Whose Consensus Is It Anyway?

The final draft of the Consensus Model for APRN Regulation was approved July 7, 2008 with very little fanfare. As an important step toward uniformity in APRN standards of practice, the document is not without its flaws. This article aims to editorialize the Model in an attempt to stimulate further discussion regarding APRN reform.

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.

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Corey Narry

About Corey Narry, MSN, RN, NP

Advanced Practice Columnist / Guide

juan de la cruz, RN, NP, CCRN-CSC is a board-certified Acute Care Nurse Practitioner working with a multidisciplinary team of intensivists in a number of multi-specialty Adult Critical Care Units at a university-affiliated tertiary medical center in the West.

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Specializes in SICU.

Awesome article. There is a need for far more clarity and specificity in the NP and CNS roles. I'm a new grad RN and I still don't understand what a CNS is or does. If this is the case, then certainly the general public is not going to understand them, and lawmakers won't see a perceived need for them.

Any advanced practice should be specifically filling a gap in our health care system. This is why CRNA's and CNM's have worked so well. They are niche providers that know why they exist and where they fit into the system. Health care providers are becoming more and more specialized, and I believe that the future of NP's also lies in specialization. Just remember to sign your name "John Smith NP", not "John Smith AGPCNP-BC, BSN, RN, LPN, CNA".

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Specializes in Nephrology, Cardiology, ER, ICU.

Juan - excellent article!

Totally agree too with the confusion - heck if we as APNs are confused, what the heck do our pts and the public think?

I'm an adult health CNS and a peds CNS - I did two complete programs for a total of 1100+ hours of clinical. Yet, for me to transfer to an FNP I would have to do a third program. How many times can you repeat the three P's????

As a CNS, my role is that of an APN: I see pts, diagnose, treat, evaluate, order tests, examine, assess, prescribe, etc..

However, there are other roles for CNS: llg is one CNS who has more the traditional role of CNS, Elkpark is another prolific CNS poster here.

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Thank you.

A much appreciated post.

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Juan - excellent article!

Totally agree too with the confusion - heck if we as APNs are confused, what the heck do our pts and the public think?

I'm an adult health CNS and a peds CNS - I did two complete programs for a total of 1100+ hours of clinical. Yet, for me to transfer to an FNP I would have to do a third program. How many times can you repeat the three P's????

As a CNS, my role is that of an APN: I see pts, diagnose, treat, evaluate, order tests, examine, assess, prescribe, etc..

However, there are other roles for CNS: llg is one CNS who has more the traditional role of CNS, Elkpark is another prolific CNS poster here.

Imagine what it's like for those of us currently pursuing APN options, and trying not only to muddle through the current mire, but trying to anticipate future changes so as not to "waste time" with curriculum that will be obsolete by the time we graduate.

The nursing lobby is powerful; it has the clout to unify and streamline Advanced Pratice Nursing as an entity unto itself, but from an outsider's POV, it seems exponentially convoluted.

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Specializes in Nursing Professional Development.

Great post, Juan.

I am happy to see the profession trying to standardize these roles. I only wish they had taken a step back and done a better job of looking at the big picture. It seems they were focusing on the NP's more than the other roles and that has left some confusion. While I support much of the direction they are taking, I have a few points of concern.

1. They didn't give enough attention to CNS's. As an old CNS from back in the 1980's, I was involved in some of the history of that role. The differences between a CNS and an NP used to be very clear. The focus of the CNS was to be a nursing expert within the traditional scope of practice of the staff nurses. We served as consultants in tough cases, evaluated care given on a unit and implemented programs to improve outcomes, did staff development, did research, etc. There was no focus on serving in an expanded role that included such things a medication prescription or medical diagnosis/management. Then, some people tried to merge the roles -- and in the process, they muddied the waters. Things have been a mess ever since. Now, the CNL role is claiming some of the parts of the traditional CNS role -- leaving CNS's caught between a rock and a hard place, with a role that overlaps NP's, Staff Development, Project Managers, and CNL's. If the CNS's had not tried to expand their role into NP territory, then CNL role would never have been created and there would be clear territory for the CNS's to occupy. Like many people of my generation in the CNS role, I wasn't interested in the expanded scope of practice (overlapping NP's) and I moved on to other roles years ago.

2. The group working on the consensus model only addressed those "advanced practice" roles -- and did not consider that their proposed changes in education would gut many MSN programs. If someone wants to focus on Staff Development, project manager, etc. roles ... what are they to do? It's tough to find an MSN program these days if you are not interested in one of the APN roles or Nursing Administration. CNL programs that accept experienced nurses are not found everywhere -- and arranging preceptorships for them for students attending online programs when no one in the are is a CNL is a problem. In my area, we have the same problem with CNS practicums. We have so few CNS's, that students in online programs have no one to precept them -- and with the local schools offering only NP, CRNA, and Nursing Administration programs, their choices are limited. And MSN's in Nursing Education focus almost exclusively these days on preparing faculty members -- not Professional Development Specialists.

So ... while I see the consensus model as a nobel effort that meant well, and probably a step in the right direction ... a lot of work still needs to be done before the mess gets straightened out for those of us being effected by their decisions.

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

llg, now that you mentioned that, I do see some bias towards NP standardization with the Consensus Model. But on the other hand, I also got the impression that in recent years, the current CNS leadership has been pursuing closer alignment to the NP role by acquiring recognition as providers with ability to diagnose, treat, and prescribe. This has certainly given rise to the CNS shedding the traditional roles they began with during their early development as a consequence. I'm not sure if this was the leadership's way of keeping the CNS role viable in an era of healthcare where one's value as provider is only as good as the amount of revenue you can pull. It's a shame that the CNS tracks, per the Consensus Model are now closely aligned to the NP tracks. This could surely bring about a blended NP/CNS role and one can only infer that eventually, one professional role will dominate (NP) and the other professional role will become obsolete (CNS). I think we already see the beginning of that now but I hope that trend doesn't continue. Surprisingly, the document is endorsed by the National Association of Clinical Nurse Specialists.

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.
Juan - excellent article!

Totally agree too with the confusion - heck if we as APNs are confused, what the heck do our pts and the public think?

I'm an adult health CNS and a peds CNS - I did two complete programs for a total of 1100+ hours of clinical. Yet, for me to transfer to an FNP I would have to do a third program. How many times can you repeat the three P's????

As a CNS, my role is that of an APN: I see pts, diagnose, treat, evaluate, order tests, examine, assess, prescribe, etc..

However, there are other roles for CNS: llg is one CNS who has more the traditional role of CNS, Elkpark is another prolific CNS poster here.

I know what you mean. On the bright side, the Consensus Model, actually allows you to practice in your adult and peds scope with a provider role similar to NP and you actually live in a state where the NPA allows that.

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