NURSING LICENSURE AND CERTIFICATION
To be a registered nurse! That is the goal of every student nurse. A worthy goal reached through study, clinical practice, and successful completion of the NCLEX-RN, the National Council Licensure Examination-Registered Nurse. In this chapter the reader will learn how and why nursing licensure developed, steps necessary to becoming licensed, licensure regulations, and the responsibilities of a registered nurse (RN).
After licensure as an RN, nurses still must maintain and increase their knowledge and skills. Some may wish to specialize in a particular area of nursing or expand their practice. Nurses with these goals may seek certification in a specialty field. This chapter describes certification, the means to achieve certification, and the organizations that administer certifying examinations. Whether it is licensure or certification, the nursing profession is continually progressing. Legal requirements to practice are continually revised to ensure the protection of the public. Just as in the past, nurses face issues and challenges as they seek to increase their competence and the nursing services they provide to patients and clients. Today it is no different. In this chapter issues related to licensure and certification are explored. Finally, future challenges emerging on the horizon are identified.
THE HISTORY OF NURSING LICENSURE
Recognition: Pins and Registries
The aim of caregivers since early times has been to be identified and recognized for one's skills and achievements. At first caregivers, particularly in the monasteries and convents of the medieval period, were identified by the habits they wore. Frequently special insignia designated health personnel. During the Crusades, a large Maltese cross adorned the black habits of the Knights Hospitalers of St. John of Jerusalem on the battlefield (Kalisch and Kalisch, 1995). These forms of identification allowed others to recognize their particular skills in care giving and healing. More recently, nurses wore a readily identifiable symbol of their school of nursing, the nursing cap.
Today, as in the past, the school of nursing pin identifies graduates from a particular school of nursing. Early in each school's history, the students and faculty crafted the pin. The pin's emblems and text symbolize the philosophy, beliefs, and aspirations of the nursing program. Students receive it at graduation in a pinning ceremony. Nurses wear their pins proudly as evidence of their achievement, learning, and skill. It is one way in which they distinguish themselves as distinct health care providers with a special body of knowledge and clinical skills.
Nursing programs also maintain a record of all graduates. Florence Nightingale started this practice by creating a list of graduates in 1860 at the St. Thomas' School of Nursing in England. This list became known as the "registry" of graduate nurses. The registry of nurses initiated by Nightingale provided institutions and clients with the means to identify graduates of nursing programs and ascertain the skills and knowledge of graduates. Today nursing programs around the world continue the tradition started by Nightingale and maintain a registry or listing of all graduates of the nursing program.
Purpose of Licensure
As nursing programs proliferated, variations developed among the programs. Entry criteria differed, and educational programs were structured to meet specific employer needs. A simple registry of graduates was not sufficient to ensure minimal levels of competency in all graduates, regardless of the training program. Another process was necessary to distinguish those sufficiently trained to provide nursing care from untrained or lesser-trained individuals. Graduate nurses, physicians, and hospitals joined to resolve the issue. The outcome was the development of criteria for licensure of nurses. Then as now, the primary purpose of licensure is the protection of the public.
Early Licensure Activities
As early as 1867, Dr. Henry Wentworth Acland suggested licensure of English nurses. However, it was not until 1896 that licensing nurses was first attempted in the United States. Nursing programs in the United States developed in much the same manner as was the pattern in England. Before the late 1800s many hospitals began training programs to prepare nursing staff for their own institutions. The programs varied based on the needs of the hospital, the availability of physicians and nurses for training students, and resources devoted to the training. To develop a standard for nurses and to improve the mobility of nurses between institutions, the Nurses Associated Alumnae of the United States and Canada, the organization that later became the American Nurses Association (ANA) in 1911, advocated licensure of nursing program graduates. But the group met with much resistance from hospitals, physicians, and nurses. These first attempts at licensure failed for lack of support (Kelly and Joel, 1996).
