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Position
Statement: The nursing profession must develop a standardized
national advanced practice nursing certification process by
the year 2000. Advanced Practice Nurse is an umbrella term appropriate
for a licensed registered nurse prepared at the graduate degree
level as either a Clinical Specialist, Nurse Anesthetist, Nurse-Midwife,
or Nurse Practitioner. Advanced Practice Nurses are professionals
with specialized knowledge and skills that are applied within
a broad range of patient populations in a variety of practice
settings (see Attachment A). All Advanced Practice Nurses should
hold a graduate degree in nursing and be certified. Each existing
and future professional nursing specialty certifying entity
must meet uniform national standards when certifying nurses
for advanced practice. Those standards would be developed and
administered by a separate organization such as the American
Board of Nursing Specialties. Professional certification validates
and standardizes the qualifications and practice competencies
of the Advanced Practice Nurse and is the appropriate mechanism
by which the public's health and safety can be protected. There
are nurses prepared at the advanced level who have roles as
administrators and educators. This position statement does not
address those individuals. Rather, it focuses on nurses prepared
for roles as direct care providers.
Background
Nurses in various advanced practice nurse categories
have been providing health care in the United States for more
than 50 years. However, neither the educational preparation
nor the certification process for these nurses has been standardized.
In many instances, nurses without advanced graduate education
are functioning in advanced practice roles. Similarly, not
all master's prepared Advanced Practice Nurses are certified.
Advanced Practice Nurses who are certified have achieved this
status through myriad processes governed by varying standards.
There are more than 30 organizations that grant certifications
for nurses with training beyond the entry-to-practice level.
1 While only a few of these organizations certify
the nurse practitioners, nurse-midwives, nurse anesthetists,
and clinical nurse specialists who are the focus of this position
statement, confusion in the public mind about the meaning
of certification suggests that a consistent set of standards
must be established for all certifications for advanced practice
nurses.
Since 1992, the issue of regulating advanced
practice nursing has become a topic of increasing concern
to the nursing profession.2 One organization proposed
a second license as a means of providing legal authority,
defining scope of practice, and protecting the professional
title for advanced practice nurses.3 Others have
maintained that regulation should take place through education
requirements and a standardized certification process. The
need for a second license versus certification as the appropriate
regulatory mechanism has been argued in the literature, and
various groups have assembled periodically to study the matter.4,5,6,7
A uniform regulatory process must be established
to assure the public of the competency of the Advanced Practice
Nurse. A standardized national advanced practice certification
process that mandates a graduate degree in nursing is the
appropriate mechanism. AACN supports advanced practice nurse
certification that requires completion of a graduate program
in nursing for advanced practice, as well as demonstration
of clinical practice experience in the specialty. Completion
of a graduate program in nursing prepares nurses to function
as practitioners, case managers, change agents, clinical teachers,
consultants, and health and social policy advocates. These
graduates utilize nursing and health care research in modifying
nursing practice.
More specifically, nurses prepared at the graduate
level function in a variety of roles as advanced practice
nurses in specialty areas of practice. For example, advanced
practice nurses plan and coordinate multidisciplinary interventions
within a variety of health care systems with diverse populations,
initiate and facilitate organizational change and continuous
quality improvement programs in the area of practice, facilitate
the conduct and utilization of research, develop educational
materials and strategies and evaluate their effectiveness
within a specialty area of practice, participate in the formulation
of health and social policies, provide clinical consultation
in a specialty area of practice, and apply ethical and legal
principles to complex health care circumstances (see Attachment
A).
The first step in ordering advanced practice
nurse practice is to assure the public that the preparation
of these nursing professionals is at a level reflective of
its advanced knowledge base, that is, graduate preparation
accomplished with a curriculum that incorporates professional
standards and clearly defined core competencies. (In 1996,
AACN published core standards for the education of advanced
practice nurses and all other registered nurses who are prepared
in master's-degree programs.8) This educational
qualification must be required for graduates of advanced nursing
programs to sit for a national certifying examination in their
respective specialties.
The certification of Advanced Practice Nurses
by professional specialty nursing organizations incorporates
professional assessment of necessary skills and measurement
of a licensed Registered Nurse's competence with regard to
established criteria. For example, Advanced Practice Nurses
certified by the American Nurses Credentialing Center must
have master's degrees and demonstrate successful completion
of an 8-hour written examination composed of in-depth questions
prepared by and reviewed by practitioners. For certain specialties,
Advanced Practice Nurses also must show evidence of specified
clinical practice experience. Once granted, certification
is effective for 5 years, whereupon the individual must apply
for recertification based on either a retest or demonstration
of continuing education credits.
The current system for recognizing advanced
nursing practice through certification was established and
is operated by professional nursing specialty organizations.
