Nursing's Leading Edges: Advancing the Profession through Specialization, Credentialing, and Certification

Nursing’s Leading Edges

American Nurses Association

8515 Georgia Avenue, Suite 400

Silver Spring, MD 20910-3492

1-800-274-4ANA

http://www.Nursingworld.org

The America Nurses Association (ANA) is the premier organization representing the interests of the nation’s 3.6 million registered nurses. ANA advances the nursing profession by fostering high standards of nursing practice, promoting a safe and ethical work environment, bolstering the health and wellness of nurses, and advocating on health care issues that affect nurses and the public. ANA is at the forefront of improving the quality of health care for all.

Copyright ©2017 American Nurses Association. All rights reserved. Reproduction or transmission in any form is not permitted without written permission of the American Nurses Association (ANA). This publication may not be translated without written permission of ANA. For inquiries, or to report unauthorized use, email copyright@ana.org.

Library of Congress Cataloging-in-Publication Data available on request.

978-1-55810-671-0 print SAN: 851-3481 12/2016

978-1-55810-672-7 ePDF

978-1-55810-673-4 ePub

978-1-55810-674-1 mobi

First published: December 2016.

Contents

Introduction i

Acknowledgments i

1 An Overview of Nursing Practice in Today’s World 1

Today’s Nursing Practice Environment 1

The Nursing Workforce 2

Recent Evolution of Nursing Education 3

Doctoral Education in Nursing 5

Development of the DNP 5

Other AACN and NLN Contributions to Nursing Education 7

Regulation and Licensure 9

National Council of State Boards of Nursing 9

Key Stakeholders in the Practice Environment 11

Professional Associations 11

Certifying Bodies 11

Accrediting Organizations 12

Recommended Competencies Associated with Nursing Education and Practice 13

The Growth of Specialization in Nursing 13

Specialty Nursing Organizations 14

Certification and Credentialing for Specialty Practice 15

Documents Essential for All Nursing Practice 15

Code of Ethics for Nurses with Interpretive Statements 15

Nursing: Scope and Standards of Practice 17

Nursing’s Social Policy Statement 18

Nursing-External Forces and Initiatives 18

Health System Reform 18

The Institute of Medicine: Five Key Reports 19

Information Technology 24

Quality Agenda 26

A Model for Defining Practice and Acceptable Competence 29

References 32

2 Specialization and Credentialing: Concepts and Definitions 37

Definition of Key Terms 38

Elements of Credentialing 41

Respective Roles and Mutual Recognition: Diagrams of Credentialing 42

Types of Credentialing 44

Credentialing of Individuals 45

Accreditation and Recognition of Organizational Programs 45

Practice Transition Accreditation Program™ (PTAP) 46

References 52

3 Specialization and Certification for RNs: Growth and Recognition 57

Formal Recognition of Nursing Specialties 58

Recognition of Specialty Nursing Competence and Expertise 59

Growth of Certification in Nursing 60

State of the Science: Research on Certification in Nursing 61

References 64

4 APRN Specialization and Certification: The Consensus Model for APRN Regulation 67

The Four APRN Roles 68

Certified Registered Nurse Anesthetist (CRNA) 70

Certified Nurse-Midwife (CNM) 71

Clinical Nurse Specialist (CNS) 74

Certified Nurse Practitioner (CNP) 78

The Consensus Model for APRN Regulation 80

What Drove the Development of the Model? 80

Development of the Consensus Model 83

Multiyear Process 84

Key Stakeholders Committed to Consensus 84

Basic Assumptions About the Consensus Model 85

ANA’s Role in the Consensus Model 86

Key Aspects of the Consensus Model 86

Definition of an APRN 87

Four APRN Roles 87

LACE: The Four Essential Elements 89

Relevance of Specialties 89

APRNs as Independent Practitioners 89

APRN Education 90

Emergence of New APRN Roles and Population Foci 91

Implementation: Strategies, Challenges, and Progress to Date 91

Implementation Strategies 91

2015 Target Date 92

Development of the LACE Network 95

Changes in APRN Certification Examinations 95

Is Additional Postgraduate Education and Certification Needed? 97

Evaluation and Implementation 98

References 100

5 Specialization and Certification: Issues, Trends, Moving Forward 103

The Impact of Occupational Licensing Reform 104

Building the Business Case for Certification 105

