May 16, 2008

May 16, 2008

APRN Regulation: Recent Trends and

Implications for Oncology APRN Practice

Julie A Ponto, RN PhD ACNS-BC AOCN®Winona State University

Past President, ONCC Board of Directors

History of APRN Regulation

Nursing Regulation

• The foremost responsibility of nursing regulation is protection of public health, safety and welfare.

• Important because unprepared and incompetent individuals who practice pose risk of harm to the public.

Licensing boards , governed by state regulations and statutes, are the final arbiters of who is recognized to practice in a given state.

State Boards of Nursing• Authorized state entity with legal authority

to regulate nursing• Regulate RN Practice in 50 states, DC and

5 U.S. Territories• Protect the public’s health by overseeing

and ensuring the safe practice of nursing– Establish standards– Issue licenses– Monitor licensees’ compliance– Take action against those who exhibit unsafe

practice

State Legislatures enact Nurse Practice Acts:

• Define the authority of the board of nursing

• Define nursing and the boundaries of the scope of practice

• Identify types of licenses• Identify requirements for licensure • Protects titles• Identify grounds for discipline

Boards of nursing develop rules and regulations consistent with the nurse practice act that have the force and effect of law.

“When a RN engages in practice that is determined to be beyond the identified scope of nursing,

legal authorization for that practice must exist in state law.

Any title, even if issued by a certifying body, only carries legal status if that title is recognized or

authorized in statute or regulation.”

NCSBN

Supports the 60 state boards of nursing in the USA and its territories in providing leadership to advance regulatory excellence for public protection. The NCSBN delegate assembly is comprised of representatives from all U.S. Boards of Nursing.

National Council of State Boards of Nursing (NCSBN)

NCSBN• “Trade association” for state boards of

nursing• No regulatory authority• Provides support and direction to state

boards on issues• Develops

Model Nurse Practice Acts Model Rules and Regulations Nursing Compacts Position Statements

NCSBN has addressed the issue of the regulation of

APRNs for several decades.

1980s

NCSBN Position on Advanced Clinical Practice stated that the preferred method of regulation for the APRN was “designation/recognition” which is the least restrictive form of regulation .

APRNs have • expanded in numbers and

capabilities over the past several decades

• become a highly valued, integral part of the healthcare system.

Between 1986 and 1992• The economic, legislation and

policy changes affecting healthcare in the U.S. regarding cost and access to care increased the interest in alternative approaches to care.

Between 1986 and 1992• There was increasing

recognition of the overlap between medical practice and that of other providers such as NP, CNS, Nurse Midwives and Nurse Anesthetists.

Between 1986 and 1992• Regulatory authorities were

required to foster these overlapping practices in the interest of cost-effective accessible care, while working to protect the public.

1990 - Present

Regulation of APRNs become progressively more structured and developed into licensure, the most restrictive form of regulation.

1990-2000• State boards began using the results

of advanced practice certification examination as one of the requirements for APRN licensure.

• There was collaboration between APRN certifiers and NCSBN to assure certification examinations were acceptable for regulatory purposes.

1990-2000

• To be suitable for regulatory purposes, APRN certification examinations were required to be entry level (test competencies of new graduates) and accredited

• Certifying bodies were required to provide information to state boards regarding the psychometric soundness and legal defensibility of examinations

2002

NCSBN approved Criteria for Evaluating APRN Certification Programs. These criteria included educational requirements for: Education concentration in the specialty 500 hours supervised clinical hours Clinical experience directly related to role

and specialty

2002

NCSBN published Position Paper: Regulation of Advanced Practice Nursing

• APRN – Umbrella term for NP, CNS, NM, NA• Licensure – Preferred method of regulation• Education in role/broad specialty must be

consistent with certification• Only broad categories to be recognized – not

“subspecialties such as disease entities”

2003-2006

NCSBN drafted APRN Vision Paper to:

• Resolve regulatory concerns such as proliferation of “subspecialties”

• Provide direction to state boards

2006• The NCSBN APRN

Vision Paper elicited a large response from a wide audience of nursing stakeholders.