Nurses worldwide mounted an extensive educational campaign explaining the purposes and safeguards inherent in licensure, and in 1901 the International Council of Nurses passed a resolution that each nation and state examine and license its nurses. In 1903 North Carolina, New Jersey, New York, and Virginia were the first states to institute permissive licensure. The licensure rules were voluntary. These permissive licenses permitted but did not require nurses to become registered.
Under permissive licensure, educational standards were set at a minimum of 2 years of training for nurses. State boards of nursing were established with rules for examinations and revocation of the license. Nurses not passing the examination could not use the title of RN. Therefore, in addition to protecting the public from unskilled practitioners, these rules were an early move to protect the title of RN. The New York State Board of Regents began a registry of nurses successfully completing all requirements. In 20 years, by 1923, all states had instituted examinations for permissive licensure. Each state's licensure examinations varied in content, length, and format and included written, oral, and practice components.
The early work in examinations for licensure was the forerunner of today's licensure and certification requirements (Kalisch and Kalisch, 1995). The early state efforts in licensing nurses were commendable. Nonetheless, there was considerable variability between states in nursing education requirements, the licensure examinations, and the nursing practice acts themselves. The widespread variability in nursing practice acts prompted the ANA and later the National Council of State Boards of Nursing to design model nursing practice acts. The model acts provided a template for states to follow. The first was published in 1915. These model practice acts have been revised and updated as nursing practice advanced (Kelly and Joel, 1996). The latest revision of the model nursing practice act occurred in 1994 (National Council of State Boards of Nursing, 1994). The model nursing practice act proposes a definition of nursing, the scope of practice for the RN, descriptions of advanced practice nursing, requirements for prescriptive authority of nurses, and guidelines for disciplinary actions against nurses who violate sections of the act. Separate sections of the model act provide guidelines for State Boards of Nursing and the necessary requirements for entry into practice. From these model acts, each state or jurisdiction developed a unique practice act. Although the individual act addresses the needs of that jurisdiction, each includes the sections described in the model act. The nursing practice act for any state may be obtained by contacting that state or territorial board of nursing. A listing of state boards of nursing addresses and Internet addresses is provided (Appendix B).
Once each state had established permissive licensure, the next movement was toward a requirement that all nurses must be licensed. This practice is termed mandatory licensure. Likewise, efforts were promulgated to standardize nursing testing procedures. In the mid 1930s New York was the first state to require mandatory licensure, although this requirement was not effective until 1947. After World War II the ANA formed the National Council of State Boards of Nursing. The council was comprised of a representative of each state and jurisdiction in the United States. As part of its original activities, the Council advocated a standardized examination for licensure. This sponsorship led to the National League for Nursing administering the first State Board Test Pool Examination in 1950. The written examination included separate sections on medical-surgical nursing, maternity nursing, nursing of children, and psychiatric nursing. This format for examination continued for over 30 years, and many of today's nurses took these examinations.
The next major event in licensure efforts occurred in 1982 with the development of the first NCLEX examination. The test was revised to include all nursing content within one section of the examination. In addition the format was changed to present questions in a nursing process format. Just as with previous versions of licensing examinations, the NCLEX has evolved over time. Paper and pencil testing was replaced with computerized adaptive testing in 1994. Extensive information on the NCLEX may be found in Chapter 26 of this text.
COMPONENTS OF NURSING PRACTICE ACTS
As discussed previously, each state develops rules and regulations to govern the practice of nursing within that state. These rules are in the nursing practice acts or rules and regulations to administer the act. Many nursing practice acts are patterned after the ANA or the National Council of State Boards of Nursing, Inc. model practice acts, and all contain comparable information.
Purpose of Act
Each act begins with a purpose. All nursing practice acts include two essential purposes. First, each includes statements that refer to protecting the health and safety of the citizens of the jurisdiction. The act describes the qualifications and responsibilities of those individuals covered by the regulations. Likewise the act delineates those excluded from the practice of nursing. These provisions ensure the protection of the public. The second purpose is to protect the title of RN. The legal title, RN, is reserved for those meeting the requirements to practice nursing. Only those licensed may use the designation of RN. Thus unlicensed personnel are prevented from using the title of Registered Nurse.
