1. Apple, Kathy MS, RN

Article Content

Dear Editor


The National Council of State Boards of Nursing (NCSBN) has been the focus of several articles and letters to the editor in past issues of the Clinical Nurse Specialist: The Journal for Advanced Nursing Practice. During a meeting in September of NACNS and NCSBN, you invited NCSBN to respond. We appreciate your offer.


On the basis of the unique aspects to the regulation of advanced practice nursing, I would like to identify what we consider to be the major clinical nurse specialist CNS regulatory issues and the corresponding NCSBN position:


* CNS practice is within the domain authorized by state-regulated initial registered nurse (RN) licensure. A second license should not be required.NCSBN Perspective: NCSBN's mission is public safety. We would have no public safety concerns if the CNSs practiced within the scope of practice of their RN license and did not practice in the expanded role of the advanced practice registered nurse (APRN) such as including prescriptive authority and making medical diagnoses without fulfilling the requirements for APRN practice.


* CNSs have a unique scope of practice.NCSBN Perspective: NACNS describes CNS practice as targeting 3 spheres of influence: patients, nurses and nursing personnel, and organizations/systems. As described by NACNS, it appears CNSs have the scope of practice of a RN.


* A master's degree should be the required academic preparation required to practice as a CNS.NCSBN Perspective: Using the NACNS Statement on Clinical Nurse Specialist Practice and Education, core areas of knowledge including nursing therapeutics, evaluation methodologies, systems thinking would be consistent with a masters-level education.


* The CNS should have a separate title with title protection.NCSBN Perspective: Based on the assumption that the CNSs would practice under their RN license, and have a unique scope of practice, title protection would be an appropriate level of regulation.


* There are not an adequate number of certification examinations for CNSs.NCSBN Perspective: If a CNS is practicing within the scope of the RN license, a more rigorous type of regulation, including a certification examination, is not warranted. In other words, a CNS would not need to take a certification examination to practice if that individual is practicing as an RN.APRNs practicing in an advanced scope of practice beyond that of the RN must meet more stringent education and regulatory criteria. If the CNS is practicing as an APRN, he/she should be required to take an APRN certification examination. Currently there are APRN certification examinations for CNSs in the following areas:


* Adult Psych/Mental Health Going Across Lifespan CNS


* Child/Adolescent Psych and Mental Health CNS


* Community Health CNS


* Gerontological CNS


* Home Health CNS


* Medical-Surgical CNS


* Pediatric CNS


* Adult Critical Care CNS


* Pediatric Critical Care CNS


* Neonatal Critical Care CNSNACNS has referred to the need for more certification examinations to cover 40 specialty areas of CNS practice. NCSBN's Advanced Practice Task Force purports the use of broad-based examinations, such as medical-surgical, psychiatric, etc, for public safety. A broad preparation gives the APRN a basis on which to recognize a range of commonly occurring health problems and to practice safely. Narrow specialty areas of practice are not appropriate as a basis for an APRN. APRNs certified in a subspecialty have a narrow scope of practice. This becomes problematic when the narrowly prepared advanced practitioner treats clients with a variety of health disorders and faces the pressures of going beyond his/her scope of practice. A recent article in the Clear Exam Review (Summer 2003) by Dale J. Atkinson cautions regulatory boards not to rely on specialty examination as opposed to those of a generalist nature.


* The CNS should have an alternative mechanism to examinations, such as portfolios, for those specialties that do not have certification examinations.NCSBN Perspective: If a CNS is practicing under an RN license, there is no need to require a certification examination. Therefore, to provide an alternative mechanism for a specialty in which there is no examinations is not needed. If CNSs are practicing as APRNs, there are an adequate number of APRN certification examinations to cover most broad specialty areas.Historically, an alternative mechanism was included in the APRN Uniform Core Requirements that were approved at the 2000 Delegate Assembly. This option was put into the APRN Uniform Core Requirements to ensure that a growing portion of the nursing profession was not restricted prematurely. However, after the APRN Uniform Core Requirements were approved, there were rapid changes in the field of advanced practice nursing. Most valid APRN specialty areas developed a certification program through examination and educational programs began developing new subspecialty programs. The proliferation of these subspecialties led to great concern among nurse regulators based on issues of how to regulate subspecialty advanced practice nurses within their narrow scope of practice. In addition, a survey of boards of nursing revealed that the alternative mechanism was being used only by 7 boards. Nurse regulators also had concerns regarding the low numbers of candidates taking these subspecialty examinations. Because of the low number of candidates, the validity and reliability of these examinations are difficult to substantiate and, therefore, they may not be psychometrically sound. At the 2002 Delegate Assembly, the delegates voted to remove the alternative mechanism option from the APRN Uniform Core Requirements.


