Understanding Regulatory, Legal, and Credentialing Requirements

Chapter 21


Understanding Regulatory, Legal, and Credentialing Requirements




Chapter Contents



It is important to note at the beginning of this chapter that the term APRN will be used throughout as this is the term used to describe advanced practice nurses in a regulatory context. The term advanced practice nurse as described in chapter 3 is an expansive, powerful idea, not a physician substitute or a narrow set of skills or credentials. The highest level of nursing practice cannot be reduced to a regulatory definition. The regulation of APRNs is more narrow as it guides state boards of nursing on how to consistently regulate APRNs across the United States. The APN concept is far larger than that and APRNs contribute to the health of the nation far beyond the regulatory requirements discussed in this chapter. So, the regulatory term, APRN is used to align with the principals of LACE in this chapter only, and is in no way intended to be reductionist to the larger idea of advanced practice nursing.



Current Issues


The current health care environment requires that any discussion of regulatory issues be fluid, dynamic, and subject to rapid change. Three national events have coalesced to bring about important effects on the regulation of advanced practice registered nurses (APRNs). First, in our last edition, work concerning the Consensus Model for Regulation: Licensure, Accreditation, Certification and Education was in its early stages. Today, this important regulatory change is being implemented across 50 states (www.aacn.nche.org/education-resources/aprnreport/pdf; www.ncsbn.org/aprn.htm).


At the same time, two other events have resulted in a careful evaluation of APRN education and practice and, more specifically, APRN regulation. In 2010, the broadest health reform legislation since the enactment of Medicare in 1965 was passed. The role of APRNs in the Patient Protection and Affordability Care Act (PPACA; U.S. Department of Health & Human Services [HHS], 2011) as primary care providers, members of accountable care organizations (ACOs), medical home configurations, and providers in nurse-managed clinics drives the need to ensure the highest levels of education and effective regulation. Finally, the Institute of Medicine (IOM, 2011) Future of Nursing report recommendation that APRNs “should be educated and practice to the fullest extent of their scope of practice” (p. 4-6) affects the state by state regulation of APRNs.


At this time, APRNs must influence health policy at the national and grassroots levels to ensure regulatory configurations that allow for successful APRN practice and reimbursement. This activity may be as simple as interpreting APRN regulatory decisions to patients, administrators, and coworkers locally or as complex as negotiating equitable regulatory decisions about reimbursement with the Centers for Medicare & Medicaid Services (CMS; www.cms.org; see Chapter 22).


Issues involving education, including advanced practice nurse competencies, competencies from APRN organizations and masters and doctoral essentials, scope of practice, reimbursement, and prescriptive authority are all embedded in regulatory language. The complexity of regulatory issues and the multiplicity of stakeholders require ongoing monitoring, reevaluating and updating. In 1998, the Pew Health Professions Commission recommended that national policy initiatives were urgently needed to research, develop, and publish national scopes of practice and continuing competency standards for state legislatures to implement (O’Neil & Pew Health Professions Commission, 1998). This work is ongoing today and continues to be vitally important, with continuous and careful input from APRNs.


This chapter will describe credentialing and regulation, provide an update on the status of the Consensus Model, the Nursing Model Act and Rules National Council State Boards of Nursing (NCSBN, 2011), and its implications and implementation. The purpose of this chapter is to help the reader understand the multiple steps in the process of licensure as an APRN.



Titling of Advanced Practice Registered Nurses


The issues surrounding the titling and credentialing of APRNs have been difficult since the inception of APRN roles. At the state regulatory level, the preference is to use the title “advanced practice registered nurse.” The Consensus Model makes this preference a permanent change. Advanced practice nursing has evolved in differing ways over time, with multiple titles, which confuse policymakers, patients, and the profession. Currently, there are four APRN roles. Certified registered nurses anesthetist (CRNA) and certified nurse-midwife (CNM) certification and credentialing are the most clearly uniform and standardized based on their longevity, singleness of purpose, and specialty. The credentialing and oversight of nurse practitioners (CNPs) and clinical nurse specialists (CNSs) is less clear because of the multiplicity of programs, areas of increasing specialty practice, and continuing need to develop certification examinations in some areas (see next section and Part III). Credentialing is furnishing the documentation necessary to be authorized by a regulatory body or institution to engage in certain activities and to use a certain title. Currently, not all states recognize all advanced practice roles for title protection. As new APRN roles evolve, the problems around credentialing and titling become increasingly acute.