Definition of Nursing
In each state or jurisdictional nursing practice act the practice of professional nursing is defined. The definition of nursing is of utmost importance because it delineates the scope of practice for nurses within the state. That is, each act outlines the activities nurses may legally perform within the jurisdiction.
Many states follow the guidelines incorporated in the model practice act, although each is specific and delineates practice within that state or jurisdiction. For example, some states describe nursing as a process that includes nursing diagnosis, whereas other states list broad areas of nursing activities. To prevent the acts from becoming outdated, there are no lists of skills or procedures in the acts. As nursing knowledge and practices advance, new techniques are frequently allowable because of the generalized nature of the definition of nursing. Many jurisdictions incorporate definitions of advanced practice nursing within one definition of nursing. In other states the definitions of advanced nursing practice and the scope of practice for advanced practice nurses are separately defined. The format of the act will be readily apparent with review of the nurse practice act.
Each state or jurisdiction establishes laws regulating practice within its borders. Therefore it is imperative for the nurse to know and understand the definition of nursing in the states in which he or she practices. Further, jurisdictions retain the rights to govern practice within the jurisdiction, even in the presence of a mutual recognition agreement with other compact states. This retention of states rights is an essential component in the Mutual Recognition Model.
A section of each nursing practice act describes the requirements and procedures necessary for initial entry into nursing practice, or nursing licensure. An initial requirement in all jurisdictions is graduation from high school and an accredited nursing program. Candidates for licensure must submit evidence of graduation as defined by each state.
At present North Dakota is the only state requiring a
baccalaureate degree for licensure as a professional nurse.
This requirement was initiated in
Additional requirements for licensure may include the mental and physical health status of the applicant. In addition, jurisdictions may conduct a review of prior legal convictions. This is especially important in reference to felony convictions. Some states have appended provisions related to recreational drug abuse. Finally, most states require statements from the school of nursing attesting the eligibility of the candidate for licensure. Frequently a transcript of coursework, a diploma, or a letter from the dean of the program attesting to the graduation of the applicant is necessary. Once again, as the laws are continually being revised to reflect the current practice of nursing, it is incumbent on the individual to be cognizant of the current licensure requirements in all states in which he or she intends to practice.
Regardless of individual state requirements, all nursing practice acts require candidates for practice to successfully complete the NCLEX-RN licensure examination. In some states it is possible to obtain a temporary permit to practice, pending receipt of success on the licensure examination. This practice was especially prevalent in past years, as in some states it took several months for results of the licensure examinations to be reported. Now, however, with the prompt response from the testing services, the need for temporary permits to practice is becoming less frequent.
A temporary permit is still available for nurses moving from one state to another. To obtain a license to practice in another state, the nurse applies for licensure by endorsement. Nurses licensed in one jurisdiction may apply for licensure in a second jurisdiction by submitting a letter to the Second State Board of Nursing. Typically evidence for the new license is similar to that for initial licensure. In addition, proof of the nurse's current license to practice, as well as any restrictions imposed on the license by the first state, is required. These procedures will continue for all States not participating in the Mutual Recognition Model. For those states designated as compact states, the nurse should contact the State Board of Nursing to determine the appropriate procedures for nursing practice. Regardless of the type of nursing practice act, the nurse is still responsible for ascertaining the requirements to practice within each jurisdiction.
Renewal of Licensure
In addition to outlining requirements for initial licensure, each nursing practice act includes the requirements and information necessary to renew one's nursing license. These regulations define the length of time a license is valid, generally from 2 to 3 years. In addition, any specific requirements for renewal of licensure are stated.
