History of APRN
Advanced Practice Registered Nurses (APRN)
NCSBN recommends the use of APRN certification examinations as a basis for licensure decisions. Below is background on this recommendation.
Recent NCSBN Activities regarding Advanced Practice Registered Nurses (APRNs)
- In 2010, NCSBN developed a video and toolkit to assist regulators and legislators in adopting the requirements outlined in the Consensus Model for APRN Regulation.
- An update regarding the APRN Joint Dialogue Group was presented at the 2008 APRN Roundtable.
- NCSBN APRN Committee worked with the APRN Consensus Work Group to develop the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education, which was endorsed by the NCSBN Board of Directors in 2008.
- The APRN Legislative Language, which parallels the Consensus Model for APRN Regulation was approved by the 2008 NCSBN Delegate Assembly.
The APRN Compact addresses the need to promote consistent access to quality-advanced practice nursing care within states and across state lines.
The Uniform Advanced Practice Registered Nurse Licensure/Authority to Practice Requirements, developed by NCSBN with APRN stakeholders in 2000, establishes the foundation for this APRN Compact. Similar to the existing Nurse Licensure Compact for recognition of RN and LPN licenses, the APRN Compact offers states the mechanism for mutually recognizing APRN licenses/authority to practice. This is a significant step forward for the increasing access and accessibility to qualified APRNs. A state must either be a member of the current nurse licensure compact for RN and LPN, or choose to enter into both compacts simultaneously to be eligible for the APRN Compact.
Historical Actions on APRNs
In April 2000, NCSBN Board of Directors appointed a special advanced practice task force to continue to examine the issue of regulatory sufficiency of advanced practice certification examinations. The Task Force was charged with conducting a retrospective evaluation of the current review process and to make recommendations to assure consistency in certification to support the boards in protecting the public.
In January 2002, the Board of Directors approved criteria for both the certification programs and for the accrediting agencies that were developed by the Advanced Practice Task Force. The Requirements for Accrediting Agencies and the Criteria for Certification Programs represent required elements of certification programs that would result in a legally defensible examination suitable for the regulation of advanced practice nurses.
In 2002, the Advanced Practice Task Force wrote a Position Paper on the Regulation of Advanced Practice. The position paper was written as a resource for Member Boards. The document can also serve to educate APRN stakeholders such as APRN certifiers, educators and advanced practice nurses. Two other advanced practice position papers were developed previously, 1986 Position Paper on Advanced Clinical Nursing Practice and 1993 Position Paper on the Regulation of Advanced Nursing Practice.
Using Nurse Practitioner Certification for State Nursing Regulation: A Historical Perspective
This information was written in 1998. We include it here to provide factual background information on this issue.
In the past, there was much confusion over nurse practitioner certification programs and NCSBN's supposed attempts to develop a core nurse practitioner examination. To communicate the most current and accurate information related to nurse practitioner certification programs and their potential for state regulatory use, NCSBN provides the following update.
Background of the Issue
The board of nursing in each state, under the authority of the Nursing Practice Act, establishes statutory authority for licensure of registered nurses (RNs), which includes the use of a title, authorization for a scope of practice, standards of practice and disciplinary grounds. When an RN engages in practice that is determined to be beyond the identified scope of nursing practice (as in advanced practice nursing), legal authorization for that practice must exist in state law. Any title, even if issued by a national certification body, only carries legal status if that title is recognized or authorized in statute or regulation.
Some jurisdictions require certification by a national professional body as one prerequisite for state authorization to practice as an advanced practice nurse. This is an appropriate means by which states may fulfill their obligation for public protection if such certification programs regularly demonstrate their sufficiency for regulatory purposes. Regulatory sufficiency is based upon examination design geared toward entry-level competencies, exclusively job-related knowledge and skills, pass/fail at the point of the minimum-essential level for safety and effectiveness, and use of generally accepted testing practices.
Nurse Practitioner Certification
Concerns about regulatory sufficiency were raised when representatives of some nurse practitioner certification programs clearly stated that their examinations were not designed for entry-level use. Additionally, uneven enforcement of admission requirements accentuated boards' concerns about their reliance on national specialty certification programs for regulatory purposes.
As a result, boards of nursing, via their 1995 Delegate Assembly, directed the NCSBN to collaborate with nurse practitioner specialty certification organizations to make significant progress toward legally defensible, psychometrically sound nurse practitioner examinations that are sufficient for regulatory purposes.
During 1995-96, the National Council and the American Nurses Credentialing Center (ANCC), National Certification Board for Pediatric Nurse Practitioners and Nurses (NCBPNP/N), National Certification Corporation (NCC) for women's health specialties and American Academy of Nurse Practitioners (AANP) met and corresponded to attempt to work out a mutually acceptable process by which evidence of regulatory sufficiency could be reviewed and conclusions drawn to allow boards of nursing to determine the appropriateness of reliance on certification programs in granting state authorization to nurse practitioners. An offer by the National Council to provide review services at its own expense foundered over issues of confidentiality and reporting to boards of nursing.