As noted, this chapter describes basic national and state regulatory and credentialing realities and discusses the critical elements of regulation and credentialing that currently affect APRNs. For specific questions about up to the minute, current APRN rules and regulations, especially those that pertain to specific state statutes regarding licensing of APRNs, prescriptive authority, and reimbursement, the reader should refer to individual state regulatory bodies for practice requirements.


The skills required for successful policy activism and advocacy, which are crucial to negotiating regulatory mechanisms, are part of the APRN core competencies of clinical, professional, health policy, and systems leadership and collaboration. These concepts and skills, outlined in Chapters 11 and 12, are crucial to the role APRNs play in shaping credentialing and regulatory policy mechanisms and should be considered as this chapter is read.



Consensus Model for Advanced Practice Registered Nurse Regulation: Licensure, Accreditation, Certification, and Education


Before a discussion of regulation can take place, it is important to understand the progress to date surrounding the Consensus Model and the Nursing Model Act and Rules for APRN licensure (NCSBN, 2011). Credentialing for APRNs is composed of four components—licensure, accreditation, certification, and education (LACE). Several years ago, the NCSBN’s Advanced Practice Committee created a vision paper that spoke to the recommendations of the Quality Chasm report (Committee on Quality of Health Care in America, IOM, 2001) and the concerns surrounding multiple roles and specialties for APRNs. At about the same time that the NCSBN began its work (March, 2004), various stakeholders, including leaders from the American Association of Colleges of Nursing (AACN; NCSBN, 2008), National Organization of Nurse Practitioner Faculties (NONPF), National Association of Clinical Nurse Specialists (NACNS), American Association of Nurse Anesthetists (AANA), American College of Nurse-Midwives (ACNM), and several APRN certifying bodies, accreditors, and regulators met to establish a process that would result in a consensus statement on the credentialing of APRNs. Both groups worked toward consensus about a regulatory model that would establish a model of education, certification accreditation, and licensure to strengthen and standardize the public and private regulatory scene. The IOM reports of 2000 and 2001 suggested that the various regulatory bodies needed to develop models of regulation that were most beneficial to patients. Several recommendations in these important reports heightened the need for collaboration, transparency, evidence-based decision making, and information exchange (O’Sullivan, Carter, Marion, et al., 2005). The vision was to implement one national regulatory scheme that would be most beneficial to patients and that allowed APRNs to be innovative and meet patient needs (NCSBN, 2008).


Since that time, many years of work by a Joint Dialogue Committee, made up of the major APRN leaders and stakeholders, crafted the Consensus Model (NCSBN, 2008). The collaborative work of this committee is currently endorsed by 48 national nursing organizations, including all the major APRN organizations. A new model for APRN regulation is now a reality and is synchronized with the credentialing stakeholders. Based on this important work, the Consensus Model is currently being implemented across the United States. It is important that readers access the Consensus Model documentation and familiarize themselves with the new changes (www.aacn.nche.org; www.ncsbn.org). The reader must understand that although the target date is 2015 for implementation, transition to the new regulation will take years to fully implement in some states (Williams, 2010; Yoder-Wise, 2010).


Unfortunately, at the current time, vast differences exist regarding rules and regulations and the credentialing process across states. Making change to this legislative process is and will be difficult, at best. State regulatory data can be reviewed in the references for this chapter (Kaplan, Brown, & Simonson, 2011; NCSBN, 2012a; Osborne, 2011; Pearson, 2012). Lugo, O’Grady, Hodnicki, et al. (2007) have demonstrated wide variations across states, which indicate that APRNs are not able to reach their full practice potential in many states. This same study analyzed the data from the perspective of patient access to NPs and NP services, again finding wide variations from state to state, which indicates lack of uniform regulations of APRNs.



Implementation of Consensus Model Regulation


LACE organizations have continued to meet regularly to move the process of implementation forward, keep lines of communication open, maintain transparency, and identify and strategize about important and ongoing issues. The LACE network is a virtual social networking configuration. A platform is in place whereby LACE member organizations pay a membership fee to belong to the working group that sustains the core components of the Consensus Model. A public site for updates is also available free at aprnlace.org.


