Policy Paper On Consensus Model For APRN Regulation: Licensure, Accreditation, Certification, And Education

POLICY PAPER ON CONSENSUS MODEL FOR APRN 24

Policy Paper on Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education

Amy Higgins, Stephanie Kimbrel, and Diane Morris

Washburn University

POLICY PAPER ON CONSENSUS MODEL FOR APRN 24

POLICY PAPER ON CONSENSUS MODEL FOR APRN 24

Policy Paper on Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education

Problem Identification

Advanced Practice Registered Nurses (APRNs) have been practicing in various capacities for years; however, a consensus on the components involved in the regulation of APRNs has been argued for some time. Disagreements on uniform state regulations are limiting the accessibility of the high quality, cost-effective care APRNs can provide. Much of the debate involved in defining the APRN profession has involved credentialing, education, scope of practice, and the actual title of APRNs. The evolving landscape of healthcare and patient demographics give APRNs the opportunity to assume a more prominent role in the delivery of care and prove the impact of APRN care on patient outcomes (Stanley, 2009). Currently, there is a lack of uniformity across states in defining the APRN role, including advanced practice education, licensing, and credentialing requirements.

Background

The APRN role has been in existence since the 1940s (Rose & Regan-Kubinski, 2010). Early APRN roles were not clearly defined or regulated. In the early 1990s, official certification examinations were beginning to be utilized by state boards of nursing, as a requirement for APRN licensure. The first position statement was written in 1993. It identified the need for certifications as a piece of the regulation for advanced nursing practice (Rose & Regan-Kubinski, 2010). Prior to that time, an APRN may simply have meant a nurse who was very experienced and skilled in her area of practice, without regard to specific education, licensure or certification. After the publication of this position statement, increased attention was directed at the structure and accreditation of APRN educational programs. A second position statement was published in 2002, which detailed several regulatory concerns regarding the APRN certification examination. March 2004 brought about the convention of a group called The Alliance for APRN Credentialing, which was comprised of 14 organizations who discussed a consensus process to address the issues related to advanced practice education and credentialing. A smaller group was then put in charge of developing the future model for APRN regulation. This Alliance APRN Consensus Work Group met routinely from 2004 to 2008. In 2007, this group joined efforts with the NCSBN APRN Advisory Committee to produce complementary recommendations that would together guide future regulation, thus giving rise to the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (LACE) (Stanley, 2009). Their goal is to have this model fully implemented by 2015 (ANA, 2008).

The LACE Consensus Model recognizes four APRN roles: certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), certified nurse-midwife (CNM), and certified nurse practitioner (CNP) (ANA, 2008). The model also states that all APRNs will be educated in one of these four roles, in addition to at least one of six population foci: family, adult-gerontology, pediatrics, neonatal, women’s health, or mental health (Stanley, 2009). Education for APRNs will consist of completion of a graduate-level program in one of the four roles with successful passage of a national certification exam. The LACE model further outlines the requirement of every APRN graduate program to have core courses in comprehensive pathophysiology, health assessment, and pharmacology. The educational programs will also include appropriate clinical and didactic experiences. The LACE model now sets forth more specific guidelines for graduate programs and requires that these programs be knowledgeable of the various states’ regulations regarding the practice of APRNs (Chornick, 2008).

All education programs must now be accredited, according to the LACE model. Accreditation of educational organizations is a voluntary, self-regulating, nongovernmental process which assures a basic level of education (Chornick, 2008). The Commission of Collegiate Nursing Education and the National League for Nursing Accreditation are the only two accrediting groups responsible for this process.

Whereas accreditation applies to an organization, licensure applies to an individual. Licensure is the granting of authority to practice (ANA, 2008). Each APRN graduate must meet individual state licensure eligibility (Chornick, 2008). APRNs will be licensed as independent practitioners who are able to practice in one of the four previously discussed APRN roles within at least one of the six population foci. An APRN may then specialize in more focused areas within his/her population focus but can no longer be educated, certified, and licensed solely within that more narrow scope of practice (Stanley, 2009).

