LINKING the terms innovation and regulation seems to be an oxymoron. In volume 1, number 1, of the American Journal of Nursing, published in October 1900, Sophia Palmer, the first editor and later the first president of the New York Board of Nurse Examiners, called for laws to regulate nursing practice in all states. Beginning with North Carolina in 1903, the movement to establish regulatory boards of nursing progressed legislatively throughout the states, and for almost 80 years not much changed in the world of nursing regulation.
Regulation worked hand-in-hand with the states' professional graduate nurse associations, which controlled work hours and salaries and surveyed schools of nursing. Probably the greatest initial contribution of regulation was establishing statewide and national inventories of nurses who had graduated from recognized training programs. These regulatory boards also stopped women who had no training, but held themselves out to be nurses. When a nurse graduated, she notified the association and was placed on the register of graduate nurses, thus becoming a "registered nurse (RN)." Licensing examinations were inconsistent, and oftentimes, graduation alone from a training program was sufficient to demonstrate competency.
There were innovations in nursing education with the establishment of bachelor's and master's degree nursing education, the Cadet Nursing Corp during World War II, and the introduction of associate degree programs that proliferated after 1950. Regulation responded by recognizing and licensing graduates from these programs.
By 1978, the American Nurses Association (ANA) was increasingly involved with the economic and general welfare concerns of nurses. Regulators, who comprised the ANA Council of State Boards of Nursing, became increasingly conflicted because regulation's role was public protection, yet the professional organization was focused on benefits and protections for the membership. Confronting this conflict of interest was painful and challenging because regulators knew that they needed to change the relationship with the ANA. This transformation resulted in establishing the National Council of State Boards of Nursing in 1978.
Major innovations in regulation are slow to be operationalized. Much of this is due to the legislative process and the guidelines established by individual states' administrative procedures acts that outline processes for change. Most procedure acts require office notification of intent to propose a change, promulgate proposed rule changes, public hearings, revisions, legislative hearings, and, if approved, lengthy timelines for implementation. In spite of the complexities of the regulatory process, during the last 30 years many innovations in nursing regulation occurred that benefited the public, enhanced access to nursing care, supported the profession, and established benchmarks in research and excellence that are used globally.
Out of the many innovations, 4 are prominent and impact the general population of nurses.
1. The National Council Licensure Examination was introduced in 1980 to replace the 5-test state board test pool examination administered through the National League for Nursing. This examination continually undergoes rigorous psychometric testing and item analysis to ensure it is evidence based and legally defensible. Examination administration migrated to computer-based testing and is available on a continual basis at multiple test sites nationally and internationally. The examination utilizes computerized adaptive testing techniques. This means the computer asks high-ability persons very few easy questions and low-ability persons very few hard questions. The minimum number of RN questions is 75 and the maximum is 265, to be completed within 6 hours. The practical nurse (PN) test has a minimum of 85 questions and a maximum of 205 questions, to be completed in 5 hours. The sophistication of the examination has allowed the passing score to be increased over the years. In 2007, the overall pass rate for US-educated first-time candidates was 85.5% (RN) and 87.3% (PN) for the practical nurse scores.
2. The Nurse Licensure Compact (NLC) is an agreement between participating states to mutually recognize RN and licensed practical nurses licenses issued by the declared state of residence and to grant the privilege to practice in other compact member states without requiring that the nurse hold additional licenses in those party states. Currently, 23 states, 39% of state boards, participate in the NLC.
3. NURSYS is the centralized electronic database managed by the National Council of State Boards of Nursing that is used for disciplinary action reporting and licensure verification as well as disciplinary information authorized through the NLC. Currently, 35 state boards contribute information to the NURSYS database on a daily or weekly basis. Upgrades over the years include reporting actions against NLC privilege, multistate license tracking, and reporting adverse actions taken against providers to the National Practitioner Data Bank and the Health Integrity and Protection Data Bank. Recently, a Fraud and Imposter Tracking System was implemented. The Fraud and Imposter Tracking System provides states with information on individuals suspected of licensure and practice fraud as well as fraudulent domestic and international nursing educational programs.
4. Consensus model for advanced practice registered nurse regulation: licensure, accreditation, certification, and education demonstrates the collaborative efforts of representatives from all stakeholder groups. Developed as a response to NCBSN's 2004 Vision Paper, this document is one of nursing's best contemporary examples of a galvanized profession working together to achieve a common goal. While there was not 100% agreement with all components of the paper, and implementation of the content remains to be fully achieved, the endorsement by major nursing organizations on a national level moves us closer to understanding, acceptance, and implementation of this innovative advanced practice registered nurse regulatory model.
We look forward to ongoing collaborative efforts to provide more consistent regulation as nursing continues to transform itself to better meet the needs of people requiring care.