Is the licensure system for nursing harming the profession?

  1. Licensure system could use an overhaul
    Stronger link between educational programs and practice roles could benefit the profession
    By Carolyn Williams, Ph.D., RN, FAAN
    (President, American Association of Colleges of Nursing since 6/2000)
    Nurseweek-July 31, 2001
    http://www.nurseweek.com/industrypulse/licensure.html

    Is the licensure system for nursing harming the profession? Serious consideration should be given to developing a new strategy that reflects both the differences inherent in the variety of entry-level educational programs and the expectations for practice upon graduation.

    Two interrelated features of licensure practice are particularly problematic. First, one licensure examination is not appropriate for graduates of all entry-level programs. Second, nursing must reconstruct the process for developing and administering the licensure examination.

    Today, graduates of all entry-level programs sit for the same examination, regardless of the type of program from which they graduate. This creates unintended negative consequences, confuses the public and potential students, and compromises the clinical development of the discipline.

    Through the years, there has been much debate about this practice, with those from baccalaureate programs arguing that the examination does not adequately reflect the scope of practice of the baccalaureate graduate. The rationale for the "one exam fits all" policy is that the state boards are charged with assuring that new graduates can perform safely and effectively as newly licensed RNs.

    Thus, all who use that title should demonstrate the same level of competency before licensure.

    Because the present approach to testing and licensure does not acknowledge differences in either educational preparation or the scope of practice, many administrators who hire nurses do not feel there is a basis for differentiating nursing roles or salaries.

    This lack of differentiation is in sharp contrast to the approach taken by other disciplines, such as physical therapy, which has physical therapy assistants, and engineering, which has technical engineers, both prepared at the associate degree level.

    Most importantly, the practice roles of the physical therapist and the engineer differ from those of their technical counterparts. In these fields, the differences in licensure are consistent with the level of educational preparation.

    Unfortunately for nursing, the lack of differentiation based on education and reinforced in many work settings serves to diminish the importance of education in clinical practice and is a major disincentive to associate degree- and diploma-prepared nurses to continue their education.

    What can be done about the licensure situation? One path is to focus on the scope of practice of the various types of nurses and connect the educational preparation and licensure process to the scope of practice.

    This would demand that those associated with AD and BSN programs and nursing service leaders come to grips with this issue and amend the examination and licensure process accordingly.

    Perhaps nursing should adopt a more sequential process with some parts of the examination offered at graduation and others after graduates transition into the full scope of their new role.

    It might make sense to have BSN and AD graduates take a part of the exam that is similar, but if the scope of practice is different, BSN graduates would be required to pass additional components that may address the science base and other facets of the broader scope.

    Nursing is at a crossroads in a highly complex health care environment. We know that we need nursing personnel at various levels; the question is how best to structure the educational preparation, the transition into practice, the practice roles and the licensure/certification processes to achieve the best outcomes for the public.

    In an effort to address the issues from the baccalaureate perspective, the American Association of Colleges of Nursing has formed a Task Force on Education and Regulation to define a more logical and coherent approach to linking education, practice roles and licensure.

    The task force believes that much more attention must be paid to how we prepare and manage entry into the field of nursing.

    Other groups are encouraged to engage this issue and work toward a more rational and effective approach to preparing and developing nurse clinicians.
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  2. 24 Comments

  3. by   MollyJ
    NRS Karen,
    I think the answer to this CLEARLY is, "Of course!"

    Now folks, please don't start a my school is better than your school thread here.

    There is a saying that you teach others how to treat yourself, and no where is that more clear than in nursing. Williams says this:

    "This lack of differentiation is in sharp contrast to the approach taken by other disciplines, such as physical therapy, which has physical therapy assistants, and engineering, which has technical engineers, both prepared at the associate degree level.

    Most importantly, the practice roles of the physical therapist and the engineer differ from those of their technical counterparts. In these fields, the differences in licensure are consistent with the level of educational preparation.

    Unfortunately for nursing, the lack of differentiation based on education and reinforced in many work settings serves to diminish the importance of education in clinical practice and is a major disincentive to associate degree- and diploma-prepared nurses to continue their education."

    This, people, is where we have shot ourselves in the foot. We've made the term "Registered Nurse" SO generic AND so confusing that it denotes NO leveled competencies. What do we say to the public and incoming students when we have three levels of prep (4 counting the mail order degrees)? We say, "This is the same body of knowledge and you can MASTER it through the mail OR in a 2 year setting or in 3 year setting or in a 4 year setting." [Please let me clarify: My objection to mail order degrees centers more on the mail order ADN than the BSN.]