At that juncture, NCSBN's Board of Directors initiated a nurse practitioner job analysis study, as it had been directed by the boards of nursing to do if sufficient progress was not made. Shortly thereafter, the parties came back to the table to discuss the possibility of a third-party review process, which ultimately proved mutually acceptable. NCSBN stated its acceptance of third-party review performed by mutually agreed upon consultants and review by the National Commission of Certifying Agencies (NCCA), an arm of the National Organization for Competency Assurance. The NCCA criteria were to be supplemented by criteria specified by the National Council that pertained to regulatory use for granting state authorization (i.e., entry level, job related and minimum level required for safety and effectiveness).
In August 1996, NCSBN received a report from the ANCC, performed by independent consultants knowledgeable in state regulation of professionals, which evidenced meeting most criteria and made minor recommendations for improvements. The ANCC outlined plans to accomplish those improvements. As of February 1997, the ANCC also underwent NCCA review and is awaiting the NCCA report.
The AANP and NCC underwent NCCA review in July 1996 and provided additional requested information in August/September 1996, which was reviewed by the NCCA in late October 1996. These organizations received their certification from the NCCA and are awaiting the NCCA's final report, which addresses the examination-related requirements outlined by NCSBN(criteria included in the NCCA process as well as the supplemental criteria).
The NCBPNP/N underwent NCCA review in July 1996 and received full NCCA recognition. The final report was delivered to the NCBPNP/N and forwarded to NCSBN in November 1996.
Following receipt of each of the reports, the NCSBN will respond to the individual organizations regarding the fulfillment of the agreed-upon steps for demonstrating regulatory sufficiency and disseminate a report of these results to boards of nursing. Additionally, NCSBN is initiating discussions, which will include its Member Boards and the certifying bodies, regarding a mechanism(s) that may be used to assure the certification examinations' ongoing regulatory sufficiency to boards of nursing.
Because progress is being made toward legally defensible, psychometrically sound nurse practitioner examinations that are sufficient for regulatory purposes, as directed by the NCSBN's Delegate Assembly, NCSBN suspended performance of an incumbent nurse practitioner job analysis. The job analysis would only be resumed if progress were again impeded.
There are no current NCSBN activities directed toward the development of additional examinations, core or specialty, for any category of advanced practice registered nurse.
The nursing press, including the numerous publications of organizations concerned with advanced practice nursing, has given frequent coverage to advanced practice regulatory issues since first raised by the NCSBN in 1992. Much of the coverage has been incomplete, out-of-date or patently misleading. And, several points in recent articles require comment for the correction of the record.
NCSBN's Positions & Actions
Much confusion surrounds the positions of the NCSBN (set by its Delegate Assembly) regarding advanced practice. Following are the actions of the NCSBN's Delegate Assembly, which is comprised of representatives of all boards of nursing in the United States and five U.S. territories.
The position paper on the Licensure of Advanced Nursing Practice and the additions of Model Language for Advanced Nursing Practice in the Model Nursing Practice Act (available for purchase through the publication order form on this web site) was referred back to the Subcommittee to Study the Regulation of Advanced Nursing Practice for the purpose of reviewing the comments received from the delegates and interested nursing organizations and for developing the model rules; the position paper and model were to be brought to the 1993 Delegate Assembly for consideration.
The Delegate Assembly adopted the position paper on the regulation of advanced nursing practice with the proviso that the Board of Directors continue collaboration with the American Nurses Association, American Association of Nurse Anesthetists, American College of Nurse-Midwives and other nursing organizations, including nurse certifying bodies.
The Delegate Assembly adopted the Model Legislation Language and Model Administrative Rules for Advanced Nursing Practice, to be incorporated into the newly adopted Model Nursing Practice Act and Model Nursing Administrative Rules.
NCSBN performed a study to identify core competencies of nurse practitioners.
NCSBN performed a study exploring the regulatory, fiscal and political implications of developing a core competency examination for nurse practitioners.
NCSBN established a task force to develop a database of advanced practice credentialing requirements (licensure, recognition, certification, authority to practice, etc.) for each Member Board with enough specificity for other Member Boards to make credentialing decisions; as well as studied whether or not additional mechanisms could be developed to facilitate interstate mobility of advanced practice nurses.
NCSBN collaborated with nurse practitioner specialty certification organizations to make significant progress toward legally defensible, psychometrically sound nurse practitioner examinations which are sufficient for regulatory purposes; benchmarks for progress were established and evaluated by the Board of Directors. The Board of Directors reported to the 1996 Delegate Assembly with specific recommendations regarding future actions. When the Board of Directors determined that significant progress was not being made, the Board was authorized to conduct a job analysis of entry-level nurse practitioners.