All four LACE groups are working to meet new requirements and assist with state implementation. NCSBN has launched the Campaign for Consensus (www.ncsbn.org/4214.htm) to help individual states implement the new regulatory process by offering administrative and technical support. Access maps showing states’ progress can be found at www.ncsbn.org/aprn.htm. Also, the American Nurses Credentialing Center has information on their website regarding changes in APRN certification offerings (www.nursecredentialing.org). See other APRN websites for updated changes in any LACE category for a particular role.



Definitions Associated with the Regulation of APRNs


It is important for APRNs to understand the language and terms used to describe the credentialing process. Credentialing, including education, national certification, and licensure, involves several steps before one has full authority to practice as an APRN. To complicate matters, as noted, the credentialing procedures and requirements vary somewhat among states and practice settings. Definitions for the major components of APRN credentialing are presented in Box 21-1.



imageBox 21-1   Advanced Practice Registered Nurse Credentialing Definitions


Accreditation. The voluntary process whereby schools of nursing are reviewed by external nursing educational agencies for the purpose of determining the quality of a nursing and/or APRN program.


Certification. A formal process (usually an examination, but may be a portfolio) used by a certifying agency to validate, based on predetermined standards, an individual’s knowledge, skills, and abilities. Certification provides validation of the APRN’s knowledge in a particular specialty. It is used by most states as one component of second licensure for APRN practice.


Credentialing (institutional level). The process that an individual institution uses to permit an APRN to practice in an APRN position within the institution. Generally, APRNs submit particular documentation to an institutional credentialing committee, which reviews and authorizes the APRN’s practice.


Credentialing (state level). The requirements that a state uses to assess minimum standards of competency for APRNs to be authorized to practice in an APRN role. The purpose of credentialing is to protect the health and safety of the public. These requirements include an unencumbered RN license, graduate education transcripts, national certification in one of six population foci.


Legal authority. The authority assigned to a state or agency with administrative powers to enforce laws, rules, and policies.


Licensure. The process whereby an agency of state government grants authorization to an individual to engage in a given profession. For nursing, licensure is usually based on two criteria—the applicant attaining the essential education and degree of competency necessary to perform a unique scope of practice and passing a national examination. APRNs are licensed first as RNs and second as APRNs.


Regulations. The rules and policies that operationalize the laws and policies that recognize APRNs and credential them for practice in an APRN role.



State Licensure and Recognition


Individual state nurse practice acts define the practice of nursing for registered nurses (RNs) throughout the 50 states and territories. State laws overseeing APRN’s are divided into two forms: (1) statutes as defined by the nurse practice act are enacted by the state legislature; and (2) rules and regulations are explicated by state agencies under the jurisdiction of the executive branch of state government. Historically, under Title X of the U.S. Constitution, states have the broad authority to regulate activities that affect the health, safety, and welfare of their citizens, including the practice of the healing arts within their borders. Licensure stems from this history, grounded in public protection, whereby each state creates standards to ensure basic levels of public safety. In 27 states, the state board of nursing has sole authority over advanced practice nursing; in others, there is joint authority with the board of medicine, board of pharmacy, or both (NCSBN, 2012; Pearson, 2012). The states require that all APRNs carry current licensure as RNs. Authority to practice as an APRN is tied to scope of practice and varies from state to state, depending on the degree of practice autonomy that the APRN is granted. The current status of advanced practice nurse licensure and scope of practice and application information in a particular state can be easily obtained by accessing the NCSBN website (www.ncsbn.org), which has a link to each individual state board of nursing.


Some states require a temporary permit for a new graduate to practice as an APRN while awaiting national certification results (Pearson, 2012) or other requirements, such as an internship or added pharmacology hours for prescriptive authority. New graduates should contact their state board of nursing and submit the required application for a temporary advanced practice nursing permit if the state allows this practice. With the advent of electronic testing, the time lapse between testing and obtaining results for licensure is minimal and markedly reduces the need for a temporary permit. When the Consensus Model takes effect, states will have removed the need for a temporary license option.



Prescriptive Authority


Credentialing and licensure for prescriptive authority also occur at the state level. Pharmacology requirements vary among states although, currently, most states require a core advanced pharmacotherapeutics course (a requirement of the Consensus Model) during the graduate APRN educational program and some states require yearly continuing education (CE) credits thereafter to maintain prescriptive privilege. Prescriptive authority may be regulated solely by the board of nursing, as it is in several states, jointly by the board of nursing and board of pharmacy, as it is in several others, or by a triad of boards of nursing, medicine, and pharmacy (NCSBN, 2012; Pearson, 2012). It is incumbent on the APRN to understand the mechanism of prescriptive authority regulation clearly in his or her state and to understand whether ongoing continuing education is required (Armstrong, 2011; Lovatt, 2010).