    We've managed to kid ourselves about this issue for years now and if you are in doubt the read the bloody and angry, "My school's better 'n yours," posts that have proliferated on these pages.

    The quadruple levels of preparation denigrate the profession. Sadly, they are likely to for much longer INSPITE of eloquent editorials by the likes of Dr. Williams specificially because NURSES AND NURSE EDUCATORS THEMSELVES continue to delude themselve that they can promote the profession even as they blur it.

    Please understand that this post has nothing to do with a personal vendetta against any of the preparations (well, maybe, the mail order ADN) BUT it has everything to do with wanting to see nursing get acknowledged as the grand profession it is. That's not going to happen so long as NURSES themselves allow a quadruple approach to Registered Nursing preparation.
  4. by   live4today
    HERE IS A SOLUTION TO THE VARIOUS DEGREES, TRAINING, EXAMS TAKEN, LICENSES RECEIVED:

    IMHO:

    ALL NURSES SHOULD START AT THE ADN LEVEL TO ASSURE ADEQUATE AND DETAILED TRAINING IN THE CLINICAL AREA OF NURSING. ONCE THEY GRADUATE FROM THE ADN PROGRAM, THEY SHOULD TAKE THE STATE BOARDS, AND BECOME LICENSED PROFESSIONAL REGISTERED NURSES WHO WOULD BE AUTHORIZED TO PERFORM DIRECT PATIENT CARE IN ANY CLINICAL SETTING, BUT NEVER HOLD CHARGE OR MANAGEMENT LEVEL ASSIGNMENTS.

    IF AN RN/ADN WANTS TO ADVANCE TO MANAGEMENT LEVELS OF NURSING, OR DO COMMUNITY HEALTH NURSING, BECOME A SCHOOL NURSE, OR GO INTO NURSING RESEARCH, THE NEXT STEP MUST BE TAKEN WHICH SHOULD BE REFERRED TO AS THE "RN TO BSN LEVEL.

    FOLLOWING GRADUATION FROM THE BSN PROGRAM, EACH RN TO BSN STUDENT SHOULD TAKE A FINAL QUALIFYING "COLLEGE EXAM" IN THE AREA OF SPECIALTY NURSING THEY CHOSE TO PURSUE IN THE BEGINNING OF THEIR RN TO BSN PROGRAM OF STUDY. AT THIS LEVEL, NURSES SHOULD BE ALLOWED TO HOLD CHARGE POSITIONS OVER EACH SHIFT, BUT SHOULD NOT BE ALLOWED AS YET TO BE NURSE MANAGERS OR SUPERVISORS.


    AFTER THE RN/BSN PASSES THE COLLEGE EXAM, THEY SHOULD BE ISSUED THEIR CERTIFICATION IN THE AREA OF EXPERTISE THEY CHOSE TO PURSUE. NO NEED FOR SITTING FOR ANOTHER STATE BOARD AT THIS LEVEL OF CERTIFICATION. IF A TITLE IS PREFERRED BY THE NURSE AFTER HER NAME, IT COULD READ: RN/ADN/BSN-C [THE "C" STANDING FOR CERTIFIED].

    THEN, IF A THE RN/BSN DESIRES TO GO INTO A PRACTICUM SUCH AS MED STUDENTS OFTEN CHOOSE TO DO, (I.E. RESEARCH, OB/GYN SPECIALIST, NURSE PRACTITIONER, COLLEGE LEVEL NURSING EDUCATOR, ETC.), THE RN/BSN MUST COMPLETE A MASTER LEVEL PROGRAM FIRST.

    FOLLOWING COMPLETION OF THE MASTER LEVEL PROGRAM, THE NURSES SHOULD BE REQUIRED TO SIT FOR ANOTHER COLLEGE LEVEL EXAM IN ORDER TO RECEIVE THEIR MSN CERTIFICATION TO ASSURE EQUAL HEALTH CARE STANDING ACROSS THE 50 STATES. THESE MASTER LEVEL NURSES CAN NOW PRACTICE IN A CAPACITY EQUAL TO A PHYSICIAN ASSISTANT, OR A STEP DOWN FROM THE DOC HIMSELF (THESE MSNs SHOULD BE REQUIRED TO WORK UNDER A PHD NURSE).