Mandatory Continuing Education
The nurse will find information on mandatory continuing education for renewal of licensure in the section on license renewal. All nurses are expected to remain competent to practice through various means of continuing education. In 1976 California was the first state to institute mandatory continuing education for renewal of licensure. Since that time a number of states have instituted requirements of continuing education for renewal of licensure. The number of hours necessary varies, depending on the jurisdiction, ranging from 20 to 40 hours over a 2- to 3-year period. An additional obligation has been instituted in some jurisdictions. These jurisdictions require specific continuing education content such as health care ethics or the state nursing practice act. Clinical course content may be designated for specific health problems such as sexually transmitted infections, human immunodeficiency virus-acquired immune deficiency syndrome, and family violence. In other states the Board of Nursing allows the nurse wide latitude in meeting the requirements for renewal of licensure.
ROLE OF REGULATORY BOARDS TO ENSURE SAFE PRACTICE
Membership of the Board of Nursing
An important section of every nursing practice act is the designation of a regulatory board of nurses and consumers to administer the nursing practice act. Frequently this responsibility is assigned to a State Board of Nursing. The practice act outlines guidelines for membership on the board. In addition, procedures by which members are appointed to the Board of Nursing are designated. In most cases, the members are appointed by the Governor's office. Interested individuals or organizations, such as the state nurses association may submit names to the Governor for consideration.
Duties of the Board of Nursing
The responsibilities and duties of the Board of Nursing are delineated in detail. Specific duties of the board may be outlined in the act itself or in the enabling laws. These enabling administrative statutes are frequently designated as Rules and Regulations for the Practice of Nursing. It is through the work of the Board of Nursing that nursing licenses are granted and renewed and disciplinary action taken when provisions of the act are violated. Just as all nurses need to be cognizant of their nursing practice acts, nurses should also become familiar with the role of the State Board of Nursing.
A major responsibility of the Board of Nursing is responding to concerns about a nurse's practice. The review of a nurse's potential malfeasance, violation of the act, or other state and federal laws are within the responsibilities of the Board of Nursing. The nursing practice act describes the due process and procedures for this review. The Board of Nursing will then assign appropriate disciplinary action. These activities are a key responsibility of the Board of Nursing. Actions may include restrictions on the license or suspension or revocation of a nurse's license when provisions of the act are violated. Just as all nurses need to be cognizant of their nursing practice acts, nurses should become familiar with the role of the State Board of Nursing.
SPECIAL CASES OF LICENSURE
Military and Government Nurses
There are many nurses whose practice takes them throughout the country on a regular basis. For example, many nurses are members of the military or join the military nursing services after graduation. The Veterans Administration or Public Health Service employs thousands of nurses. These nurses serve in many jurisdictions, as well as outside the United States boundaries. It is not necessary for these nursing personnel to obtain a nursing license in each jurisdiction in which they practice. The graduate takes the NCLEX-RN examination in one state. On successful completion, as an employee of the United States government, he or she may practice in other jurisdictions without additional licensure requirements.
Foreign Nurse Graduates
A growing number of nurses practicing in the United States completed their nursing education in another country. The nurses met the requirements for practice in those jurisdictions.
When these nurses move to the United States, they take a special examination administered by the Commission on Graduates of Foreign Nursing Schools. The examination is given in English and tests the knowledge required to practice in this country. On successful completion, the foreign nurse graduate may apply for a license to practice in this country.
In a similar manner nurses licensed in the United States may want to practice in other countries. Nurses interested in these opportunities may contact either the International Council of Nurses or the nursing regulatory board of the country in which they wish to practice.
