The purpose of this article is to inform nurse practitioners about the impact of the APRN Model Act/Rules and Regulations (hereafter called the Model Act), which is based on concepts put forth in the Consensus Model. The Model Act provides professional standards that will be recognized across states.

Rules and regulations governing the education and practice of advanced practice registered nurses (APRNs) in the United States vary across each state. This variation results in challenges for many APRNs who wish or need to move from one state to another state or from one employer to another employer. Recognizing these challenges, nursing leaders who comprise the APRN Consensus Work Group and the APRN Committee of the National Council of State Boards of Nursing (NCSBN) met to develop the Consensus Model. Implementation of this model nationwide will help standardize the components of regulation—licensure, accreditation, certification, and education (known by the acronym LACE)—which will lead to improved patient safety and heightened professional accountability, as well as provide greater mobility for APRNs.

For example, Ms Smith lives in State A, where she is a pediatric nurse practitioner specializing in pediatric oncology, but without national certification. She practices at an academic institution in State A. She must move to State B, which will not recognize her as a certified NP because she does not have national certification. What must Ms Smith do to get certified? As another example, Mr Jones is a palliative care NP. He is practicing in State C but wishes to move to State D. Will he be allowed to practice in State D? As the number of APRNs in the United States increases, scenarios like these are becoming more prevalent. Following a period of transition, the Model Act will prevent the types of challenges faced by Ms Smith and Mr Jones, and lead to improved recognition and mobility for NPs.

What is the definition of an APRN?
The Model Act defines the advanced practice registered nurse as a nurse: “1. who has completed an accredited graduate-level education program preparing him/her for one of the four recognized APRN roles; 2. who has passed a national certification examination that measures APRN role and population-focused competencies and who maintains continued competence…through the national certification program; and 3. who has acquired advanced clinical knowledge and skills preparing him/her to provide direct care to patients, as well as a component of indirect care; however, the defining factor for all APRNs is that a significant component of the education and practice focuses on direct care of individuals.¹

Nurses pursuing a career as an APRN will choose a graduate program pre-approved to comply with the requirements of the Model Act. Transcripts from approved programs will indicate the particular APRN role and the particular population studied. After an APRN passes a psychometrically sound and legally defensible certification examination that matches the specific role and population for which he/she has been prepared, a second license will be issued that will build on the RN license. This second license will be in one of four roles described in the Consensus Model: certified nurse practitioner (CNP), clinical nurse specialist (CNS), certified nurse-midwife (CNM), or certified registered nurse anesthetist (CRNA). After obtaining this license, NPs will use the credentials APRN, CNP. APRNs graduating from a doctoral program will be allowed to refer to themselves as doctor, but they will also use the nomenclature described above.

What is the background of the Consensus Model?
The ranks of APRNs/CNPs have exploded over the past 45 years. There were more than 240,000 APRNs in 2004, which was just over 8% of the RN workforce.² These professionals fill the demand for exceptionally skilled nurses to provide high-quality healthcare services throughout the nation.^3-5 Despite the increase in the number of APRNs and the high quality of care that they deliver, a lack of consistency in educating and regulating APRNs has prevailed. Rapid growth of educational programs and roles has resulted in practitioners with varying levels of skill and knowledge. Each state licensing board of nursing, governed by statutes and regulations, determines who can practice in that jurisdiction. No uniformity exists, which has affected the APRN services that consumers can receive. A synthesis of the variety of regulations has resulted in states being ranked based on NP practice environment and consumer health choices.⁶

Nursing leaders have recognized a need for more consistency in the regulation of APRN practice. National standardization of licensure, accreditation, certification, and education would enhance patient safety, professional accountability, and APRN mobility. More than 70 leading national nursing organizations and state boards, representing each of the components of licensure, accreditation, certification, and education (ie, LACE), met to develop a regulatory model. This model was the culmination of the combined work of a national APRN Consensus Work Group and the APRN Committee of the NCSBN. In addition, members from each of these two groups, called the APRN Joint Dialogue Group, met to facilitate the movement of a nationwide consensus on APRN regulatory issues. In July 2008, the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education was completed. Readers can log on to http://www.nonpf.com/displaycommon.cfm?an=1&subarticlenbr=26 or https://www.ncsbn.org/170.htm for a list of professional nursing organizations that have endorsed this model.

The Consensus Model defines APRN practice, describes the APRN regulatory model, identifies the titles to be used, defines specialty, describes the emergence of new roles and population foci, and presents strategies for implementation.⁷ As mentioned earlier, this document recognizes APRNs in one of the four direct care roles: CNP, CNS, CNM, and CRNA. Each APRN will be educated in one of these roles and in one of six population foci: neonatal, pediatrics, women’s health/gender-related, family/individual across the lifespan, adult/gerontology, or psychiatric mental health (Figure). In addition to the population foci, CNPs are prepared to practice in the acute care and/or primary care domain.

What are the rules and regulations of the APRN Model Act?
Over past decades, the NCSBN has had Model RN and APRN Acts for states to use as guidance. The NCSBN committee developed the APRN Model Act of 2008 to reflect the issues surrounding the variety of Nurse Practice Acts (NPAs) in each state. The goal was to develop uniformity across the country. The APRN Model Act serves as a template for state boards of nursing to examine their own existing regulatory language as they revise their state NPAs, as well as a means of promulgating new ideas for future goals. The APRN Model Act changes as nursing evolves and the need arises to propose new laws to regulate the practice of nursing.