Ethical Factors

From an ethical standpoint, it is important for the public to trust that any APRN providing care is educated, certified, and licensed within his/her scope of practice. This will ensure patients that they are receiving safe and equitable care from providers with the title of APRN. Creating and implementing a timely consensus for APRNs is critical to assure the public about the consistency and quality of their healthcare providers (Yoder-Wise, 2010).

Political and Legal Factors

Politically, APRNs need an effective consensus model to more clearly define the profession and to move forward in healthcare as a united front with agreement on the regulations of the profession across all 50 states. As health care reform begins to change the delivery of care to individuals in our country, the APRN profession needs to be ready to speak as a unified voice about what care APRNs can contribute and why the professional development plan is essential (Yoder-Wise, 2010).

From a legal perspective, a consensus model is required to outline the scope of practice for each of the four APRN roles. As the APRN profession attempts to maximize the existing scope of practice, there is potential to do so by expanding: amendments to state nurse practice acts, judicial decisions, and federal enactments (Watson & Hillman, 2010).

Further, agreement among states is needed to align the prescriptive authority of APRNs. Currently, APRNs have some degree of prescriptive authority in all 50 states; however, these varying degrees of authority cause much confusion among consumers. Legislative changes are needed to expand APRN prescription privileges in all states to include:

· Authority to prescribe without physician involvement

· Authority to prescribe with physician collaboration

· Written protocol required to prescribe

· Authority to prescribe controlled substances (Watson & Hillman, 2010)

A consensus regarding prescriptive authority is needed to bring uniformity in scope of practice and alleviate confusion among healthcare consumers.

Additional liability issues that exist for APRNs include:

· Unlicensed practice of medicine

· Failure to adequately diagnose

· Negligence in the delivery of healthcare

· Conduct exceeding physician-delegated authority—resulting in harm

· Conduct exceeding scope of practice –resulting in harm

· Failure to refer appropriately (Guido, 2010).

Essentially, APRNs have dual legal liability including nurse adherence to the state nurse practice act and the APRN’s requirement to national specialty certification and/or secondary licensure requirement. If APRNs continue to expand practice roles, there will likely be an increase in the APRNs level of accountability and liability (Watson & Hillman, 2010).

Issue Statement

How can the LACE model be expeditiously implemented in all states to ensure that the APRN profession continues to grow and meet the demands of changing healthcare, while increasing the APRN scope of practice and assuring that licensure, accreditation, certification, and education are uniform across all 50 states?

Stakeholders

There are a variety of stakeholders with regard to the LACE consensus model. The most obvious stakeholder is the APRN, both existing and newly graduating. Existing APRNs have a definite stake in the implementation of the consensus model and a grandfather clause does allow for any APRN who is already practicing to continue to do so in the state he/she is currently licensed (ANA, 2008). Once the LACE model is fully implemented, it will allow APRNs to move from one state to another and be able to obtain licensure, if certain criteria are met.

Individual states and state legislatures represent another group of stakeholders. In order for the LACE model to promote uniformity among APRN regulation, states must meet the new Uniform APRN Requirements in order to enter into the APRN compact which will facilitate interstate APRN practice (Chornick, 2008). To achieve the expectations of the consensus model, every state must agree to the same terms, definitions, and conditions outlined in the LACE document (Yoder-Wise, 2010).

As mentioned earlier, the consumers or “patients” are certainly a stakeholder in the LACE consensus model. Assuring the public consumers that the quality and consistency of care they receive from an APRN is essential and makes consumers a definite stakeholder (Yoder-Wise, 2010). The American Association of Retired Persons (AARP) in Hawaii commented that consumers of all ages need access to primary care and chronic care management, so that people with diabetes, hypertension, and other chronic ailments can lead productive and health lives. They also stated that APRNs should be able to practice to their full extent and be reimbursed for the care they provide to help fill the gap in primary care (Mathews et al . , 2010).

Nursing education programs have a pronounced role as stakeholders with regard to the LACE consensus model. Once implemented, the LACE model will require all APRN education programs be accredited to ensure that each program meets the minimum curriculum guidelines, as well as clinical and didactic experiences. Graduate nursing programs will need to re-visit their current curriculum to meet these new standards and be more abreast of the various states regulations, until interstate uniformity is reached (Chornick, 2008).