* The CNS should have prescriptive authority if wanted.NCSBN Perspective: Prescriptive authority is part of the APRN scope of practice. It is not part of the RN scope of practice. The CNS would have to meet the requirements for legal recognition as an APRN. According to NCSBN's Criteria for APRN Certification Programs, prescriptive authority should be granted only upon completion of substantial pharmaco-therapeutic course work and clinical supervision of prescribing in the master's program. If prescriptive authority requirements are met after program completion, a preceptorship/specific clinical hours, continuing education, or clinical supervision component should be added.


* The CNS should have third-party reimbursement.NCSBN Perspective: This is not a regulatory issue.


* The practice preference of CNSs is to practice for the most part under their RN license.NCSBN Perspective: Many boards of nursing have reported that most CNSs in their jurisdictions want to practice in the advanced practitioner role including independent practice, medical diagnosing, and prescriptive authority. According to data collected by NCSBN in 2002, 32 states grant some level of prescriptive authority to CNSs. However, NACNS states that their membership wants to practice in the more traditional CNS role. Membership of NACNS consists of approximately 2000 CNSs and, according to NACNS, there are 60,000 practicing CNSs. This leaves a large number of CNSs without a voice in terms of their practice preferences. Data are lacking at this time to determine the actual practice preferences of CNSs.


* There is no evidence over the past 50 years of public safety issues regarding CNS specialty nursing services.NCSBN Perspective: APRNs have similar public safety issues as licensed practice nurses (LPNs) and RNs. Results of a study conducted by the NCSBN through the Commitment of Public Protection Through Excellence in Nursing Regulation project indicated that the rates for all of the discipline-related variables such as "nurses disciplined in past 3 years," "nurses disciplined during 2000," "licensees with new complaints during 2000," and "previously disciplined nurses who were disciplined during 2000" were similar across LPN, RN, and APRN groups including CNSs. Moreover, the independent practice of APRNs makes public safety issues even more important than for LPNs and RNs.


* The requirement to obtain a second license and to be certified by examination as a CNS adversely affects the majority of CNSs who practice within the domains authorized by the RN license. The vast majority of CNSs will never be able to obtain certification in their specialty area.NCSBN Perspective: If CNSs do not desire to practice in the role of the advanced practice nurse, there would not be a need for CNSs to take an APRN certification examination. A CNS acting in this capacity would be practicing within the scope of the RN license. However, for those nurses practicing in the advanced practice nurse role, board-based examinations such as medical-surgical, psychiatric, etc, are necessary to ensure that the APRN has the necessary broad preparation to recognize a range of commonly occurring health problems and to practice safely.


* NCSBN has undue and inappropriate control over state regulatory processes.



NCSBN Perspective: NCSBN has no control whatsoever over state regulatory processes. NCSBN is the forum for its members, state boards of nursing, to dialogue and counsel with each other. NCSBN is not a regulatory authority and supports the autonomy of its 60 member boards as independent state and territorial regulators of nursing practice. Boards of nursing, through individuals acting in the capacity of NCSBN committee members, board of directors, and voting delegates, control the direction of the work of the NCSBN.


The NCSBN has an APRN Task Force, consisting of APRN regulators, advanced practice nurses, and educators, that reviews and makes recommendations regarding APRN issues to the Board of Directors. They are committed to promoting communication between APRN regulators and other APRN stakeholders and hold an annual APRN Roundtable for APRN stakeholders to discuss issues of common concern. They are always open to discussion regarding APRN issues.


There are many areas in which professional nursing groups and regulation agree. For instance, both want what is best for the patient and have concerns regarding public safety. However, differences between professional nursing groups and nursing regulation do exist. The NCSBN recognizes these differences and is committed to working together with willing organizations to try to find creative solutions to some very difficult situations. We were very encouraged during a recent American Board of Nursing Specialty meeting when APRN certification groups and regulation met to discuss the issues, accept that there were differences, and then started to explore win-win solutions.


Thank you for this opportunity to provide your readers with NCSBN's viewpoint. If any of your readers have comments or questions, please direct them to Nancy Chornick, PhD, RN, CAE, Director of Credentialing and staff to the APRN Task Force at the National Council.