To assure that Member Boards have psychometrically sound and legally defensible nurse practitioner examinations available for their regulatory purposes, and pending the receipt of final examination evaluations and mutually acceptable plans for correction, the Board of Directors continued to negotiate with nurse practitioner certifying organizations.
If, at any time, the Board of Directors determines that significant progress is not being made, the Board is authorized to proceed with phase two of the nurse practitioner job analysis. Furthermore, the Board of Directors is charged to determine a mechanism for assuring continued adherence with established standards for psychometrically sound, legally defensible nurse practitioner examinations used for regulatory purposes.
In the past, it was suggested that the NCSBN's primary motive for involvement in nurse practitioner examination matters is financial. In fact, in 1994-95, during the analysis of the fiscal, regulatory and political implications of developing a core licensure examination for nurse practitioners, NCSBN determined that a significant financial outlay would be required for the start-up work on even a single (core) examination, and that the best return which could be expected for ongoing expenses was at break-even.
Thus, future decisions all revolved around the necessity of efforts to meet nursing boards' regulatory requirements, not the possibility of creating a new market for the NCSBN.
Multiple articles confound the NCSBN's position on advanced practice licensure with the relationship to nurse practitioner certifying bodies. As indicated previously, in 1993 NCSBN adopted a position advocating the licensure of advanced practice registered nurses (APRNs) on the basis that the level of care they provide and the autonomy of their practice are of such significance to consumers that, if provided incompetently or unethically, the public could be exposed to severe harm. Unlike physicians, scopes of practice for nurses are not generally expansive enough to include all aspects of advanced practice nursing; thus, additional legal authority must be secured through nursing statute or regulation.
The NCSBN position also advocates that regulatory jurisdiction for APRNs be solely under boards of nursing, a master's degree be required as minimum educational preparation and prescriptive authority be granted as appropriate to the practice area. Appropriate considerations for transition periods, such as grandfathering, are described in several places in the model administrative rule language, which was adopted concurrently with the position statement.
The current status of this issue is that, as of Jan. 1, 1997, all states regulate advanced practice nurses in some manner. Eighteen states currently license nurse practitioners. Thirty-two additional jurisdictions grant authority to practice through certificates, recognition, registration or similar means. In granting authority to practice beyond the RN scope of practice, boards rely upon conventional authority mechanisms, including graduation from approved educational programs and, in many cases, certification examinations. Thirty-eight jurisdictions currently rely upon national certification programs to measure competency.
The status of the other issue, regulatory use of certification examinations, is distinct. The 1995-to-present interactions with the nurse practitioner certifying bodies are focused on the needs of states for examinations that provide a sufficient basis for them to discharge their regulatory responsibilities. These activities are not a proposal for second licensure, but a means of implementing, fairly and responsibly, existing legal requirements in states.
If the examinations provided by certifying bodies are -- or can be made to be within a reasonable time -- sufficient for regulatory purposes, no further provision is needed nor will it be sought via the NCSBN. If not, all avenues will have to be explored to meet the regulatory mandate for public protection.
Current Nurse Practitioners
Claims that practicing nurse practitioners stand to lose their eligibility to practice and receive reimbursement are without foundation under the NCSBN's position on APRN licensure and its negotiations with nurse practitioner certifying bodies. Mechanisms such as transition periods and grandfathering are available to states to assure that current nurse practitioners are fairly treated and express the value of current competent practitioners to boards of nursing and the public they serve.
The endpoint of the NCSBN's activities related to nurse practitioner certification activities is anticipated to be when closure is reached on a mechanism to assure ongoing demonstration of regulatory sufficiency.
Other APRN Categories
There has been activity over the past several years in monitoring the status of clinical nurse specialists. Based on a 1996 report, monitoring of the role is the only current NCSBN activity with respect to clinical nurse specialists.
Activity related to certified registered nurse anesthetists includes availability of material in the NCSBN's clearinghouse of information provided by the certifying bodies and a relationship in which the certification corporation reviews information about disciplinary actions taken against licenses by boards of nursing.
Clearinghouse information is also available regarding certification for nurse midwives, with the additional interest in assessing regulatory implications of the recently announced policy to admit non-nurses to the certification program.
Reports from the NCCA relative to the criteria for the nurse practitioner examinations provided by the NCC, AANP and ANCC are expected to be completed and forwarded to NCSBN in the near future. A report to boards of nursing and a press release will subsequently be distributed to summarize the status of the issue of use of certification examinations for regulatory purposes.
By Summer 1997, it is anticipated that a mechanism for assuring ongoing regulatory sufficiency will be identified. A progress report on all of these issues will be presented to the official representatives of the boards of nursing at the 1997 NCSBN Annual Meeting.
At present, NCSBN is not pursuing a job analysis or any form of test development related to any category of APRNs.