In response to a need to be more formally organized as a national
peer review program for APN nursing certification bodies,
the American Nurses Credentialing Center and more than a dozen
certification boards joined the American Board of Nursing
Specialties (ABNS). This umbrella board established in 1991
approves membership of those APN certifying bodies that have
met the standards and principles of ABNS. One of the 12 standards
that must be met is a requirement for uniform educational
preparation, i.e., a graduate degree in nursing. The ABNS
resembles the American Board of Medical Specialties whose
mission is to maintain and improve the quality of medical
care by assisting member boards in their efforts to develop
and utilize professional and educational standards for the
evaluation and certification of physician specialists. Not
unique to nursing and medicine, this approach also parallels
the means used to board certify dentists, pharmacists, and
attorneys to specialize in a particular practice area. All
of the professions require a license to commence practice
but rely on professional certifications as a basis for specialization.
AACN is not suggesting that there be one examination
for all advanced practice nurses; rather its position is that
all advanced practice nursing certification procedures must
meet a recognized and uniform national certification standard,
integral to which is a requirement for a graduate degree in
nursing.
Certification has national precedence and respect
and adheres to the principles of regulation promulgated by
the International Council of Nursing and adopted by major
nursing organizations and regulators. Moreover, certification
assures national consistency of professional standards, imposes
standard titles, helps the public understand the professional's
scope of practice, and provides a venue for the public to
raise practice grievances. The professional certification
process meets the objectives of greater professional autonomy
and provides recognition of a nationally uniform measure of
competence that can be relied upon by the public in making
health care provider choices with confidence.
Certification and licensure both are forms
of regulation of a profession. State Boards of Nursing, guided
by Nurse Practice Acts, regulate the practice of nursing through
enabling legislation that authorizes Boards to test graduates
of accredited nursing schools for licensure as Registered
Nurses. This process has a long and successful history. With
nursing having standardized much of the approved certification
process for advanced practice nursing, a second license is
not necessary to regulate nursing practice in the public's
interest. Indeed, the National Council of State Boards of
Nursing has withdrawn its recent proposal for second licensure
of nurse practitioners and will recognize the certifying exams
of nurse practitioner certifying organizations.
With certification as the regulatory mechanism
for advanced practice nursing, nursing can pool resources
and move forward expeditiously on the process of regulation
in the interest of public safety.
(Approved by Membership, October 31, 1994)
(Revised January 28, 1998)
References
1. Fickeissen, J.L. (March 1990).
"Fifty-six ways to get certified." American Journal
of Nursing , 50-57.
2. Minarik, P.A. (1992). "Second
license for advanced nursing practice." Clinical Specialist,
6:4, 221-222.
3.
National Council of State Board of Nursing, Inc. (July 1993).
"National Council Fact Sheet." Chicago: Author.
4.
Havens, D.H. (1992). "Licensure of Advanced Practice
Nurses" Journal of Pediatric Health Care, 6:6,
378-380.
5.Andreoli,
K.G. and Dvorak, E. (1993). "Regulation - When it is
appropriate and when it is not." Journal of Professional
Nursing, 9:6, 310.
6.Smreina, C. (1993). "Licensure
of Advanced Practice Nursing." Orthopedic Nursing,
12:1, 13.
7.Krauss,
J. (1992). "Regulation of Advanced Practice Nursing -
the cog in the health policy engine" Journal of Professional
Nursing, 8:4, 200.
8.American Association of Colleges
of Nursing. (1996). The Essentials of Master's Education
for Advanced Practice Nursing. Washington, DC: Author.
Attachment
A
Examples*
of the Role and Scope of Advanced Practice Nurses
| Advanced
Practices Nurses |
Application
of Advanced Knowledge and Skills |
Patient
Population Served |
Practice
Settings |
Certified
Nurse-
Midwives
|
Well-women health care, management of
pregnancy, childbirth, antepartum and postpartum care.
Health promotion. |
Childbearing women |
Homes
Hospitals
Birthing centers
Ambulatory care |
Clinical Nurse
Specialists |
Management of complex patient health
care problems in various clinical specialty areas through
direct care, consultation, research, education and administrative
roles. |
Individuals with:
-physical or psychiatric illness and disability
-maternal and child health problems
-gerontologic problems |
-Teritiary care
-Ambulatory care
-Community care
-Home health care
-Rehabilitation |
| Nurse Anesthetist |
Pre-operative assessment, administration
of anesthesia; and management of post-anesthesia recovery.
|
Individuals
in all age groups undergoing surgical procedures |
-Hospital
operating rooms
-Ambulatory care
-Surgical settings |
| Nurse Practitioners |
Management of a wide range of health
problems through physical examination, diagnosis, treatment,
and patient/family education and counseling. Primary
care and health promotion. |
Individuals and families:
-Women
-Infants and children
-Elderly
-Adults and others |
-Primary care
-Long-term care
-Ambulatory and community care
-Tertiary care |
*These
are examples and are not intended to be an exhaustive description
of knowledge, patient populations, or practice.
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