APRN Joint Dialogue Group Activities Update

1. APRN Joint Dialogue GroupActivities Update C. M. Hanson NCSBN APRN Advisory Panel March 22, 2007

2. The Joint Dialogue Group • The Joint Dialogue Group is a sub-group that came out of dialogue from last years Round Table in Chicago. • The work group is made up of representatives from the Consensus Work Group formed by the Alliance for APRN Credentialing and the NCSBN APRN Advisory Panel

3. Goal of Dialogue Group • To create a comprehensive regulatory model (LACE) for APRN Education and Practice • To address the issues raised in creating a new model • To prepare complementary papers that bring together collaborative views on regulation that represent the viewpoints of APRN stakeholders. • (LACE: legal, accreditation, certification, education)

4. Support for the Development of a New Regulatory Model • IOM Report (2001), Crossing the Quality Chasm. • Recommends increased coordination and communication among professional boards both within and across states as the patchwork of APRN regulation is resolved over time • With national statistics indicating an increasing shortage of both nurses and primary care physicians, state regulation continues to restrain the full scope of practice for ANPs.

5. Support for the Development of a New Regulatory Model • PEW Health Professions Commission (1998) and IOM . • Emphasized the need for regulation to be evidenced based, consistent, and protective of patients • Wing, O’Grady, and Langelier (2005). • Increase in numbers of APRNs but greatly underutilized due to variable regulation limits in autonomy, and entry into practice relative to skills and potential contribution.

6. Support for the Development of a New Regulatory Model • Rudner, O’Grady, Hodnicki & Hanson (2007). • State rankings suggest that wide variations exist in state regulation of advanced practice indicating the strong possibility that in some states, NPs cannot reach their full capacity to care for patients.

7. State Nurse Practitioner Regulatory Environments Affecting Consumer Choice and Access

8. Setting the Ground Rules for the Joint Dialogue Group • Ground Rules • Enhancing Communication • Sharing of information • Transparency • Defining vision • Thinking outside the box • Doesn’t go rapidly because it takes time to get out of the “now” • Coming to common ground

9. Coming to Common Terminology • Defining terms • Regulation • Role • Specialty • Sub-Specialty • Population foci • Illness-wellness continuum

10. Areas of Agreement • Boards of Nursing will be the sole regulators of APRNs • Joint regulation by other boards is not desirable or necessary • All categories of APRNs should be regulated by Boards of Nursing • Boards of Nursing should have APRN representation at the Board and staff levels.

11. Areas of Agreement • APRN Licensure/Recognition will be at the role and population level of nurse anesthetist, nurse midwife, nurse practitioner, and clinical nurse specialist. • Caveat: CNS will be prepared at the advanced practice level and meet the same criteria as other APRN roles including education, certification, and practice.

12. Areas of Agreement • APRN Educational Programs will be pre-approved before admitting students • To ensure that graduates meet requirements for licensure/approval. • To ensure that programs include the Masters or Doctoral Essentials and the role competencies in the population context.

13. Areas of Agreement • All programs leading to APRN licensure including the clinical/practice doctorate and post masters programs will meet established educational requirements. • Educational programs at the masters, post-masters and doctoral level must be accredited. • Clinical experiences should be of sufficient depth and scope to ensure role/population competencies. • Clinical experiences should cover the intended scope of practice with sufficient oversight by qualified faculty and preceptors.

14. Areas of Agreement • All programs leading to APRN licensure including the clinical/practice doctorate and post masters programs will meet established educational requirements. • Educational programs will distinguish between those programs leading to advanced practice licensure/approval and those that do not require board of nursing authorization (education, administration) or those beyond the relevant license (sub-specialties in wound care or diabetes management). • If programs implement generalist/specialty tracks, these must be reviewed to assure graduates will be eligible for licensure.

15. Areas of Agreement • APRNS will be regulated at the role (NP, CNS, CNM, CRNA) and population focus (adult, child, gender, older adult, across lifespan ---family). • Competencies for regulatory purposes will be tested at the APRN Role and Population Focus. • Specialty competencies such as oncology, palliative care, cardiovascular, can be obtained beyond the role and population competencies and will not be subject to requirements for licensure. • Certification examinations and other mechanisms can be used to measure specialty competencies.

16. Areas of Agreement • Evidence of continued competence will be required for license renewal • A variety of recertification mechanisms can be used, including examinations, peer review, portfolio, and practice hours. • APRNs will have to maintain competence in their area of practice.

17. Areas of Agreement • Fully licensed APRNs will be independent practitioners. After licensure there will be no regulatory requirements for supervision. • Like other health care professionals, APRNs are responsible for appropriate collaboration and referral. This is a minimum standard of care for all health care professionals. • Until fully licensed, supervision is appropriate.

18. Unresolved Issues • Examination for licensure/approval • For regulatory purposes, an individual must graduate from an accredited program that includes: • the 3 P’s across the lifespan (Advanced pathophysiology, Physical Assessment, Pharmacology) • Role Core (NP, CNM, CNS, CRNA) • Population foci core and have all 3 levels assessed by a psychometrically sound and defensible method. (Resolved)

19. Unresolved Issues • How will core content be tested? • Will there be one test or two? • Should one test cover the APRN Core, role, and population competencies? • Who will do it? • How will testing be accomplished • Should one exam cover APRN and Role competencies and be used for licensure overseen by BONs with a second exam for population competencies overseen by certifying bodies? • Should there be one test by certifiying bodies do it all?

20. Unresolved Issues • Each APRN need to be prepared across the illness-wellness continuum, from acute through primary care. • At the role level, all APRNs would be prepared across the illness-wellness continuum, which includes preparation from wellness to limited acute illnesses. • Neither wellness or acute care is confined to a particular setting • Critical care/intensive care would be a specialty • Neonatal is a population focus

21. Unresolved Issues • How do we improve communication between accreditors, education, certification, and regulatory bodies?

22. Next Steps for Dialogue Meeting Group • June 2007 is the original target date for completion of the APRN Joint Dialogue work. Two complementary papers may be produced but recommend a joint statement from this group when work is completed. • Several issues discussed at this and the February meeting will be discussed with constituent groups • Next Meeting of the APRN Joint Dialogue Group is May 22 and 23, 2007 in Chicago.