APRN Vision Paper Update and Outcomes from the NCSBN Sponsored Member Board Summit Summit held February 26, 2007 Chicago, IL Randall Hudspeth, MS, APRN-CNS/NP Board Member, Idaho Board of Nursing Member, APRN Committee

Purpose of Summit Update member Boards of Nursing Update member Boards of Nursing Provide a historical perspective for new board members Provide a historical perspective for new board members Provide review of original Draft Vision Paper released March 2006 and its 8 recommendations Provide review of original Draft Vision Paper released March 2006 and its 8 recommendations Provide information on stakeholder response to Draft Vision Paper Provide information on stakeholder response to Draft Vision Paper Provide information on work to date on APRN issues resulting from feedback Provide information on work to date on APRN issues resulting from feedback

APRN Historical Perspective 1986 first position paper by NCSBN addressing Advanced Clinical Nursing Practice 1986 first position paper by NCSBN addressing Advanced Clinical Nursing Practice 1993 NCSBN Delegate Assembly adopts position paper on regulation of advanced nursing practice 1993 NCSBN Delegate Assembly adopts position paper on regulation of advanced nursing practice 1994 exploratory study on implications of developing a core exam for NP 1994 exploratory study on implications of developing a core exam for NP 1995 met with certifying bodies to establish a process relying on certification for granting state authorization to practice 1995 met with certifying bodies to establish a process relying on certification for granting state authorization to practice

APRN Historical Perspective 2000 APRN Task Force appointed to examine regulatory sufficiency of certification exams 2000 APRN Task Force appointed to examine regulatory sufficiency of certification exams 2002 approved the Requirements for Accrediting Agencies and the Criteria for Certification Programs (based on 1 year foundation work) 2002 approved the Requirements for Accrediting Agencies and the Criteria for Certification Programs (based on 1 year foundation work) 2002 Delegate Assembly adopts Uniform APRN Licensure Requirements and Position Paper on Regulation of Advanced Practice 2002 Delegate Assembly adopts Uniform APRN Licensure Requirements and Position Paper on Regulation of Advanced Practice 1992 and annuallyAPRN Roundtables held 1992 and annuallyAPRN Roundtables held

APRN Historical Perspective Draft Vision Paper released in March Draft Vision Paper released in March Volumes of feedback received Volumes of feedback received Opinions expressed both positive and negativeOpinions expressed both positive and negative Feedback reviewed and acted upon Feedback reviewed and acted upon NCSBN meetings with Stakeholder groups NCSBN meetings with Stakeholder groups NCSBN and APRN Consensus Group working together and form APRN Joint Dialogue Group NCSBN and APRN Consensus Group working together and form APRN Joint Dialogue Group

Current APRN Discussions Stakeholders Stakeholders NCSBN APRN Committee NCSBN APRN Committee APRN Consensus Workgroup APRN Consensus Workgroup 23 organizations representing education, accreditation, certification, practice and regulation23 organizations representing education, accreditation, certification, practice and regulation APRN Joint Dialogue Group APRN Joint Dialogue Group Individual Boards of Nursing Individual Boards of Nursing Stakeholder Professional Associations Stakeholder Professional Associations

Guest Speaker Gail Adcock, MSN, APRN-NP Case study presentation of a new graduate NP who decided to live and work in different states and presented a comparison of the wide variety of legislation that this NP faced in the practice environment. Case study presentation of a new graduate NP who decided to live and work in different states and presented a comparison of the wide variety of legislation that this NP faced in the practice environment.

Developments NCSBN NP/CNS Role Delineation Study NCSBN NP/CNS Role Delineation Study NACNS and ANCC certification efforts NACNS and ANCC certification efforts Based on nationally vetted core CNS competencies Based on nationally vetted core CNS competencies NCSBN APRN Committee meeting individually with stakeholder groups NCSBN APRN Committee meeting individually with stakeholder groups Known areas of agreement Known areas of agreement Identified areas still holding opportunity for further discussion Identified areas still holding opportunity for further discussion

Reasons Presented at Summit for a Common APRN Model Lack of common definitions related to APRN roles Lack of common definitions related to APRN roles Lack of standardization in programs leading to APRN preparation Lack of standardization in programs leading to APRN preparation Initial accreditation/approval necessary Initial accreditation/approval necessary Blended programs with variable clinical hours Blended programs with variable clinical hours Inconsistent Masters Essentials compliance Inconsistent Masters Essentials compliance Programs graduating students that cannot be licensed Programs graduating students that cannot be licensed