• NCSBN APRN Advisory Committee met with the APRN Consensus Work Group and agreed to begin a joint dialogue, working together toward a future model for APRN regulation.

2006

• The APRN Consensus Work Group and the NCSBN APRN Advisory Committee publish the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education

2008

The Present

Both APRN requirements and approaches to APRN regulation continued to vary widely from state to state.

Interstate Compact

• Offer states the mechanisms for mutually recognizing licenses/authority to practice

• RN/LPN/VN Compact– Enacted in 2000– Currently includes 22 states

APRN Interstate Compact

• Model language adopted 2002• Only states that have adopted

RN/LVN/PN may participate • Utah, Iowa and Texas have

passed ARPN Compact into law• No rule writing has begun• No date for implementation

Carlton G. Brown, PhD APRN AOCN®Georgetown University

President, ONCC Bard of Directors

Data on Oncology APRNs and Educational Programs

ONCC Survey of Oncology APRNsApril 2008

• E-mail invitation to participate sent to 3734 ONS members who list NP or CNS as their primary position

• Response rate = 1248 (33%)• Demographics of respondents

indicate they are representative of the ONS members who are APRNs

Post -Graduate Program

Graduate Programs in Oncology Nursing

• 23 Programs– 14 NP– 12 CNS– 1 Blended

• Most Linked to Broader Specialty– Adult – Medical-Surgical– Acute Care

• Number of oncology-specific courses offered ranges from 2-10

Transcript Review

AOCNP® Candidates2005-2007Role Focus

NP 98%Blended NP/CNS 2%

Transcript Review

AOCNS® Candidates2005-2007Role Focus

Unspecified 56%CNS 41%NP 3%

Transcript ReviewAOCNP® Candidates

2005-2007Specialty Focus

Family 33%Adult 30%Oncology 21% *Acute Care 8%Gerontology 2%Other 6%* Includes oncology combined with others such as adult or

acute care

Transcript ReviewAOCNS® Candidates

2005-2007Specialty Focus

Oncology 31%* Adult 17%Medical –Surgical 9%Administration 8%Education 7%Community 6%Family 5%Other 12%None 5%* Includes oncology combined with others such as adult or acute care

Oncology (AOCN®) 38%Oncology (AOCNS®) 27%Adult/Medical-Surgical CNS 21%

12-15% of CNSs who hold AOCNS® or AOCN® also hold another CNS certification

Survey DataCertifications Held

CNS

Adult Primary Care NP 36%Family NP 33%Oncology (AOCNP®) 21%Oncology (AOCN®) 17%Adult Acute Care NP 10%Gerontological NP 4%

60-65% of NP who hold AOCNP® or AOCN® also hold another NP certification

Survey DataCertifications Held

NP

State Board Regulation

Credentialed by State Board of NursingCNS 52% NP 97% Blended 87%

Title ProtectionCNS 29% NP 34% Blended 46%

State Board Regulation

Expanded Scope of Practice APRN License

CNS 35% NP 87% Blended 81%

Prescriptive AuthorityCNS 13% NP 91% Blended 73%

Required by State Board of Nursing to Hold Certification

CNS 40% NP 82% Blended 80%

State Board RegulationCertification Used by CNS

Oncology (AOCN®) 16%Adult or Medical Surgical CNS 10%Oncology (AOCNS®) 7%Pediatric CNS 1%Other 6%

State Board RegulationCertification Used by NP

Adult (Primary and/or Acute) NP 38%Family NP 27%Oncology (AOCNP®) 5%Oncology (AOCN®) 4%Women’s Health NP 2%Pediatric NP 1%Gerontological NP 2%Other 3%

State Board RegulationCertification Used by Blended Role

AOCN® 27%Adult NP 26%Family NP 10%Adult or Medical-Surgical CNS 10%AOCNS® 5%AOCNP® 4%

Cyndi Miller Murphy, RN MSN CAEExecutive Director

Oncology Nursing Certification Corporation

Consensus Model for APRN Regulation: Licensure,

Accreditation, Certification and Education

Currently there is no uniform model of APRN regulation across states. Each state independently determines:

• APRN legal scope of practice• Roles that are recognized• Criteria for entry into advanced practice• Certification examinations accepted for

entry-level competence assessment

Issue

This lack of uniformity has created a significant barrier for APRNs to move from state to state and has limited access to care for patients.