As prescriptive authority has evolved over the past several years, certain basic requirements have become fairly standard for APRN prescribers (Box 21-2). These requirements vary among states but provide a core regulatory process for prescriptive authority (Buppert, 2012; Pearson, 2012).



As noted, state boards of nursing should clearly document the numbers of hours of pharmacology required for an APRN to receive and maintain prescriptive privilege in terms of the APRN educational program and annual CE. APRN programs that previously integrated pharmacologic content in clinical management courses are required to have a stand-alone advanced pharmacotherapeutics course to comply with state requirements and accreditation standards (www.aacn.nche.edu/Accreditation). Pharmacology content should be taught by faculty pharmacists or a nurse-pharmacist faculty team who have an in-depth knowledge of therapeutic prescribing. Some states are requiring that APRN nursing programs verify specific course and content hours that can be used in a board of nursing application for prescriptive authority. Furthermore, several states require documentation of the number of hours of CE for pharmacology per year or per cycle. The direction is clearly to require APRNs to attend ongoing CE in pharmacology to maintain prescriptive privileges, although APRNs should update their knowledge in this changing area whether or not their state requires it. Timely CE offerings and distance learning modalities (e.g., podcasts, Internet-based offerings) are available to meet the needs of busy clinicians. Over time, the states will likely move in the direction of interdisciplinary pharmacology education for nurses and physicians. Technologic advances, including handheld smartphones and tablets, offer clinicians on-site information about prescribing modalities and state of the art drug information. These represent a positive response to the increasing evidence of medication prescribing errors (Committee on Quality of Health Care in America et al., 2000; www.Epocrates.com).




Scope of Practice for Advanced Practice Nurses


By definition, the term scope of practice describes practice limits and sets the parameters within which nurses in the various advanced practice nursing specialties may legally practice. Scope statements define what APRNs can do for and with patients, what they can delegate, and when collaboration with others is required. Scope of practice statements tell APRNs what is actually beyond the limits of their nursing practice (American Nurses Association [ANA], 2003, 2012; Buppert, 2012; Kleinpell, Hudspeth, Scordo, et al., 2012). The scope of practice for each of the four APRN roles differs (see Part III). Scope of practice statements are key to the debate about how the U.S. health care system uses APRNs as health care providers; scope is inextricably linked with barriers to advanced practice nursing. CRNAs, who administer general anesthesia, have a scope of practice markedly different from that of the primary care nurse practitioner (NP), for example, although both have their roots in basic nursing.


In addition, it is important to understand that scope of practice differs among states and is based on state laws promulgated by the various state nurse practice acts and rules and regulations for APRNs (Lugo, O’Grady, Hodnicki, et al., 2007, 2009; NCSBN, 2012; Pearson, 2012). On the Internet, scope of practice statements can be found by searching state government websites in the areas of licensing boards, nursing, and advanced practice nursing rules and regulations, or by visiting the NCSBN site (www.ncsbn.org). Recent federal policy initiatives, including the IOM Future of Nursing Report, (2011). the PPACA (HHS, 2011), and the Josiah Macy Foundation (Cronenwett & Dzau, 2010) have all issued recommendations with important implications for expanding the scope of practice for APRNs. The National Health Policy Forum (www.nhpf.org/library/background-papers/BP76_SOP_07-06-2010.pdf) and Citizen Advocacy Center (www.ncsbn.org/ReformingScopesofPractice-WhitePaper.pdf) reports state firmly that current scope of practice adjudication is far too technical, subject to political pressure, and therefore not appropriate in the legislative sphere. There must be a more powerful forum so that the public can enter into the dialogue (see Chapter 22).


As scope of practice expands, accountability becomes a crucial factor as APRNs obtain more authority over their own practices. First, it is important that scope of practice statements identify the legal parameters of each APRN role. Furthermore, it is crucial that scope of practice statements presented by national certifying entities are carried through in language in state statutes (Buppert, 2012). Our society is highly mobile and APRNs must recognize that their scope of practice will vary among states; in a worst case scenario, one can be an APRN in one state but not meet the criteria in another state (Minnesota Nursing, 2011; Taylor, 2006). This is discussed more fully later in the chapter.