Reasons Presented at Summit for a Common APRN Model Proliferation of specialties and subspecialties Proliferation of specialties and subspecialties Examples-Palliative Care NP, Forensic NP and Homeland Security NP Examples-Palliative Care NP, Forensic NP and Homeland Security NP Lack of common legal recognition across jurisdictions Lack of common legal recognition across jurisdictions Less than 30 states recognize or title protect CNS Less than 30 states recognize or title protect CNS Not all states license/authorize CRNA same as NP Not all states license/authorize CRNA same as NP

Vision Paper Goals To envision a common future model for APRN legal recognition. To envision a common future model for APRN legal recognition. (additional outcome) To develop a paper on APRN legal recognition that is complementary to the APRN Consensus Group paper. (additional outcome) To develop a paper on APRN legal recognition that is complementary to the APRN Consensus Group paper.

March 2006 Draft Vision Paper Overview for Attendees Discussed the Vision Paper so that all attendees had common baseline information. Discussed the Vision Paper so that all attendees had common baseline information. Reviewed each recommendation with a summary of feedback received. Reviewed each recommendation with a summary of feedback received. Shared the outcomes of joint workgroups so baseline knowledge was current. Shared the outcomes of joint workgroups so baseline knowledge was current.

Summit Discussion Groups As a method to facilitate discussion and demonstrate the complexity of the issue, small groups discussed each of the 8 recommendations and attempted to achieve some consensus. As a method to facilitate discussion and demonstrate the complexity of the issue, small groups discussed each of the 8 recommendations and attempted to achieve some consensus. 80 participants representing APRN board members, Executive Directors and legal counsel (10 per table) gave feedback. 80 participants representing APRN board members, Executive Directors and legal counsel (10 per table) gave feedback.

Summit Discussion Group Outcomes Work to achieve consensus on APRN definitions of role, specialty, subspecialty, and core. Work to achieve consensus on APRN definitions of role, specialty, subspecialty, and core. APRN must be clinically focused. APRN must be clinically focused. Does it matter that the CNS and NP have common role functions? Does it matter that the CNS and NP have common role functions? How are psych CNS different than psych NP? How are psych CNS different than psych NP? Administer an exam by BON. Administer an exam by BON. Maintain current certification exam system. Maintain current certification exam system.

Summit Discussion Group Outcomes APRN is beyond the scope of the RN. APRN is beyond the scope of the RN. Will take years to change all of the Practice Acts. Will take years to change all of the Practice Acts. Keep our eye on years in the future and move beyond historical concerns. Keep our eye on years in the future and move beyond historical concerns. Move beyond vested interests for the good of the profession and to meet a growing public need. Move beyond vested interests for the good of the profession and to meet a growing public need. There is no consensus on population or specialty. There is no consensus on population or specialty. How do you monitor practice site appropriateness, ACNP in primary care? How do you monitor practice site appropriateness, ACNP in primary care?

Summit Summary Much good work was accomplished in one year. Much good work was accomplished in one year. Everyone was welcomed to the table and is participating. Everyone was welcomed to the table and is participating. Consensus is difficult to achieve. Consensus is difficult to achieve. Everyone realizes this is hard work that requires compromise to be successful. Everyone realizes this is hard work that requires compromise to be successful.

Vision Paper: The Future Regulation of Advanced Practice Nursing March 2006 version was a DRAFT March 2006 version was a DRAFT There is not a final document There is not a final document All feedback has been reviewed, discussed and seriously considered. All feedback has been reviewed, discussed and seriously considered.

2006 Vision Paper DRAFT Introduction and discussion lengthy with the purpose to capture the richness of debate and the complexity of the issue. Introduction and discussion lengthy with the purpose to capture the richness of debate and the complexity of the issue. Proposed 8 recommendations to achieve uniform regulatory requirements. Proposed 8 recommendations to achieve uniform regulatory requirements. Stimulated national debate. Stimulated national debate. Brought stakeholders together to collectively address the issues. Brought stakeholders together to collectively address the issues.

