APRN Regulation

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APRN Regulation

• Kathy Thomas
• Executive Director
• Texas Board of Nurse Examiners

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State Budget Crises
IOM reports
Technological advances
Consumers Expectations
Board quality improvement
Changes in nursing roles/practice
Radical transformation of health care delivery
system
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Uniform Advanced Practice Registered Nurse
Licensure/Authority to Practice
RequirementsNCSBN (2000/2001)
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Uniform Core Licensure Requirements

• APRN regulation lacked uniformity
• Awareness of the value of uniformity to
  facilitate mutual recognition
• Uniformity diminishes concerns over disparate
  qualifications for licensure in Compact states
• Adoption of uniform requirements drives
  consistency across states

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Uniform Core Licensure Requirements

• Recognition that an APRN Compact would need to be
  predicated on uniformity
• Development included stakeholder groups
• Five meetings were held between December 1997 and
  December 1998, in Chicago, San Diego and
  Washington, DC.

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Uniform Core Licensure Requirements

• Adopted by the NCSBN Delegate Assembly in 2000
• Compact Administrators Commit to Adoption in 2001
• Requirements for Education and Examination are
  already met

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Uniform Core Licensure Requirements --Principles

• Avoid simply choosing the least common
  denominator.
• Legal recognition can be any of the various ones
  used by states to authorize advanced practice,
  e.g., certificate of authority, licensure, or
  recognition.
• The underlying goal is to promote public safety
  in the least restrictive manner.

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Uniform Core Licensure Requirements--Issues

• Alternative mechanism to certification
• originally included in the requirements (2000)
  Currently certified by national certifying body
  in the APRN specialty appropriate to educational
  preparation
• Delegate Assembly voted to expire this provision
  (2001)
• For applicants for whom there is no appropriate
  certifying exam available, states may develop
  alternate mechanisms to assure initial competence
  until January 1, 2005. Evidence of an equivalent
  mechanism to certification examinations will not
  be accepted after January 1, 2005 and individuals
  will no longer be licensed without an approved
  APRN examination.

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NCSBN Position Paper on Regulation of Advanced
Practice

• Changes in the United States health care system
• nursing evolved into multiple levels of practice
  with an increasingly differentiated body of
  knowledge.
• APRNs are practicing independently and performing
  procedures previously reserved for physician
  practice.
• Nurses with advanced skills are seeking
  professional and economic recognition through
  certification and the authority to practice
  through nursing regulation.
• Lack of consistency in education, titling,
  credentialing, program accreditation, scope of
  practice and reimbursement is confusing.

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Regulation Perspective

• Legal recognition to practice carries with it
  certain standards
• Formal Education
• Examination
• Legally defensible
• Psychometrically sound

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Regulation Perspective

• Limited resources
• In the position of denying graduates who do not
  qualify
• Dealing with complaints against APRNs who are
  working outside their scope because they could
  not be employed in their narrow scope of
  preparation

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NCSBN Position Paper Issues

• EDUCATION
• Most BONs do not approve APRN programs
• Accrediting bodies should assure standards are
  met.
• Although Essentials of Masters Education (AACN)
  have been published since 1995
• There are still programs which do not comply with
  these standards

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Issues -- Scope of Preparation

• Minimum preparation for entry into advanced
  practice nursing for legal recognition
• Examples of broad preparation include areas such
  as adult health, pediatrics, psychiatric mental
  health, etc.
• APRNs who are certified in a subspecialty, such
  as a specific disease entity, have a narrow scope
  of practice
• Difficult to evaluate the validity and
  reliability of certification examinations
  administered to only a small number of candidates
• Graduates of these programs expect to be licensed
  as APRNs
• Educational programs may wish to provide special
  emphasis areas that are subspecialty focused

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Issues -- Informed Students

• Students must be given accurate information about
  their eligibility for certification and
  subsequent licensure, and that certifying bodies
  are given accurate information about the program.
  For regulatory purposes, it is important that
  accreditation processes provide for conclusive
  verification of these elements.

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Issues -- Certification

• It is necessary for these examinations
• to measure only job-related knowledge, skills,
  and abilities
• to be at entry-level
• require minimal level competence and
• be psychometrically sound.

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NCSBN Position Paper Conclusions

• The current approach to licensure involves
  reliance on educational credentials,
  certification examinations and the information
  provided by the applicant.
• Thus, cooperation of educational institutions,
  accrediting bodies, credentialing organizations,
  regulators and licensees is essential to produce
  the best result for the health care of the
  public.

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Definitions

• APRN
• Masters preparation
• Program of study in a specialty area in an
  accredited nursing program
• Taken a licensing exam in same area
• Granted licensure in advanced practice
• Hallmark is direct patient care
• Subcategories CRNA, CNM, NP, CNS

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Definitions

• APRN Nursing
• Expanded scope which includes RN scope
• Scope includes advanced assessment, diagnosing,
  prescribing, selecting, administering, and
  dispensing therapeutic measures, including OTC,
  legend and controlled substances within the role
  and specialty appropriate education and
  certification.

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Definitions

• Specialty
• A broad, population based focus of study
  encompassing common problems of that group of
  patients and likely co-morbidities, inteventions
  and repsonses to those problems
• e.g., neonatal, child, women, adult, family,
  mental health, anesthesia, midwifery
• NOT a specific disease/health problem or specific
  intervention

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Definitions

• Sub-Specialty
• A focus of practice within a specialty assuring
  expert knowledge of a particular area of patient
  problem, e.g., cardiovascular disease, palliative
  care, oncology, substance abuse, orthopedics,
  critical care, etc.

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APRN Regulatory Principles

• Scope of Education, Certification and Practice
  are congruent
• Role and title should reflect educational
  preparation and examination
• APRN licensure is necessary because scope of
  practice exceeds RN scope
• Boards must approve educational programs leading
  to licensure

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APRN Regulatory Principles

• Individuals must graduate from approved programs
  in the specialty
• Licensing exams must be acceptable to Boards of
  Nursing
• Exams leading to licensure must be legally
  defensible and psychometrically sound. Content
  validity must be based on a job analysis.

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APRN Regulatory Principles

• All educational programs leading to licensure
  must be accredited.
• For dual track programs, each track must have a
  minimum of 500 clinical hours.
• The APRN specialty must consist of broad
  population-based focus of study.
• Curricula should be standardized and based on
  nationally recognized core competencies.

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