APRN Regulation: Recent Trends and Implications for Oncology APRN Practice May 16, 2008

History of APRN Regulation Julie A Ponto, RN PhD ACNS-BC AOCN® Winona State University Past President, ONCC Board of Directors

Nursing Regulation

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The foremost responsibility of nursing regulation is protection of public health, safety and welfare.

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Important because unprepared and incompetent individuals who practice pose risk of harm to the public.

Licensing boards

, governed by state regulations and statutes, are the final arbiters of who is recognized to practice in a given state.

• • • State Boards of Nursing Authorized state entity with legal authority to regulate nursing Regulate RN Practice in 50 states, DC and 5 U.S. Territories Protect the public’s health by overseeing and ensuring the safe practice of nursing – Establish standards – – – Issue licenses Monitor licensees’ compliance Take action against those who exhibit unsafe practice

• • • • • • State Legislatures enact Nurse Practice Acts: Define the authority of the board of nursing Define nursing and the boundaries of the scope of practice Identify types of licenses Identify requirements for licensure Protects titles Identify grounds for discipline

Boards of nursing develop rules and regulations consistent with the nurse practice act that have the force and effect of law.

“When a RN engages in practice that is determined to be beyond the identified scope of nursing, legal authorization for that practice

must exist in state law

. Any title, even if issued by a certifying body, only carries legal status if that title is recognized or authorized in statute or regulation.” NCSBN

National Council of State Boards of Nursing (NCSBN) Supports the 60 state boards of nursing in the USA and its territories in providing leadership to advance regulatory excellence for public protection. The NCSBN delegate assembly is comprised of representatives from all U.S. Boards of Nursing.

NCSBN

• • • • “Trade association” for state boards of nursing No regulatory authority Provides support and direction to state boards on issues Develops  Model Nurse Practice Acts  Model Rules and Regulations  Nursing Compacts  Position Statements

NCSBN has addressed the issue of the regulation of APRNs for several decades.

1980s

NCSBN Position on Advanced Clinical Practice stated that the preferred method of regulation for the APRN was “ designation/recognition” which is the least restrictive form of regulation .

APRNs have • expanded in numbers and capabilities over the past several decades • become a highly valued, integral part of the healthcare system.

• Between 1986 and 1992 The economic, legislation and policy changes affecting healthcare in the U.S. regarding cost and access to care increased the interest in alternative approaches to care.

• Between 1986 and 1992 There was increasing recognition of the overlap between medical practice and that of other providers such as NP, CNS, Nurse Midwives and Nurse Anesthetists.

• Between 1986 and 1992 Regulatory authorities were required to foster these overlapping practices in the interest of cost-effective accessible care, while working to protect the public.

1990 - Present

Regulation of APRNs become progressively more structured and developed into licensure , the most restrictive form of regulation.

1990-2000

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State boards

began using the results of advanced practice certification examination as one of the requirements for APRN licensure.

• There was collaboration between APRN certifiers and NCSBN to assure certification examinations were acceptable for regulatory purposes.

1990-2000

• To be suitable for regulatory purposes, APRN certification examinations were required to be entry level (test competencies of new graduates) and accredited • Certifying bodies were required to provide information to state boards regarding the psychometric soundness and legal defensibility of examinations

2002

NCSBN approved

Criteria for Evaluating APRN Certification Programs

. These criteria included educational requirements for:    Education concentration in the specialty 500 hours supervised clinical hours Clinical experience directly related to role and specialty

2002

• • • • NCSBN published Position Paper :

Regulation of Advanced Practice Nursing

APRN – Umbrella term for NP, CNS, NM, NA Licensure – Preferred method of regulation Education in role/broad specialty must be consistent with certification Only broad categories to be recognized – not “subspecialties such as disease entities”

2003-2006

• • NCSBN drafted

APRN Vision Paper

to: Resolve regulatory concerns such as proliferation of “subspecialties” Provide direction to state boards

2006

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The NCSBN

APRN Vision Paper

elicited a large response from a wide audience of nursing stakeholders

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2006

• NCSBN APRN Advisory Committee met with the APRN Consensus Work Group and agreed to begin a joint dialogue, working together toward a future model for APRN regulation.