    AT THE PHD LEVEL OF NURSING, THIS LEVEL WOULD BE FOR THOSE NURSES INTERESTED IN WRITING NURSING JOURNALS, MAKING LEGAL CHANGES IN NURSING LAWS FROM A LEGAL STANDPOINT, BEING HEAD OF THE ENTIRE NURSING STAFF AT A HOSPITAL, WORKING AS DOCTORATE LEVEL ADVANCED NURSE PRACTITIONERS WHO CAN OPEN THEIR OWN "HEALTHY PATIENT CLINICS" OR "MINOR HEALTHCARE CLINICS", AND TEACH MASTER DEGREE LEVEL NURSES AT THE UNIVERSITY.

    THIS LEVEL OF PROGRESSION FOR ALL NURSES WILL ASSURE PATIENTS AND THEIR FAMILY MEMBERS OF EQUAL CARE AND SKILL IN ALL NURSES WHO ARE ASSIGNED TO DIRECT PATIENT CARE. IT WILL ALSO ASSURE THAT EVERY NURSE WHO BECOMES A MANAGER IN NURSING WILL HAVE FIRST PAID HER DUES AS A CLINICAL (BEDSIDE) NURSE, HAVING OBTAINED THE VERY SAME TRAINING AS ALL OTHER DIRECT PATIENT CARE CLINICAL NURSES.

    WELL, DOES THIS SOUND LIKE A WORKABLE PLAN, NURSES???
    Last edit by live4today on Feb 18, '02
  5. by   MollyJ
    Renee,
    I think your pathway makes a fine plan for an individual but is short sighted as prescription for the entire profession.

    A corrollary of this thinking would be that all psychologists (Phd's) must start as Mental health techs and all docs must start as Orderlies or EMT's.

    The professional approach to PT ed means there is mobility for PT Assistants BUT that a person may enter the field as a Master's prepared PT--the educational preparation stands alone.

    Thanks for the throughtful reply.
  6. by   live4today
    Not a bad idea, Molly!
  7. by   JillR
    I personally have no problem with your plan Renee, but this would effectively shut down the community hospital I work at. The DON has a MSN, one supervisor has her BSN, the others are ADN, all of the clinical directors are ADN and the clincal director for outpatient services is an LPN. If something like this went into effect it would disinigrate rural community hospitals. The idea is a good one but not realistic. Something like this would only serve to make the nursing shortage worse, at least in my area.

    I can't imagine what it would be like for an ambulance to take someone, not only 25 minutes to get to the hospital, but now 1-2 hours. Would you like that kind of health care for your family just because the hospital could not recruit BSN's for managerial positions. Makes no sense to me.

    Molly makes good points. While we are at it, lets make all nurses start at nursing assistant, then LPN ect.
  8. by   live4today
    Hi Jill,

    The plan that I proposed would only be implemented with those entering the nursing field as of year _______(to be determined by a governing body). It would quite naturally NOT be implemented by kicking other nurses working in the current system to the curb, so to speak.

    Just like the "grandfather clause" would protect all RNs if the minimum educational requirement for RNs were to change to BSN, the same clause would encapsulate those who are already nurses, and as those nurses retire or move on, a gradual implementation of my proposed plan would take effect.

    I guess I should have clarified that in my above post, that way you and Molly would not have come to the conclusion that I meant "Right Now"! NO, it would not work in the current way that nursing is managed, but it would be great for long term planning of how to restructure the future of nursing.

    Any plan worth implementing is worth waiting for if the plan is enacted in a professionally sound manner in a due course of time.

    _____________________________________________

    "Just when you think you've graduated from the school of experience, someone thinks up a new course."-- Mary H. Waldrip
    Last edit by live4today on Feb 22, '02
  9. by   NurseExplorer
    I agree it doesn't make sense to have multiple entries to RN. I hope this task force can come up with some licensure system that acknowledges the different pathways. Then maybe RN salaries will reflect the differences in education.
  10. by   JillR
    Renee,