Building a Stronger Research Base 105

The Potential Role of Electronic Health Records 106

Expanded Use of the National Provider Identifier (NPI) 107

Proliferation of Specialties and New Models of Certification 108

Proliferation of Specialties and New Specialties 108

Interprofessional Certification 109

Certification of Teams 111

Impact of Globalization 112

Public Understanding 113

Continuing Competence 116

Lifting Barriers to APRN Practice

Conclusion

References

Glossary of Acronyms 125

Index 129

Introduction

Wherever you work in the health care industry—whether hospital administrator, credentialing professional, regulator, educator, or nurse—you need to understand the profession of nursing. The nation’s 3.6 million registered nurses, who comprise the largest sector of the health care workforce, have been called the glue that holds our health care system together for the patients who must navigate its services. Nurses work in every sector of health care, from small rural health centers to massive urban tertiary hospitals and multihospital systems. They provide primary and preventive care as well as highly specialized nursing care and disease management. Quite literally from cradle to grave—from the newborn nursery to hospice—we encounter nurses, and therefore the nursing profession.

Because nurses are integrated throughout our health care system, as health care has become increasingly complex, so has the profession of nursing. Nurses have developed the skills and knowledge necessary to keep a tiny preemie alive in the neonatal intensive care unit, or manage the operating room throughout a multiorgan transplant surgery. The nursing profession, through its professional and specialty organizations, has defined standards of practice to ensure safe, quality nursing care and, ultimately, to protect the public.

Specialization and credentialing—significant concerns for many professions—are especially important in light of the responsibilities assumed by the registered nurse. The American Nurses Association (ANA) has done groundbreaking work in this area for decades, creating and revising essential documents such as Code of Ethics for Nurses with Interpretive Statements and Nursing: Scope and Standards of Practice. Since the late 1990s, ANA has been the steward of a process to formally recognize new nursing specialties. Additionally, the American Nurses Credentialing Center (ANCC), an ANA subsidiary, is one of the oldest credentialing organizations promoting excellence in nursing and health care in the United States and globally.

While many nurses have contributed to the development of specialization and credentialing in nursing, Magretta Gretta Styles, EdD, RN, FAAN, was recognized as a thought leader in this field for many years. (For a snapshot of her career, see http://nursecredentialing.org/CertifiedNursesDay-MeetGrettaStyles.) At the time of her death in 2005, Dr. Styles was creating a subsequent edition to her work, On Specialization in Nursing: Toward a New Empowerment (1989).

ANA committed to continuing the work of Dr. Styles, and in 2008 published Specialization and Credentialing in Nursing Revisited: Understanding the Issues, Advancing the Profession, her final written work. The book’s emphasis on advanced practice nursing and related topics helped frame the discussions of the Advanced Practice Registered Nurses (APRN) Stakeholder’s Group, at whose meeting the book was unveiled. Later that same year, the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (the Consensus Model), was completed and endorsed.

As stakeholders began activities to implement the Consensus Model, the importance of Dr. Styles’s foundational work became increasingly clear. Yet the 2008 book had become outdated as it was published, given the completion of the Consensus Model in the same year.

The subsequent years have been called a perfect storm for nursing, with the passage of the Affordable Care Act in 2010 and the publication that same year of The Future of Nursing: Leading Change, Advancing Health Practice, a report from the what was then the Institute of Medicine (see pg. 20 for the name change). Policy makers are increasingly aware of the need to ensure an adequate nursing workforce to meet demands, and to ensure that all nurses practice to the full extent of their education.

And so the decision was made to once again revisit specialization and credentialing in nursing with a redux of the 2008 book.