2008

• The APRN Consensus Work Group and the NCSBN APRN Advisory Committee publish the

Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education

The Present

Both APRN requirements and approaches to APRN regulation continued to vary widely from state to state.

Interstate Compact

• Offer states the mechanisms for mutually recognizing licenses/authority to practice • RN/LPN/VN Compact – Enacted in 2000 – Currently includes 22 states

APRN Interstate Compact

• • Model language adopted 2002 Only states that have adopted RN/LVN/PN may participate • • • Utah, Iowa and Texas have passed ARPN Compact into law No rule writing has begun No date for implementation

Data on Oncology APRNs and Educational Programs Carlton G. Brown, PhD APRN AOCN® Georgetown University President, ONCC Bard of Directors

ONCC Survey of Oncology APRNs April 2008

• • • E-mail invitation to participate sent to 3734 ONS members who list NP or CNS as their primary position Response rate = 1248 (33%) Demographics of respondents indicate they are representative of the ONS members who are APRNs

Post -Graduate Program

Graduate Programs in Oncology Nursing

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23 Programs

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14 NP 12 CNS 1 Blended Most Linked to Broader Specialty

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Adult Medical-Surgical Acute Care Number of oncology-specific courses offered ranges from 2-10

Transcript Review AOCNP® Candidates 2005-2007

Role Focus

NP Blended NP/CNS 98% 2%

Transcript Review AOCNS® Candidates 2005-2007

Role Focus

Unspecified CNS NP 56% 41% 3%

Transcript Review AOCNP® Candidates 2005-2007

Specialty Focus Family Adult Oncology 33% 30% 21% * Acute Care Gerontology 8% 2% Other 6% * Includes oncology combined with others such as adult or acute care

Transcript Review AOCNS® Candidates

Oncology

2005-2007

Specialty Focus 31%* Adult 17% Medical –Surgical Administration Education Community 9% 8% 7% 6% Family 5% Other None 12% 5% * Includes oncology combined with others such as adult or acute care

Survey Data Certifications Held

CNS Oncology (AOCN®) 38% Oncology (AOCNS®) 27% Adult/Medical-Surgical CNS 21% 12-15% of CNSs who hold AOCNS® or AOCN® also hold another CNS certification

Survey Data Certifications Held

NP

Adult Primary Care NP 36% Family NP 33% Oncology (AOCNP®) 21% Oncology (AOCN®) 17% Adult Acute Care NP 10% Gerontological NP 4% 60-65% of NP who hold AOCNP® or AOCN® also hold another NP certification

State Board Regulation

Credentialed by State Board of Nursing CNS 52% NP 97% Blended 87% Title Protection CNS 29% NP 34% Blended 46%

State Board Regulation

Expanded Scope of Practice APRN License CNS 35% NP 87% Blended 81% Prescriptive Authority CNS 13% NP 91% Blended 73%

Required by State Board of Nursing to Hold Certification CNS NP Blended 40% 82% 80%

State Board Regulation Certification Used by CNS Oncology (AOCN®) 16% Adult or Medical Surgical CNS 10% Oncology (AOCNS®) 7% Pediatric CNS 1% Other 6%

State Board Regulation Certification Used by NP

Adult (Primary and/or Acute) NP 38% Family NP 27% Oncology (AOCNP®) 5% Oncology (AOCN®) 4% Women’s Health NP 2% Pediatric NP 1% Gerontological NP 2% Other 3%

State Board Regulation Certification Used by Blended Role

AOCN® Adult NP Family NP Adult or Medical-Surgical CNS AOCNS® AOCNP® 27% 26% 10% 10% 5% 4%

Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education Cyndi Miller Murphy, RN MSN CAE Executive Director Oncology Nursing Certification Corporation

Issue

• • • • Currently there is no uniform model of APRN regulation across states. Each state independently determines: APRN legal scope of practice Roles that are recognized Criteria for entry into advanced practice Certification examinations accepted for entry-level competence assessment

Issue

This lack of uniformity has created a significant barrier for APRNs to move from state to state and has limited access to care for patients.