    Thanks for clarifying. Just for the record, I was not trying to be confrontational here, just looking at the realities of rural community hospitals. As far as a can figure, we have two BSN's in the facility and the one that is not a supervisor was offered a position as one and turned it down. The majorty of RN's are ADN, with a couple of Diploma RN's in the mix. We just don't have an awful lot to choose from and it does not look like things will change soon. We have had one supervisor opening since July 2001 and lets just say we don't have anyone breaking down the door for the position from any diploma/degree status. No one in the facility wants the position.
  11. by   RoaminHankRN
    I have read similar posts here an I still find it hard to believe no on suggests CEU's be mandated in every state for RN's actively practicing. Don't MD's and EMT-P have to maintain similar requirements. Kind of sad, here in Illinois, as long as my check clears every two years, I get a license to practice. What is it 40 hours you must maintain every 4 years to recertify for TNS? You can't tell me you remember everything from nursing school even one year out let alone five or ten.
  12. by   live4today
    YOU ARE SO RIGHT, ROAMINHANKRN! MANY STATES DO MANDATE THAT CEUs BE TAKEN EACH LICENSE RENEWAL PERIOD, ONLY A FEW DO NOT... SUCH AS COLORADO AND NORTH CAROLINA. HOWEVER, IN THE STATES THAT DON'T MANDATE THEM, THE HOSPITALS AT LEAST OFFER CEUs IN THEIR CLASSFORMATS ON EDUCATIONAL DAYS AT THE HOSPITAL FOR THEIR NURSES. AT LEAST FROM MY PERSONAL EXPERIENCE THEY'VE DONE THIS.
  13. by   live4today
    Hello JillR,

    Thanks for your response. No, I did not read your post as being of a "confrontational nature", so don't worry about it. You're "A-OK" in my neck of the woods.

    I think the problems nursing is having today -- as far as licensure status, this level that level, etc. -- are a product of what could have been prevented had the American Journal of Nursing not gone on their "degree warpath" years ago trying to "BRING INTO LAW" the BSN level as the only "entry level" into nursing.

    At some point or other, this situation today was bound to happen and what a mess it seems to have made. It's like anything else women have tried to implement for themselves, then eventually end up "eating that which they 'birthed' into being". (i.e., the feminist movement, equal rights for women, etc.)

    With every change comes a reform that many will not be happy with, but "a certain few" started this chain of reactions years ago, now here we are trying to decide what the heck to do with nursing education and what qualifies a nurse to do what???????

    OH, THE WEB WE HAVE WEAVED FOR OURSELVES!!! TSK! TSK!
  14. by   MollyJ
    JillR,
    KS, where I live, is also a rural state. We have one BSN program in the western half of the state (and a number of ADN programs). Period. (In our eastern half we have a multiplicity of ADN and BSN programs, two MSN programs and Phd program.)

    I think it is clear that ANY plan would start with grandfathering in present nurses OR giving them a date by which they must accomplish a BSN but for rural states like ours, I think the answers will include linkages with Baccalaureate granting institutions AND distance learning via interactive video downlink at community college centers. This maximimizes the sparsity of Nurses with MSN's and PHd's and allows for the education of nurses within their communities. MANY of those nurses who attend western KS ADN programs do so so that they can work locally and then they do this for the rest of their careers BUT wouldn't it be great if they could obtain a BSN locally and have better personal career mobilitiy if they moved. (Problem with this: What's in it for the community colleges, cash wise? They want to help their communities, but not at the expense of their existences. Not a good time to go to state legislatures and ask them to subsidize nursing ed in this way "for the public good". KS legislature is up to its' ears in financial woes.)

    Again, it would be interesting to see how Dr. Williams (re: the above article) would level out the different functions of the LPN, ADN, BSN, MSN and Phd. Also should CNA become somehow licensed or tested for uniformity (beyond the CMA level of function, which in our state is a certification by the Department of Health and Environment, while nurses are licensed by the Board of Nursing).

    When I was completing my MSN I took some classes via interactive video. It was a surprisingly positive experience and it gave me access to a different faculty. Since I was sitting in a room with 20 other nurses, I still had classroom level collegiality and a local proctor.

    I can envision a system of nursing education where nurses from several junior colleges receive lectures from the BSN faculty at KS colleges but do their practicums locally and receive a BSN while getting their education locally.

    Nursing needs to come to terms with the imbalance of federal funding that favors ADN programs as technical programs--making it more lucrative for a college to have an ADN program than a BSN program. Nurses don't mind reaping the benefits of taking a technical education (lower cost) but once graduated, they want the benefits of the professional education, the BSN. Let's face it--VERY FEW OR NONE OF US appreciated the politics of this thing when we chose our educational origins, but the issues are ongoing and impact all of us.

    Another question for Dr. Williams I would have is just how many levels of nursing does the industry need?
    CNA
    CMA
    LPN
    RN-ADN
    RN-diploma
    RN-BSN
    MSN
    Phd in Nursing

    To keep all levels and define them as separate and necessary would seem redundant. This all brings us back to Dr. Williams article. What do nurses do that is uniquely nursing?
    Last edit by MollyJ on Feb 26, '02

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