In my role as Senior Policy Advisor for APRN Issues in ANA’s Department of Health Policy, the primary incentive for taking a fresh look at Dr. Styles foundational work and updating it in this book was ANA’s involvement in implementation of the Consensus Model for APRN Regulation. I did not have the privilege of knowing or working with Dr. Styles, (and I confess that I read her work only as I became involved in implementation of the Consensus Model in 2009), but have felt her strong influence nonetheless. Each time this book hit a slowdown, there would be a conversation or an inquiry that would remind me of the importance of this relatively narrow but critically important topic of specialization and credentialing of the largest cadre of healthcare professionals.

Most recently, I fielded an inquiry that led to a connection to Dr. Styles’ children and the work they are doing through The Gretta Foundation. The Foundation funds nursing and midwifery scholarships to impoverished persons living in disease burdened countries, and consistent with her legacy, the Gretta scholars attend accredited programs in their country’s system of education.

ANA is in the unique and important role of advocating for all nurses—registered nurses and advanced practice registered nurses—across all roles and specialties. As the profession of nursing has evolved and the industry in which we work has undergone seismic changes, ANA has fielded inquiries from a wide variety of stakeholders. Nurses long credentialed in a role or specialty wonder how the changes affect them, while nurses seeking to advance their career wonder how to choose between a growing number of new programs. Employers wonder how to retain experienced nurses with old credentials and how to attract the most qualified new nurses. Policy makers seek to make sense of competing requests for changes in the legislative and regulatory framework. And payers (both private sector and in the government) are wielding influence as they move toward limiting reimbursement to providers with particular credentials.

This book sets out to meet the difficult challenge of providing concise background and information for this broad audience. In some instances, decisions and the path forward are clear. In others, there are important questions that remain to be answered. ANA has and will continue to work closely with colleagues in the nursing community toward a unified message.

Chapter 1 provides a foundation for understanding nursing in today’s rapidly changing health care environment. Discussion of the nursing workforce, evolution of nursing education, regulation and licensure, and components of the practice environment provide insights about the context and complexities of contemporary nursing practice.

Chapter 2 borrows heavily from the foundational work of Dr. Styles. When discussing specialization and credentialing in nursing, it is important to have a clear understanding of definitions and basic concepts. In Chapter 2 of Specialization and Credentialing in Nursing Revisited, Dr. Styles provided a series of definitions and figures that helped to clarify the relationships between various forms of credentialing. Although Dr. Styles presented this as a foundation for thinking about the practice of advanced practice registered nurses, the basic concepts are applicable to credentialing of RNs and APRNs alike.

Chapter 3 and Chapter 4 expand on these basic concepts. While Chapter 3 addresses RN specialization and credentialing, the process of formal recognition of nursing specialties described in that chapter formed the foundation for understanding specialty practice for APRNs as well. There is also a brief review of the state of the science on certification in nursing.

Chapter 4 brings us up to date on how this basic work evolved into the Consensus Model for APRN Regulation. The four APRN roles are described as well as the factors that drove the development of the Consensus Model. Key aspects of the model are explained; there is a brief summary of implementation of the Consensus Model to date.

The final chapter looks to the future, addressing some of the emerging issues and questions being tackled as the profession of nursing evolves, along with health care delivery sites, systems, and technologies.

The audience for this book is a broad one, and we hope it meets the needs of practitioners, administrators, employers, and regulators.

—Lisa Summers, MSN, DrPH, FACNM

Acknowledgments

Mary Jean Schumann, DNP, RN, MBA, CPNP, an author of Specialization and Credentialing in Nursing Revisited, introduced me to that book early on in my tenure at ANA. It provided a foundation I was lacking and made me want to see that critical information updated and widely disseminated. Colleague Carol J. Bickford, PhD, RN-BC, CPHIMS, FHIMSS, FAAN, another author of Specialization and Credentialing in Nursing Revisited, proved to be an invaluable ally and supporter moving through the creation and publication of this professional resource.

Many colleagues answered queries, contributed sections, and reviewed drafts. At the risk of overlooking some (and accepting full responsibility for the final product), we want to acknowledge in particular the following ANA colleagues: Janet Haebler MSN RN, Senior Associate Director, State Government Affairs; and Peter McMenamin, PhD, Kelly Cochran, MS, RN; and Maureen Dailey, PhD, RN, CWOCN in the Department of Health Policy. Martha Turner, PhD, RN-BC, Assistant