Development of APRN Consensus Work Group 2004

An invitation to participate in the process was sent to 50 organizations with a stake in advanced practice nursing

Development of APRN Consensus Work Group 2004

32 organizations (including ONS and ONCC) convened in June to initiate a discussion of issues related to APRN definition, specialization, subspecialization, education, certification and licensure.

Development of APRN Consensus Work Group 2004

Based on recommendations generated at the June conference, a smaller work group of designees of 23 organizations with broad representation from APRN certification, licensure, education, accreditation and practice was formed.

Development of APRN Consensus Work Group 2004

The group was charged with developing a statement that addresses the issues delineated during the Conference with the goal of envisioning a future model for APRNs

Goals of APRN Consensus Process

• Strive for harmony and common understanding in the APRN regulatory community that would continue to promote quality APRN education and practice • Develop a vision for APRN regulation, including education, certification, licensure

Goals of APRN Consensus Process

• Establish a set of standards that protect the public, improve mobility, and improve access to safe, quality APRN care • Produce a written statement that reflects consensus on APRN regulatory issues

APRN Consensus Work Group

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October 2004 – April 2008

Sixteen days of in-person intensive discussion and multiple conference calls •

December 2005

ANA convened a meeting of the broad stakeholder group

APRN Consensus Work Group

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April 2006

APRN Consensus Work Group met with NCSBN APRN Advisory Panel to discuss

the NCSBN Vision Paper and to request feedback from

NCSBN on the Consensus Group draft paper

APRN Joint Dialogue Group

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January 2007

Representatives from the APRN Consensus Work Group met with representatives from the NCSBN APRN Advisory Panel with the goal of assuring that the revised

Vision Paper

and the final paper from the Consensus Group would not conflict, but rather complement one another .

APRN Joint Dialogue Group

As the two groups continued to meet in joint dialogue, much progress was made regarding areas of agreement and it was determined that one joint paper would be developed which reflects the work of both groups.

APRN Joint Dialogue Group

Sixteen months after the Joint Dialogue Group was formed, the draft paper was released to the boards of the stakeholders groups .

APRN Regulatory Model: LACE

• • • • Licensure – granting of authority to practice Accreditation – formal review and approval by a recognized agency of education degree programs or certification programs Certification – formal recognition of knowledge, skills and experience demonstrated by the achievement of standards identified by the profession Education – formal preparation of APRNs in graduate degree – granting or post-graduate certificate programs

Definition of APRN

• • • Completed accredited graduate level education program in one of four roles of CRNA, CNM, CNS, CNP Passed national certification that measures APRN role and population-based competencies Acquired advanced clinical knowledge and skills to provide direct care to patients (Defining factor for all APRNs is that significant component of education and practice focuses on the direct care of individuals)

Definition of APRN

• Practice builds on RN competencies with – Greater depth/breadth of knowledge – – Greater synthesis of data Increased complexity of skills and interventions – Greater role autonomy

Definition of APRN

• Educationally prepared to assume responsibility/accountability for: – Health promotion/ maintenance – Assessment, diagnosis, management of patient problems – Use and prescription of pharmacologic and nonpharmacologic interventions

Definition of APRN

• Clinical experience with sufficient depth and breadth • Licensed as independent practitioner to practice as APRN in role of CRNA, CNM, CNS or CNP

APRN Titles

• APRN required to be used • Role and population included • Specialty title may be used

Broad-based APRN Education

For entry into practice and regulatory purposes APRN education must: • • • Be through a formal graduate or post graduate accredited institution Comprehensive, at graduate level Prepare graduates to practice as CRNA, CNM, CNS or CNP across at least one population foci (neonatal, pediatric, adult, gender-specific or psych-mental health)

Broad-based APRN Education

For entry into practice and regulatory purposes APRN education must: Include at least three separate comprehensive graduate-level courses: • • • Advanced physiology/pathophysiology Advanced health assessment Advanced pharmacology

Broad-based APRN Education

May also include preparation in a specialty area of practice, but it must build upon the APRN role and population – focus competencies .