Issue

An invitation to participate in the process was sent to 50 organizations with a stake in advanced practice nursing

Development of APRN Consensus Work Group

2004

32 organizations (including ONS and ONCC) convened in June to initiate a discussion of issues related to APRN definition, specialization, subspecialization, education, certification and licensure.


2004

Based on recommendations generated at the June conference, a smaller work group of designees of 23 organizations with broad representation from APRN certification, licensure, education, accreditation and practice was formed.


2004


2004

The group was charged with developing a statement that addresses the issues delineated during the Conference with the goal of envisioning a future model for APRNs

• Strive for harmony and common understanding in the APRN regulatory community that would continue to promote quality APRN education and practice

• Develop a vision for APRN regulation, including education, certification, licensure

Goals of APRN Consensus Process

• Establish a set of standards that protect the public, improve mobility, and improve access to safe, quality APRN care

• Produce a written statement that reflects consensus on APRN regulatory issues

Goals of APRN Consensus Process

October 2004 – April 2008• Sixteen days of in-person intensive

discussion and multiple conference calls

December 2005• ANA convened a meeting of the

broad stakeholder group

APRN Consensus Work Group

April 2006• APRN Consensus Work Group met

with NCSBN APRN Advisory Panel to discuss the NCSBN Vision Paper and to request feedback from NCSBN on the Consensus Group draft paper

APRN Consensus Work Group

January 2007• Representatives from the APRN

Consensus Work Group met with representatives from the NCSBN APRN Advisory Panel with the goal of assuring that the revised Vision Paper and the final paper from the Consensus Group would not conflict, but rather complement one another.

APRN Joint Dialogue Group

As the two groups continued to meet in joint dialogue, much progress was made regarding areas of agreement and it was determined that one joint paper would be developed which reflects the work of both groups.


Sixteen months after the Joint Dialogue Group was formed, the draft paper was released to the boards of the stakeholders groups.


• Licensure – granting of authority to practice• Accreditation – formal review and approval by

a recognized agency of education degree programs or certification programs

• Certification – formal recognition of knowledge, skills and experience demonstrated by the achievement of standards identified by the profession

• Education – formal preparation of APRNs in graduate degree – granting or post-graduate certificate programs

APRN Regulatory Model: LACE

• Completed accredited graduate level education program in one of four roles of CRNA, CNM, CNS, CNP

• Passed national certification that measures APRN role and population-based competencies

• Acquired advanced clinical knowledge and skills to provide direct care to patients (Defining factor for all APRNs is that significant component of education and practice focuses on the direct care of individuals)

Definition of APRN

• Practice builds on RN competencies with – Greater depth/breadth of

knowledge– Greater synthesis of data– Increased complexity of skills

and interventions– Greater role autonomy

Definition of APRN

• Educationally prepared to assume responsibility/accountability for:– Health promotion/ maintenance– Assessment, diagnosis, management

of patient problems– Use and prescription of

pharmacologic and nonpharmacologic interventions

Definition of APRN

• Clinical experience with sufficient depth and breadth

• Licensed as independent practitioner to practice as APRN in role of CRNA, CNM, CNS or CNP

Definition of APRN

• APRN required to be used

• Role and population included

• Specialty title may be used

APRN Titles

For entry into practice and regulatory purposes APRN education must:

• Be through a formal graduate or post-graduate accredited institution

• Comprehensive, at graduate level• Prepare graduates to practice as CRNA,

CNM, CNS or CNP across at least one population foci (neonatal, pediatric, adult, gender-specific or psych-mental health)

Broad-based APRN Education

For entry into practice and regulatory purposes APRN education must:

Include at least three separate comprehensive graduate-level courses:

• Advanced physiology/pathophysiology• Advanced health assessment• Advanced pharmacology


May also include preparation in a specialty area of practice, but it must build upon the APRN role and population – focus competencies.