Recommendations The following 8 recommendations are presented as they were written in the March 2006 DRAFT version of the Vision Paper. Areas of Agreement and Disagreement of what has evolved are stated. The following 8 recommendations are presented as they were written in the March 2006 DRAFT version of the Vision Paper. Areas of Agreement and Disagreement of what has evolved are stated. When clarity of terms was appreciated fewer differences actually existed. When clarity of terms was appreciated fewer differences actually existed. Note that many of these recommended concepts have been revised and will be presented differently in future drafts. Note that many of these recommended concepts have been revised and will be presented differently in future drafts.

Recommendation 1: Boards of Nursing will be the sole regulators of APRN. Areas of Agreement Areas of Agreement General agreement once intent clarified that this meant BON, and not BOM or other groups would regulate APRN. General agreement once intent clarified that this meant BON, and not BOM or other groups would regulate APRN. Disagreement Disagreement ACNM is a proponent of separate midwifery boards.

Recommendation 2: APRN licensure will be in the categories and titles of nurse anesthetist, nurse midwife and nurse practitioner. Areas of Agreement Areas of Agreement CNS, CNP, CNM, CRNA will be the 4 roles of APRN. CNS, CNP, CNM, CRNA will be the 4 roles of APRN. CNS will meet same criteria as other APRN roles including education, certification and practice. CNS will meet same criteria as other APRN roles including education, certification and practice. Disagreement Disagreement Not all stakeholder groups agree to the 2 license concept. Unresolved what population foci are regulated

Recommendation 3: Boards of Nursing will approve APRN programs for the purposes of licensure. Areas of Agreement Areas of Agreement APRN education programs will be pre-approved before admitting students. APRN education programs will be pre-approved before admitting students. Programs include masters or doctoral essentials and role competencies in the population context. Programs include masters or doctoral essentials and role competencies in the population context. Regulation will be at the role and population foci. Regulation will be at the role and population foci. Disagreement Disagreement

Recommendation 4: All programs leading to APRN licensure including clinical practice doctorates and Post Masters Certificates will meet established educational requirements. Areas of agreement Areas of agreement Must be accredited. Must be accredited. Clinical experience is of sufficient depth and scope to ensure role and population competencies. Clinical experience is of sufficient depth and scope to ensure role and population competencies. Clinical experience covers the intended scope of practice with sufficient oversight by qualified faculty/preceptors. Clinical experience covers the intended scope of practice with sufficient oversight by qualified faculty/preceptors. Disagreement Disagreement

Recommendation 5: Requirements for licensure as a NP will include successful completion of a core NP licensure examination and a residency program. Areas of Agreement Areas of Agreement The term NP was expanded to APRN roles. The term NP was expanded to APRN roles. Clinical Experience or Clinical Practicum for all four roles will replace the term residency. Clinical Experience or Clinical Practicum for all four roles will replace the term residency. Testing for legal recognition will include the role core, 3 Ps across the lifespan and population foci. Testing for legal recognition will include the role core, 3 Ps across the lifespan and population foci. Disagreement Disagreement Will there be one test or two? What constitutes a meaningful licensure exam? Who will administer? How is testing accomplished? How will transparency between certification bodies and boards of nursing be achieved.

Recommendation 6: Evidence of continued competency will be required for purposes of licensure renewal. Areas of Agreement Areas of Agreement Maintain competence in area of specialty and practice. Maintain competence in area of specialty and practice. Disagreement Disagreement How is this operationalized?

Recommendation 7: Fully licensed APRN will be independent practitioners. After licensure there will be no regulatory requirement for supervision. Areas of Agreement Areas of Agreement Stakeholder agreement on the general principle. Stakeholder agreement on the general principle. Disagreement Disagreement not discussed yet... not discussed yet... Is there a period where some degree of supervision will be required?

Recommendation 8: The Advanced Practice Compact will be the regulatory model used to effect mutual recognition of APRN. Areas of Agreement Areas of Agreement Compact promotes consistency between states for licensure. Compact promotes consistency between states for licensure. Disagreement Disagreement Some professional associations and some Boards of Nursing are not supportive of the compact licensure concept.

We have everything we need to make good decisions for the future except perhaps the will to act. Al Gore Academy Award Winner I am hopeful that the APRN Summit and this work has given us that will to act. Faith Fields, MSN, RN NCSBN President NCSBN President