APRN Specialties

– – – Build upon role and population focused competencies • • Represent a focused area of practice Specific population subset Specific patient needs – – Disease states Body system Developed, recognized, monitored by the profession (not regulatory agencies)

APRN Specialty

• Preparation cannot replace role/population focused education • • • Cross over roles and populations Title may not be used in lieu of licensing title which include role and population Competencies must be assessed separately from role and population competencies

Emergence of APRN Roles and Populations

• • • New roles or populations that include a unique or significantly differentiated set of competencies from the current roles and populations may evolve over time. To be recognized criteria must be met: Education standards, core competencies Accredited graduate, post-graduate educational programs Certification program that meets accreditation standards

Strategies for Implementation Specific Criteria for each prong of regulation Licensure Accreditation Certification Education Target date: December 31,

2015

Strategies for Implementation Grandfathering

When states adopt new eligibility requirements for APRNs, currently practicing APRNs will be permitted to continue practicing within the states(s) of their current licensure. If APRN applies for endorsement by another state, they will need to meet new criteria OR criteria in place when they became licensed.

The ONS and ONCC Boards of Directors have approved the concepts in the Consensus Model for APRN Regulation.

Draft of the complete paper

Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education

Can be found on the ONS website at http://www.ons.org/clinical/profess ional/QualityCancer/issues.shtml

Slide show used to present the model to representatives of stakeholder groups on April 14, 2008 can be found at: http://www.aacn.nche.edu/educat ion/apnpresentations.htm

Implications of the New Model for Oncology APRNs Barbara B. Rogers CRNP MN AOCN® ANP-BC Fox Chase Cancer Center Past chair, ONCC Advanced Practice Test Development Committee

Goals of the Consensus Model

• Standardization in educational programs • Enhanced mobility of APRNs due to consistency in licensure requirements • Uniformity in independent APRN practice • Greater access to APRN care for patients

Challenges for Education

Programs must ensure:  Students attain APRN core, role and population competencies  Inclusion the three “Ps”  Graduates are eligible for certification in the role/population focus  Transcripts specify role/population focus

Challenges for Education

Adult and Family CNS and NP programs will need to incorporate comprehensive gerontology content into adult program curriculums

Oncology- Specific Challenges for Education

 Integration of specialty content, along with the core and population content will lengthen didactic and clinical requirements  Graduates not required to have specialty competencies

Oncology -Specific Opportunities for Education

 Specialty competencies do not have to be obtained within the formal graduate program  Development of post-graduate programs  Development of comprehensive continuing education by ONS to provide APRN competencies  Acquired through professional practice

Challenges for Licensure

State boards of nursing will:  License only at the role and population level  Grant licenses for all four roles of CNS, NP, NM, NA

Challenges for Licensure

State boards of nursing will need to:  Revise rules and regulations for APRN licensure  Grandfather all who currently are recognized to practice in a specific role

Opportunities for Licensure

 APRN regulation exclusively by boards of nursing  Standardization of criteria for licensure  Implementation of APRN interstate compact

Challenges for Certification

 Population-based certifications for CNS will need to be developed for all six population foci  Specialty competencies will be assessed separately from the role and population competencies

Oncology- Specific Challenges for Certification

Need to demonstrate the value of specialty certification  Oncology APRNs must be encouraged to attain and demonstrate specialty competencies  Employers must be encouraged to require certification for specialty practice

Oncology-Specific Opportunities for Certification  Not required for regulatory purposes  Eligibility criteria not dictated by state boards of nursing  Educational criteria, other than that obtained within the graduate program, can be required

Challenges for Oncology APRNs

 Those who currently meet regulatory criteria, will be grandfathered within the same state, but may need to meet new criteria in a new state

Challenges for Oncology APRNs

 In states where regulation does not currently exist (e.g. for CNS), grandfathering will occur for those in practice, or APRNs will need to meet the new criteria for licensure  Education  Certification

Discussion of State Specific Examples

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Current model and regulations

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Changes that will need to be implemented

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How oncology APRNs will be affected