APRNs owe Barbara Safriet, former Associate Dean at Yale Law School, a debt of gratitude for her vision and clarity in helping APRNs understand and think strategically about scope of practice and regulatory issues. In her landmark 1992 monograph, Safriet noted that APRNs are unique in that there is a multiprofessional approach to their regulation based on ignorance and on the fallacy that medicine is all-knowing, particularly about advanced practice nursing (Safriet, 1992).


As Safriet has implied, restraints on advanced practice nursing result from ignorance about APRNs’ abilities, rigid notions about professional roles, and turf protection. She cited reforms in scope of practice laws in Colorado that encouraged solutions to long-time tensions over control of practice between organized medicine and nursing. Their new provision defines the term practice authority in terms of ability and thus redirects the regulatory focus from providers’ status to the APRN’s training and skills (Safriet 2002, 2010). This example and the imminent move to Consensus Model regulation offers hope that in the future, policies can be formulated to close the gap between what APRNs can do and what they are allowed to do by scope of practice statutes. Scope of practice is hampered in many states where APRN practice is carved out of the medical practice act as a medically delegated act that precludes reasonable autonomy for the APRN. The ability to diagnose disease and treat patients, inherent in the role of the APRN, is fluid and evolving and is often tied to the collaborative relationships that APRNs have with physician colleagues. It is important to note that although APRNs desire autonomous licensure through the state boards of nursing, the need to work interprofessionally as colleagues and team members is essential to attaining high-level patient outcomes (Interprofessional Education Collaborative [IPEC], 2011; HHS, 2011).



Benchmarks of Advanced Practice Nursing and Education


Three components of APRN education and practice are related to scope of practice and provide additional important benchmarks—APRN competencies, professional APRN competencies, and master’s and Doctor of Nursing Practice (DNP) essentials These three benchmarks form the foundation on which boards of nursing develop APRN statutes. It is important to mention here that in the Consensus Model, six designations for practice for NPs and CNSs have been identified—adult-gerontology, pediatric, family (primary care and acute), psychiatric–mental health, neonatal, and women’s health–gender-related. In the new model, APRNs are licensed within a population focus. Specialty areas such as palliative care, oncology, and orthopedics are additional certifications above the population focus at which APRNs are licensed.



Advanced Practice Nurse Competencies


Underpinning scope of practice statements are termed APRN competencies, which are carefully outlined in Part II of this text. They form the core that distinguishes APRN practice. Scope is directly linked to the APRN competencies of direct clinical practice and coaching and guidance. These two interact with other core competencies to make up the quality care spectrum that APRN providers offer to their patients. These competencies are mirrored in the master’s and doctoral essential competencies described here.




Master’s and Doctor of Nursing Practice Essentials

The AACN has promulgated the Essentials of masters and doctoral education for advanced practice nursing (AACN, 2006a, 2011; NONPF, 2006). These documents support scope of practice for APRNs by providing the requirements for graduate core content and APRN core advanced physical assessment and diagnosis, pathophysiology, and pharmacotherapeutics. At the DNP level, a stronger foundation in population-based care, organizational leadership, collaboration, public policy, and information systems enhances APRN roles (AACN, 2006a).



Standards of Practice and Care for Advanced Practice Nurses


Standards of practice for nursing are defined by the profession nationally and help explicate and delineate scope of practice further. Standards are overarching authoritative statements that the nursing profession uses to describe the responsibilities for which its members are accountable (ANA, 2012; www.nursingworld.org). As such, they complement and enable the APRN core, population focus, and specialty competencies. APRNs are held to the standards of practice promulgated by the nursing profession and to standards of the various APRN specialties. At both levels, standards of practice describe the basic competency levels for safe and competent practice (e.g., see Chapters 14 through 18 for the standards of practice for NPs, CNS, CNMs, and CRNAs). Professional standards of practice match closely with the core competencies for APRNs, outlined in Chapter 3, which undergird advanced practice nursing.


Standards of care differ from the standards of practice set forth by the nursing profession. These standards are often termed practice guidelines. Practice guidelines provide a foundation for health care providers to administer care to patients. Ideally, these guidelines cross-cut the health professions’ disciplines and provide the framework whereby basic safety and competent care are measured. For APRNs, this means that the standard used to evaluate advanced practice is often the same as the standard used to review medical practice. Clinical guidelines are used as the standard of care in legal decisions; therefore, it is essential for APRNs to be part of the team developing new guidelines.