REVISION OF NURSING PRACTICE ACTS
Nursing practice acts, just as other sections of states codes, are written and passed by legislators Just as in any legislative endeavor, many governmental agencies, administrators, consumers and special interest groups seek to influence the legislation. These groups become actively involved in developing the accompanying rules and regulations. For example, physicians, dentists, pharmacists, licensed practical nurses, certified nursing assistants, emergency personnel, and physician's assistants are just a few of the health care providers who are directly affected by the scope and definition of nursing practice. Likewise, organizations such as schools, hospitals, home health agencies, and extended care facilities are vitally concerned with the role of nurses today. Because of these multiple interest groups, the nursing practice act as finally passed or amended by the state legislature represents the aims and concerns of many, not only nurses. Review of a state's practice act reveals the influential parties involved in creating the act. Each group participates in defining the scope and practice of nursing and regulations affecting nursing practice within the jurisdiction. Because of these varied interests, it is essential for nurses to understand the practice act and the additional legislation that influences control their practice. Further, as proposals to amend the nursing practice act are promulgated suiting at the state level, it is imperative for all nurses to be involved in this process. The resulting lows affect your profession, your practice, and your livelihood.
One example of legislative activity affecting nursing practice acts is sunset legislation. Sunset laws are found in many states. These laws are intended to ensure that legislation is current and reflects the needs of the public. When sunset provisions are included in nursing practice acts, the act must be reviewed by a specific date. If the act is not renewed, it is automatically rescinded. This review process allows for revisions to update practice acts to be consistent with current nursing practice. Many nursing practice acts contain provisions of sunset legislation. It is through: these activities that the scope of nursing practice is updated and the diagnosis of nursing problems has been incorporated into many definitions of nursing. Other changes include requirements for mandatory continuing education for renewal of licensure. Equally important, sunset laws have provided the means to define advanced practice nursing and incorporate prescriptive authority for advanced practice nurses.
DELEGATION OF AUTHORITY TO OTHERS
The rapid expansion of health care providers, changes in health care delivery systems, and efforts to control health care costs have led to participation of many types of unlicensed personnel in the provision of health care. These personnel present a challenge to RNs working with them. Questions arise as to who can delegate what activities to which unlicensed provider groups. Guidelines for delegation have been developed by many nursing organizations, in eluding the ANA and the National Council of State Boards of Nursing. However, the most current regulations may be found in the nursing practice acts of individual states. Because regulations differ among states, each nurse must identify and understand the regulations for the state in which he or she practices. Chapter 18 presents a detailed discussion of delegation and supervision.
CURRENT LICENSURE ACTIVITIES
Mutual Recognition Model
Efforts to provide common definitions of nursing practice, standards of education, and testing for entry into practice across state boundaries have been very successful. Nonetheless, most nurses are still required to apply for licensure in each state in which they practice. With the increased mobility of nurses, the telecommunications movement, and the necessity of caring for clients across long distances, state boards of nursing have recognized the need to provide practicing nurses with more than procedures of endorsement of their initial license. This need has led to further changes in nursing licensure. In 1997 the Delegate Assembly of the National Council of State Boards of Nursing moved to a new level of nursing regulation. The assembly approved a resolution endorsing a mutual recognition model of nursing regulation. Through this model individual state boards will develop an interstate compact allowing nurses licensed in one state to practice in all other states and territories. Nurses will be responsible for following the laws and regulations of those states, although they will not be required to apply for individual state licensure (National Council of State Boards of Nursing, 2001).
A number of issues associated with mutual recognition concern nurses. On the other hand, mutual recognition would greatly facilitate interstate practice and to areas of shortage. A national database would provide information practice and movement of nurses to areas of shortage. A national database would provide information on individual nurses' practice and tracking mechanisms. On the other hand, concerns relate to monitoring nurses who practice in multiple jurisdictions, nurse privacy, and due process rights. Differences in practice requirements in different states may cause nurses confusion as to their rights and responsibilities.
The results of mutual recognition compacts will affect all nurses. Nursing students and graduates must remain apprised of changing conditions. The most comprehensive and current sources of information are the Internet sites for the American Journal of Nurses and the National Council of State Boards of Nursing. In addition, the Online Journal of Nursing at the American Journal of Nursing website and the individual state boards of nursing can provide current information to interested nurses.
