May 16, 2008

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

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

3. Nursing Regulation • The foremost responsibility of nursing regulation is protection of public health, safety and welfare. • Important because unprepared and incompetent individuals who practice pose risk of harm to the public.

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

5. 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

6. 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

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

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

9. 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.

10. 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

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

12. 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 .

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

14. 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.

15. 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.

16. 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.

17. 1990 - Present Regulation of APRNs become progressively more structured and developed into licensure, the most restrictive form of regulation.

18. 1990-2000 • 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.

19. 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

20. 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

21. 2002 NCSBNpublished 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”

22. 2003-2006 NCSBN draftedAPRN Vision Paperto: • Resolve regulatory concerns such as proliferation of “subspecialties” • Provide direction to state boards

23. 2006 • TheNCSBN APRN Vision Paperelicited a large response from a wide audience of nursing stakeholders.

24. 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.

25. 2008 • The APRN Consensus Work Group and the NCSBN APRN Advisory Committee publish the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education

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

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

28. 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

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

30. 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

39. Post -Graduate Program

42. Graduate Programs in Oncology Nursing • 23 Programs • 14 NP • 12 CNS • 1 Blended • Most Linked to Broader Specialty • Adult • Medical-Surgical • Acute Care • Number of oncology-specific courses offered ranges from 2-10

43. Transcript ReviewAOCNP® Candidates2005-2007Role Focus NP 98% Blended NP/CNS 2%

44. Transcript ReviewAOCNS® Candidates2005-2007Role Focus Unspecified 56% CNS 41% NP 3%

45. Transcript ReviewAOCNP® Candidates2005-2007Specialty Focus Family 33% Adult 30% Oncology 21% * Acute Care 8% Gerontology 2% Other 6% * Includes oncology combined with others such as adult or acute care

46. Transcript ReviewAOCNS® Candidates2005-2007Specialty Focus Oncology 31%* Adult 17% Medical –Surgical 9% Administration 8% Education 7% Community 6% Family 5% Other 12% None 5% * Includes oncology combined with others such as adult or acute care

47. 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

48. 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

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

50. State Board Regulation Expanded Scope of Practice APRN License CNS 35% NP 87% Blended 81% Prescriptive Authority CNS 13% NP 91% Blended 73%