Standards of care are derived from evidence-based practice and are continuously evolving. At the federal policy level, the Agency for Healthcare Research and Quality (AHRQ) has responsibility for conducting the research needed to evaluate clinical practice guidelines that define a standard of appropriate care in specific areas (AHRQ, 2012 [www.AHRQ.gov]; Buppert, 2012). The Centers for Disease Control and Prevention (CDC) and professional medical and nursing specialty organizations also promulgate guidelines for practice (www.aafp.org). It is important that APRNs be part of interdisciplinary teams that develop and test practice guidelines for care. The ability of APRNs to download cutting edge practice guidelines onto electronic devices such as tablets, smartphones, and PDAs for use in clinical settings and at the bedside is a major step toward competent and safe practice.



Components of Advanced Practice Nurse Credentialing and Regulation


Credentialing used to ensure that APRNs meet competency and safety standards to protect the public has developed rather haphazardly. The Consensus Model of regulation that embraces all credentialing stakeholders is a major step forward. Two credentialing changes have or will occur as states move to the new regulation. First, titling will require that APRNs legally represent themselves as an APRN first and then by their role (CRNA, CNM, CNP, CNS). Many states already use this title, but some do not (NCSBN, 2011). Second, APRNs will need to have a second license. Second licensure means that an APRN must meet certain criteria established by a state board of nursing to receive an additional license or recognition to be authorized to practice at an advanced level of nursing practice. The notion of second licensure is unprecedented among the health professions and is onerous to some nurses but, given the various routes of entry into the nursing profession, it seems the only way to ensure a minimum set of competencies or requirements. The issue of titling and second licensure is an important issue for all APRNs and one to which individual APRNs must pay attention to protect their ability to practice, prescribe, and be reimbursed for their services.



Elements of Regulation


Several important steps lead the way to state licensure as an APRN. The regulatory process begins when a student is admitted to a university-based, accredited APRN program and proceeds through national certification in a population focus and then to second licensure and prescriptive authority. As APRNs become more mobile across state and international boundaries, and as communications allow for increased interaction, it is important that credentialing and regulatory parameters be well understood. Box 21-3 lists the elements of regulation for APRNs.




Credentialing


Credentialing is an umbrella term that refers to the regulatory mechanisms that can be applied to individuals, programs, or organizations (Styles, 1998). Credentialing can be defined as getting your ducks in a row for the purpose of meeting standards, protecting the public, and improving quality. For the purposes of this text, credentialing (as it relates to APRNs) is defined as follows: credentialing is furnishing the documentation necessary to be authorized by a regulatory body or institution to engage in certain activities and use a certain title. Credentialing occurs at a state level in terms of applying for a second license as an APRN. The term can also apply to a local institutional process that requires certain documentation from an APRN before the individual is allowed to practice and use an APRN title within the institution or facility. Credentialing in health care is used to ensure the public that the individual meets proposed standards and is prepared to perform the duties implied by the credential. National certification is only one part of credentialing and is used by many states as a vehicle to ensure a basic level of competence to practice; education is the other one. Certification alone does not provide a credential to practice as an APRN. Regulatory groups commonly request evidence of the primary criteria of graduate education, national certification, and patient-focused practice (see Chapter 3).


Credentialing may be mandatory, as in state second licensure, or voluntary, as with some states that only register APRN providers in the state (very few of these states remain). State boards of nursing and others that regulate APRNs to ensure public safety recognize voluntary credentialing bodies, such as national nursing certification organizations, as part of their mandatory state credentialing mechanism.


APRN program accreditation and approval, scope of practice, standards of practice, practice guidelines, and collaborative practice agreements all have important implications for APRNs in terms of proper credentialing and interactions with the judicial system. The documents specified in Box 21-3 create the standard whereby advanced practice nursing is monitored and regulated and deemed safe or unsafe, and whereby APRNs are disciplined from state to state. The components of advanced practice nursing education and practice are described in the following section.



