and certification but lack the specific information needed to legally practice within the state.
The situation described here is not uncommon. Nurses need specific, current information on licensure and renewal of licensure. The most comprehensive sources for this information are the state nurse practice act and the state board of nursing. These resources provide accurate descriptions of the law governing nursing practice within each state and the U.S. territories. Every nurse and nursing student will benefit from obtaining a copy of their state’s nurse practice act and becoming familiar with its contents.
Questions to Consider While Reading This Chapter
1. Who establishes the “rules” for nursing practice—the state or the employer?
2. Do graduates from different types of nursing education programs require different types of licenses?
3. If a nurse graduate passes the NCLEX-RN® examination, does this person still need a license?
4. What happens if a nurse’s license expires? Can the nurse still practice?
5. Must a nurse complete graduate school and take an examination to be an advanced practice nurse?
6. Are the regulations governing advanced practice the same in all states?
The History of Nursing Licensure
Recognition: Pins and Registries
The aim of caregivers throughout history has been to be recognized and acknowledged for one’s skills and achievements. Early caregivers, particularly in the monasteries and convents of the medieval period, were identified by the habits they wore. Frequently, special insignias designated health personnel. During the Crusades, a large Maltese cross adorned the habits of the Knights Hospitalers of St. John of Jerusalem on the battlefield (Kalisch and Kalisch, 2003). These forms of identification allowed others to recognize their particular skills in caregiving and healing. More recently, nurses around the world wore a readily identifiable symbol of their school of nursing—the nursing cap.
Early Licensure Activities
U.S. nursing programs developed in much the same manner as was the pattern in England. As early as 1867, Dr. Henry Wentworth Acland encouraged licensure of English nurses. However, it was not until 1896 that attempts were made to license nurses in the United States. Prior to the late 1800s, many hospitals established training programs to prepare nursing staff for their own institutions. The programs varied based on the needs of the hospital, the availability of physicians and nurses for training students, and resources devoted to the training. It became apparent to many nurses that consistent minimum standards to practice across settings were necessary. These standards would provide for safety of the public and improve the mobility of nurses among institutions. A key advocate for these standards was the Nurses Associated Alumnae of the United States and Canada. This organization later became the American Nurses Association (ANA). However, the group met with resistance from hospitals, physicians, and even nurses. The early attempts at nursing licensure failed for lack of broad-based support (Joel, 2006).
Under permissive licensure, educational standards were set at a minimum of 2 years of training for nurses. State boards of nursing were established with rules for examinations as well as revocation of the license. Nurses not passing the examination could not use the title of RN. These early regulations served two purposes: first to protect the public from unskilled practitioners, and second to provide legal sanctions to protect the title of RN. The New York State Board of Regents began a registry of nurses successfully completing all requirements. In 20 years, by 1923, all states had instituted examinations for permissive licensure. Each state’s licensure examinations varied in content, length, and format and included written, oral, and practice components. The early work in examinations for licensure was the forerunner of today’s licensure and certification requirements (Kalisch and Kalisch, 2003).
The early state efforts in licensing nurses were commendable. Nonetheless, there was considerable variability among states in nursing education requirements, the licensure examinations, and the nurse practice acts themselves. The widespread variability in nurse practice acts prompted the ANA (and later the National Council of State Boards of Nursing [NCSBN]) to design model nurse practice acts. The model acts provided a template for states to follow. The first was published in 1915. These model practice acts are revised and updated as nursing practice advances. For example, the NCSBN approved the most recent revision of the model practice act and administrative rules in 2011 (NCSBN, 2012c).
The model nurse practice act is composed of many sections including a definition of nursing and the scope of practice for the RN, descriptions of advanced practice nursing, requirements for prescriptive authority of nurses, nursing education, compact guidelines, and processes for disciplinary actions against nurses who violate sections of the act. Separate sections of the model act provide guidelines for state boards of nursing and the necessary requirements for entry into practice. The most recent model practice act is available online at the NCSBN website (NCSBN, 2009c).
Mandatory Licensure
The next major event in licensure efforts occurred in 1982 with the development of the first NCLEX-RN examination. The test was revised to include all nursing content within one section of the examination. In addition, the format was changed to present questions in a nursing process format. Just as with previous versions of licensing examinations, the NCLEX-RN examination has evolved over time. Paper-and-pencil testing was replaced with computerized adaptive testing in 1994. Extensive information on the NCLEX-RN examination may be found in Chapter 28 of this text.