– Build upon role and population-focused competencies

– Represent a focused area of practice• Specific population subset• Specific patient needs

– Disease states– Body system

– Developed, recognized, monitored by the profession (not regulatory agencies)

APRN Specialties

• Preparation cannot replace role/population focused education• Cross over roles and populations• Title may not be used in lieu of

licensing title which include role and population• Competencies must be assessed

separately from role and population competencies

APRN Specialty

New roles or populations that include a unique or significantly differentiated set of competencies from the current roles and populations may evolve over time. To be recognized criteria must be met:

• Education standards, core competencies• Accredited graduate, post-graduate

educational programs• Certification program that meets

accreditation standards

Emergence of APRN Roles and Populations

Specific Criteria for each prong of regulation

LicensureAccreditationCertification

Education

Target date: December 31, 2015

Strategies for Implementation

Grandfathering When states adopt new eligibility

requirements for APRNs, currently practicing APRNs will be permitted to continue practicing within the states(s) of their current licensure. If APRN applies for endorsement by another state, they will need to meet new criteria OR criteria in place when they became licensed.

Strategies for Implementation

The ONS and ONCC Boards of Directors have approved the

concepts in the Consensus Model for

APRN Regulation.

Draft of the complete paper Consensus Model for APRN

Regulation: Licensure, Accreditation, Certification and

EducationCan be found on the ONS website

athttp://www.ons.org/clinical/professional/QualityCancer/

issues.shtml

http://www.ons.org/clinical/professional/QualityCancer/issues.shtml



Slide show used to present the model to representatives of

stakeholder groups on April 14, 2008 can be found at:

http://www.aacn.nche.edu/education/apnpresentations.htm



Barbara B. Rogers CRNP MN AOCN® ANP-BCFox Chase Cancer Center

Past chair, ONCC Advanced Practice Test Development Committee

Implications of the New Model for Oncology APRNs

Goals of the Consensus Model• Standardization in educational

programs• Enhanced mobility of APRNs due

to consistency in licensure requirements• Uniformity in independent APRN

practice • Greater access to APRN care for

patients

Challenges for EducationPrograms must ensure: Students attain APRN core, role

and population competenciesInclusion the three “Ps”Graduates are eligible for

certification in the role/population focus

Transcripts specify role/population focus

Challenges for Education

Adult and Family CNS and NP programs will need to incorporate comprehensive gerontology content into adult program curriculums

Oncology- Specific Challenges for Education

Integration of specialty content, along with the core and population content will lengthen didactic and clinical requirements

Graduates not required to have specialty competencies

Oncology -Specific Opportunities for Education

Specialty competencies do not have to be obtained within the formal graduate program

Development of post-graduate programsDevelopment of comprehensive

continuing education by ONS to provide APRN competencies

Acquired through professional practice

Challenges for Licensure

State boards of nursing will:

License only at the role and population level

Grant licenses for all four roles of CNS, NP, NM, NA

Challenges for Licensure

State boards of nursing will need to:

Revise rules and regulations for APRN licensure

Grandfather all who currently are recognized to practice in a specific role

Opportunities for Licensure

APRN regulation exclusively by boards of nursing

Standardization of criteria for licensure

Implementation of APRN interstate compact

Challenges for Certification

Population-based certifications for CNS will need to be developed for all six population foci

Specialty competencies will be assessed separately from the role and population competencies

Oncology- Specific Challenges for Certification

Need to demonstrate the value of specialty certification

Oncology APRNs must be encouraged to attain and demonstrate specialty competencies

Employers must be encouraged to require certification for specialty practice

Oncology-Specific Opportunities for Certification

Not required for regulatory purposes

Eligibility criteria not dictated by state boards of nursing

Educational criteria, other than that obtained within the graduate program, can be required

Challenges for Oncology APRNs

Those who currently meet regulatory criteria, will be grandfathered within the same state, but may need to meet new criteria in a new state

Challenges for Oncology APRNs

In states where regulation does not currently exist (e.g. for CNS), grandfathering will occur for those in practice, or APRNs will need to meet the new criteria for licensureEducationCertification

Discussion of State-Specific Examples

Current model and regulations

Changes that will need to be implemented

How oncology APRNs will be affected

Documents

May 16, 2008