Policy Objectives

The policy objectives for the LACE model are aimed at creating uniformity among the states with regard to APRN licensure, accreditation, certification, and education. While there is much debate about how to carry out this policy change, several steps need to be taken to achieve this goal:

· Nurses should practice to the full extent of education and training.

· Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

· Nurses should be full partners, with physicians and other health care professionals

· Effective nursing workforce planning and policy making require better data collection and improved information structure (Oleck et al., 2011).

While these objectives are not exclusive for APRNs, they most certainly apply to the LACE consensus model’s objectives for reaching uniformity for the profession.

Policy Alternatives

One possible policy alternative would be to follow the recommendation of The American Association of Colleges of Nursing (AACN) for all master’s level APRN programs to be changed to doctorate of nursing practice (DNP) by 2015 (Watson & Hillman, 2010). This recommendation is not included in the LACE consensus model. Implementation of this alternative would have a huge impact on existing APRN educational programs both organizationally and financially.

Another policy alternative includes the specialists’ model which has been criticized as being restrictive in its focus, uneconomical and at variance with the World Health Organization whom advocates for the preparation of general nurses (Fealy et al., 2009). In restricting registrants to a specialized area, it decreases workplace mobility. Despite this, there have been calls to return to specialists’ model because the generic comprehensive model does not prepare APRNs in some specialty areas. The generic model prepares graduates with a more broad and comprehensive knowledge base. The generic model assumes that a generalist practitioner can assess the needs of all patients, regardless of age and healthcare setting. Graduates are prepared with beginner-practitioner competencies that can differentiate, integrate, and generalize from knowledge gained. It also presupposes that branching into specialists’ area will occur after initial registration (Fealy et al., 2009).

Evaluation Criteria

The criteria for evaluation of a policy alternative includes: the likelihood of ongoing funding, size and availability of funding stream, ability to meet current and future demands, and political feasibility.

Analysis for Option 1- Do Nothing

Criterion 1: Likelihood of Ongoing Funding

Pro: With health care reform and the need for accessible healthcare providers money is being poured into primary care education including increasing the number of APRN’s. The Patient Protection and Affordable Care Act has allotted $200 million program to educate more APRN’s in primary, preventive, and chronic care management (Carlson, 2010). This is an addition other federal funding by the government such as: Title VII, Title VIII, and Medicare education funding.

Con : The United States Health Care system is failing. Healthcare costs continue to rise without the ability of the American people or government to afford these changes. The increasing costs will continue to bring close examination of government spending and needed healthcare system changes. If changes are not made to increase the accessibility of ARNP care, then funds could be diverted from graduate nursing education to other means of providing primary care and prevention.

Criterion 2: Size and Availability of Funding Stream

Pro : The Title VIII Nursing Workforce Development programs administered by the Health Resources and Services Administration (HRSA) are the primary source of Federal funding for nursing education. They include major grants such as the Advanced Nursing Education Grants which provide nursing schools, academic health centers, and other entities funds to enhance education and practice for masters and post-masters nursing programs (American Nurses Association, 2011). According to the FY 2011 Appropriations: Senat e (see Appendix B), funding for nursing education, retention and workforce has greatly increased from $137,000 to $64,438 million, under Title VIII Advanced Education Nursing grant (Nursing, 2010).

Con : Difficulty exists in fully examining the amount of monies allotted to nursing education. However, the majority of these funds are discretionary. In negotiations for FY 2011 Continuing Resolution (CR) H.R. , the House opted to cut the Nursing Workforce Development Programs and Health Professions Programs by $145.1 million, which represents a decrease of 29% in the funding over the FY 2010 (American Nurses Association, 2011).

Criterion 3: Ability to Meet Current and Future Demand

Pro : The great need for primary care providers is evident. It is apparent that APRN’s can help to fill this hole. There are 50 million uninsured Americans (AlterNet, 2011) that will have health insurance after the Health Care Reform Act is implemented. As the number of insured individuals rises, there will be an even larger shortage of providers. A solution to this problem is APRN’s.