As discussed in preceding paragraphs, the primary purpose of nurse licensure is protection of the public. Thus mandatory continuing education was instituted as a strategy to ensure that nurses were competent to remain in practice. These programs have continued for a number of years. However, a growing number of nurses believe that more is required than just attending seminars to demonstrate the degree of competence. Consortiums of nurses in a number of states are examining other alternatives for renewal of licensure. These requirements may include clinical practice hours, portfolios, and other exemplars of practice.
There is increasing concern for patient safety and treatment in today's health care system. Models of continued competency are but one attempt by professional nurses to ensure that patients and clients receive safe, effective nursing care. Another strategy in this quest is establishing programs of certification of advanced practice nurses.
Purpose of Certification
There are distinct differences between licensure and certification. At the most basic level, licensure establishes minimal levels of practice, whereas certification re cognizes excellence in practice. Because of this difference, the background, requirements, and practice opportunities for licensure and certification differ markedly.
Just as with the development of nursing licensure, at its inception certification was not legally required; rather it was voluntary. In an effort to recognize nurses who had completed additional education and demonstrated competency in clinical practice, a number of nursing graduate schools and nursing specialty organizations offered certification programs. In the 1970s and later, advanced clinical courses were designed for nurses as a certificate program. The programs varied in length and content and did not offer a full master's course of study in nursing.
A second distinct difference in licensure and certification pertains to the organizations that grant certification. Whereas licensure is granted and governed by legislation and administered through the State Boards of Nursing, certification is awarded by nongovernmental agencies. Typically these agencies are professional nursing specialty organizations. These organizations have created certification boards that are separate from the parent organization to conform to Department of Education requirements. See Appendix A for a list of specialty organizations.
The first field of nursing practice to certify practitioners was nurse anesthesia in 1946. Since that time the National Association of Nurse Anesthetists has maintained strict standards for education, certification, and practice of practicing nurse anesthetists. The policies and procedures established by nurse anesthetists provided a model for subsequently certifying advanced practitioners in nursing. Similarly in 1961 the American College of Nurse Midwives, founded in 1955, began certifying nurse midwives.
As certificate programs developed, it became apparent that standardization in programs was a necessity. In 1975 the ANA convened a national study group at the University of Wisconsin-Milwaukee to explore the issue. Seventy-five nursing specialty organizations attended. The report of the group recommended the formation of a central organization for certification of nurses. This report, in conjunction with efforts of many nurses, resulted in the formation of the American Nurses Credentialing Center. At present the American Nurses Credentialing Center (2001) has certified more than 200,000 nurses in 25 areas of specialty practice. Subsequently in 1991 the American Board of Nursing Specialties organized with eight members: the ANA and the certifying boards of occupational health nurses, neuroscience nurses, rehabilitation nurses, nurse anesthetists, nutritional support nurses, nephrology nurses, and orthopedic nurses. This specialty board represents the majority of nursing organizations that certify nurses. Their mission is to ensure high standards and quality in education, evaluation, and practice of certified nurses. These efforts are further indication of nurses' commitment to protection of the public and the patients that nurses serve.
Certification began as a voluntary effort controlled by nursing organizations. State agencies were not involved in the credentialing process. This is still the case, although state nursing practice acts now include requirements for nurses to practice in these advanced roles. Thus state practice acts first contained provisions requiring certification for nurse anesthetists and nurse midwives. With the development of additional advanced practice roles, all states have included requirements of certification in their regulations for advanced practice nurses (National Council of State Boards of Nursing, 2001). These definitions frequently are included in the nursing practice act. A number of states differentiate the advanced practice of nursing by including separate titles for nurse practitioners and clinical nurse specialists. Although many states require a master's degree in the specialty area for practice, this is not the case in all jurisdictions (Hawkins and Holcombe, 1995). In addition, all states incorporate specific provisions for prescribing medications (McDermott, 1995).