Advanced Practice Nurse Master’s and Doctoral Education


The first criterion that any new APRN must meet is successful graduation from an approved, accredited APRN program. Educational programs for APRNs must be at the graduate nursing level (Master of Science in Nursing [MSN] or DNP); many programs are transitioning from master’s to DNP education. The recommendation by the AACN is that at least until 2015, and most likely beyond this writing, the master’s degree will be the level at which APRNs are credentialed (AACN, 2006b). The Consensus Model and Nursing Model Acts and Rules do not establish a timeline for the move to doctoral education for APRNs in the foreseeable future. Eligibility to sit for national certification and obtain APRN licensure or recognition by the state requires a transcript showing successful completion of a graduate degree from an accredited university that specifies the role and population focus of the graduate (NCSBN, 2008). This is the norm for APRN licensure or recognition in all states.



Advanced Practice Nurse Program Accreditation

For a graduate nursing program (master’s or DNP) preparing APRNs, credentialing has a somewhat different meaning. Program credentialing includes accreditation for the educational program by the Commission on Collegiate Nursing Education (CCNE) or National League for Nursing Accreditation Center (NLNAC), regional and state university boards and commissions, or groups such as the ACNM or the AANA accreditation bodies. For an institution (e.g., hospital, clinic), credentialing includes adhering to The Joint Commission (TJC) and Occupational Safety and Health Administration (OSHA) guidelines.


Graduate programs in nursing and related fields that prepare APRNs must be accredited as educationally sound, with appropriate content for the population focus or specialty and adequate clinical hours of supervised experience. As noted, the NLNAC and CCNE accredit graduate programs in the nursing major (CCNE, 2009). The accreditation process provides an overall evaluation of the graduate nursing and APRN programs. Oversight of APRN education occurs through the use of several different models. The clearest models are those administered by the ACNM and the AANA, which oversee and review their educational programs. These bodies provide a process to review and regulate CRNA and CNM programs nationwide that is separate from the overall graduate nursing accreditation processes of the CCNE and NLNAC. The National Task Force Criteria for Nurse Practitioner Education and the competencies developed by the National Task Force for Quality Nurse Practitioner Education (2012) and NACNS (2011) provide guidance to CCNA and NLNAC for the accreditation of NP and CNS programs.


Certifying agencies such as the ANCC and American Academy of Nurse Practitioners Certification Program (AANPCP) review programs, to some degree, to sanction eligibility for APRN graduates to sit for national APRN certification examinations. A change based on the work of the NCSBN and consensus groups that was suggested by Hanson and Hamric (2002) has been adopted by the accreditors. Preaccreditation procedures before the start of new programs is now the norm. Preaccreditation will ensure that all new programs are well developed with appropriate curricula in place before students are admitted and that the program prepare graduates who can be licensed as APRNs. The use of grandfathering mechanisms to protect APRNs during transition periods of standardization provides leeway for positive change to occur (NCSBN, 2008). For example, students who are in educational programs that are phasing out or phasing into new configurations will be allowed to graduate, sit for certification, and be credentialed until the transition period is complete.


The review and monitoring of NP and CNS education at the population focus level is more complex than for CRNAs and CNMs because of the multiplicity of program foci. The NONPF, National Certification Board of Pediatric Nurse Practitioners and Nurses (NCBPNP/N), NACNS, and other similar bodies provide curriculum guidelines, program standards, and competencies to assist APRN programs with curriculum planning. In 1997, 2002 and 2008, the National Task Force on Quality Nurse Practitioner Education established national criteria by which to monitor and evaluate NP programs according to broad-based criteria in six overarching areas—organization/administration, students, curriculum, resource facilities and services, faculty and faculty organizations, and evaluation. In 2012, the National Task Force (NTF) Criteria for Quality NP Education were updated and revised; these guidelines are scheduled for ongoing revision every 5 years (www.nonpf.org). The NTF criteria were developed and endorsed by a consortium of NP education and practice associations, NP regulators, and NP national certifiers and accreditors. The criteria evaluate the APRN program in the above-mentioned areas to ensure that APRN competencies are being met. The AACN’s Essentials of Master’s Education for Advanced Practice Nursing (2011) and Essentials of Doctoral Education for Advanced Nursing Practice (2006a) define graduate nursing core and advanced practice nursing core (advanced pathophysiology, physical assessment, and pharmacology) curriculum requirements. These three documents provide needed structure and guidance for NP nursing education.


The CNS community is working toward clear structure and progression of CNS specialty education to ensure compliance with credentialing and regulation as APRN providers. Core CNS competencies and doctoral level CNS competencies have been implemented (NACNS, 2010).

Oct 19, 2016 | Posted by in NURSING | Comments Off on Understanding Regulatory, Legal, and Credentialing Requirements
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