Whose Consensus Is It Anyway?

Advanced Practice Registered Nursing (APRN) as we know it arose out of the trailblazing efforts of nurses from four separate nursing specialties whose individual histories were shaped by a common thread: to answer the call to deliver a high level of healthcare to individuals and groups in an area of clinical practice where a need for such level of healthcare existed. The APRN movement, a testament to American innovation, has been copied in many parts of the globe though not always in its entirety. All four Advanced Practice Registered Nursing groups evolved from separate historical timelines but now share common characteristics: they all build upon nursing as the basis of practice by requiring active licensure as a Registered Nurse (RN), require a graduate degree for entry to practice, require a form of certification in the specific specialty, and lastly, require its practitioners to acquire in-depth training in specialties using advanced concepts some of which are not traditionally held in the nursing realm.

As part of professional nursing practice in the United States, all four APRN specialties are regulated under a nursing board in each of the 50 states, the District of Columbia, and a number of US territories. With the exception of Nebraska which has a separate board for advanced practice, APRN's are regulated by the same board that oversees the practice of RN's. The collective voice of the individual Boards of Nursing is the National Council of State Boards of Nursing (NCSBN). Among the achievements of the NCSBN is the development and implementation of two national board examinations in the US for entry to practice as either Registered Nurses or Licensed Practical/Vocational Nurses now known as the National Council Licensure Examination (NCLEX). It is along the same mission of promoting uniformity in nursing practice across all its member boards that a Consensus Model for APRN was born. Not surprisingly, 2015 became an arbitrary number as the target year when the provisions of this model shall take effect.

As relatively newer and evolving professions that challenge the norms of traditional nursing practice, APRN regulation varies considerably in terms of requirements for entry to practice among the member Boards of Nursing that NCSBN represents. Four areas of concern were identified as sources of variability in regulatory standards across all member boards: licensure, program accreditation, national certification, and education. These were referred to as the acronym LACE. In terms of licensure, member boards of the NCSBN do not have uniform regulation regarding the need for Advanced Practice Registered Nurses to acquire additional licensure separate from a Registered Nurse license in order to practice their specialty. In many states, a certification in the APRN specialty is awarded after the candidate is deemed qualified based on state requirements one of which always include an active RN license.

CRNA and CNM programs are accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs (COA-NAEP) and Accreditation Commission for Midwifery Education (ACME) respectively. National certification for CRNA's and CNM's are carried out by each profession's single specialty certification board namely, the National Board of Certification & Recertification for Nurse Anesthetists (NBCRNA) and the American Midwifery Certification Board (AMCB) respectively. Both of these professions by virtue of their narrow specialty foci developed a highly organized, unified structure and set of standards in terms of program accreditation and national certification. Sadly, the same could not be said of the CNS and NP professions.

No specialized accrediting body exists for CNS and NP programs; however, the Pediatric Nursing Certification Board (PNCB) offers recognition status to Pediatric NP programs in the Acute Care and Primary Care foci across the US. Programs in both CNS and NP specialties are accredited by either the Commission on Collegiate Nursing Education (CCNE) or the National League of Nursing Accreditation Commission (NLNAC) as part of their role in accrediting institutions offering a master's degree and/or practice doctorate in nursing. National certification programs for Clinical Nurse Specialist and Nurse Practitioner are not only divided by multiple subspecialty tracks but also by the fact that multiple national certification programs exist from different organizations offering the same type of subspecialty certification. Case in point, the American Nurses Credentialing Center (ANCC) and the American Academy of Nurse Practitioners (AANP) both offer certification in the Family and Adult NP tracks. The ANCC has various CNS specialty examinations and so does the American Association of Critical Care Nurses (AACN).

Although all educational programs for APRN's are offered at the graduate degree level, significant differences can be seen in the Clinical Nurse Specialist and Nurse Practitioner programs in terms of curricular offerings and specialty focus depending on institutional preference prior to the Consensus Model. As the final draft of the Model came to print, eight Nurse Practitioner tracks emerged as officially accepted specialty areas of practice namely: Family NP, Adult-Gerontology Primary Care NP, Adult-Gerontology Acute Care NP, Pediatric Primary Care NP, Pediatric Acute Care NP, Women's Health NP, Neonatal NP, and Psychiatric-Mental Health NP. Clinical Nurse Specialist foci appear to have been standardized along the same lines as the NP namely: Family, Adult-Gerontology, Pediatric, Neonatal, Women's Health, and Psychiatric-Mental Health CNS tracks though in reality, CNS program and certification options are not as varied. Also note that the Acute Care versus Primary Care delineation does not exist in the Clinical Nurse Specialist tracks in terms of the Adult and Pediatric foci.

As a consequence of the newly-approved CNS and NP specialties, national certification boards for both professions followed suit by enforcing new changes to their certification credentials. Despite the confusing mess of CNS and NP specialty boards with roles that overlap against each other, many of the certification boards managed to scramble in order to update the titling of their respective certification examination programs to reflect the intended content of these new and improved CNS and NP specialties. Such haste appears to be motivated by the target implementation year of 2015. Adult NP and CNS certifications were modified to add Gerontology content. Gerontology NP and CNS certifications succumbed to an untimely demise and the Child/Adolescent Psychiatric Mental Health NP and CNS content was dissolved to give way to the single broad-based Family Psychiatric Mental Health track. What ensued was loud uproar of exasperation from many practicing CNS's and NP's who hold the older versions of these new and improved certification programs.

Undeniably, some of the provisions of the Consensus model are much needed in the current APRN environment and should be accepted as steps toward progress in these professions. But the Consensus Model missed the mark on many respects and many APRN's agree. For one, the model failed to simplify certification titling for NP and CNS professions by eliminating the mambo-jambo of confusing letters and in fact added to the alphabet soup. Case in point: the ridiculously long title for Adult-Gerontology Primary Care Nurse Practitioner educational preparation and specialty certification has been lengthened to AGPCNP-BC from the previously used ANP-BC by ANCC. No other professions exhibit such a degree of obsession with acronyms in order to gain a sense of accomplishment. Multiple nursing organizations sat with NCSBN on the round-table discussions that gave rise to this Model in a Kumbayah fashion. Not surprisingly, no one dared to admonish the profession for allowing multiple overlapping entities that certify NP's and CNS's and perpetrating the lack of a unified accrediting body specific to CNS and NP educational programs.

It is also important to point out that the extent of power NCSBN exerts will only go as far as the provisions of the Nurse Practice Act that is enforced in the state (or territory) of jurisdiction the board belongs to. Boards of Nursing do not write the law in their respective states, lawmakers do. Various Scopes of Practice for APRN are affected by forces outside of the nursing profession itself. For instance, a strong physician lobby against APRN encroachment on their turf is regarded as an obstacle to full realization of a uniform APRN practice standard. The statement is never truer than the reality of independent practice and prescriptive authority which varies among all APRN groups depending on the state the provider practices in. Lastly, while the Model should be lauded for finally recognizing the CNS as a legitimate profession under the APRN umbrella, Nurse Practice Acts in many of the NCSBN member jurisdictions will need to change if prescriptive authority is to be granted to Clinical Nurse Specialists as a whole. In the end, I ask whose consensus is it anyway? Feel free to discuss.