In August 2008, the NCSBN approved the APRN Model Act based on the concepts put forth in the Consensus Model. This Model Act will guide states in terms of how to rewrite their laws in keeping with the Consensus Model.

Once states adopt the Model Act, what will be the benefits?
This visionary model has a number of benefits. The patchwork of state regulations and practices has made it difficult for APRNs to practice in another state because the criteria for authorization and the process vary. The APRN Model Act will clarify the statutes, rules, and regulations for APRNs in all jurisdictions and standardize entry into practice. Uniformity across the United States and its territories will increase APRN mobility and facilitate a smoother transition for authorization to practice. An expectation of a consistent base of knowledge and skills will protect public safety, ensure quality care, and improve healthcare access.

This new model aims to ensure quality by standardizing the regulatory components. The Model Act lists the foundational requirements for each LACE area and gives specific guidelines for boards of nursing, accreditation bodies, and certification and educational programs, thereby providing consistency for APRN education and regulation.

Within academic institutions, a pattern of specialty and subspecialty NP programs evolved that was not consistent with a foundational knowledge base. These specialty and subspecialty programs will no longer be recognized for licensure. With the Consensus Model, all programs—MSN, post-MSN certificate, and clinical doctorate—will be formally reviewed, and only those with population foci will be recognized and eligible for accreditation. Although national guidelines for these programs are available, there remains a lack of consistency in common criteria and broad-based foundational course work for the APRN roles. National certification for APRN roles and population foci will now be standardized as necessary for licensure. APRN education will include separate graduate-level core courses in the 3 P’s: advanced health/physical assessment, advanced pharmacology, and advanced physiology/pathophysiology. Core, role, and population competencies will be consistent at every school, and all programs will be at the graduate or postgraduate level, making APRN education more unified.

What are the implications of the Model Act for APRNs?
If a state chooses to adopt the Model Act, APRNs working in that state will be able to practice independently, without a collaborative or supervisory agreement with a physician. APRNs will be able to provide direct, or one-on-one, care to patients. Independent APRNs will have full prescriptive privileges for pharmacologic and non-pharmacologic interventions, without requirement for supervision by any other healthcare practitioner or limitations to a defined formulary. APRNs can be recognized as primary care practitioners, when appropriate and designated by the license given.^8,9

The Model Act will be adopted by states incrementally, with a goal of complete adoption for all states by 2015.¹⁰ For now, states vary regarding rules and regulations governing APRNs. States also differ in terms of the educational requirements, the need for national certification, and the professional title and signature mandated for APRNs. Some states will have much more work to do than others to meet criteria for Model Act adoption. All APRNs have the responsibility to comply with the current requirements of the state in which they practice. The Pearson Report is an excellent resource that includes current legislative data for each state. The 2010 version of The Pearson Report, written by Linda J. Pearson, will be available on the NP Communications website at www. webNPonline.com in March 2010.¹¹

All APRNs must assess their personal preparation as APRNs to understand the implications of the Model Act. This assessment begins with a review of their educational background, national certification, and population focus (Table 1). The Consensus Model proposes specific educational requirements for all APRNs, including completion of an accredited program in one of six populations. The curriculum must include graduate-level courses in the 3 P’s: advanced health/physical assessment, advanced pharmacology, and advanced physiology/ pathophysiology. In addition, a minimum of 500 graduate-level, supervised clinical hours in the role and population focus are required.¹² CNPs may be exempt from meeting these requirements if they were recognized by their state prior to the new mandates. The Model Act also requires all NPs to obtain national certification from an approved certifying body. Although certification is mandated in most states, some states lag behind, resulting in a number of NPs without national certification. All CNPs should consider obtaining national certification in order to comply with these upcoming changes (Table 2).

NPs certified to practice prior to the changes would be eligible to continue practicing in the state in which they are licensed. They will be “grandfathered” in, which means that the original license or recognition issued by that state will be honored as long as the CNP continues to meet the original terms. These CNPs will not be required to meet the new Consensus Model mandates as long as they remain in their state. However, a move to another state may impede practice if a CNP is not nationally certified. If national certification was not required in the state where licensure originated, then practice can continue. In addition, educational requirements in place when a person was first recognized as a CNP would continue to be recognized.

Although CNPs will be grandfathered in their practicing state, this practice may not be transferable to other states. CNPs must meet current requirements of any state to which they are applying to practice. The only exemption is the educational requirement. That is, if one state recognizes a CNP from a certificate or master’s program that did not have the 3 P’s or the 500 clinical hours until a certain year, that nurse may be recognized by other states. All other state requirements must be met, including national certification—an important consideration because some NPs will not meet the new requirements and may not be nationally certified. If they are grandfathered in their practicing state, they can continue to practice but may forfeit mobility unless they meet the new requirements. Considering the upcoming regulatory changes, NPs should be proactive in planning for future practice and career mobility. Being proactive in this context means obtaining national certification and seeking additional formal education that meets the new curriculum standards. CNPs considering additional education may choose to pursue the clinical doctorate (ie, the DNP).

Although the Model Act does not recognize specialty education (eg, oncology), CNPs may choose to pursue a specialty to enhance their practice. Specializing usually involves additional education followed by a specialty examination. Although specialization does not affect state recognition, it may be acknowledged or required by an employer institution. Specialty instruction will continue to be a valuable addition to the required broad-based CNP education.

How do I assure quality in my APRN practice?
A basic way for all APRNs to demonstrate quality assurance is to know and practice under the guidelines of the Nursing Code of Ethics, Nursing Social Policy Statement, and Nursing Scope and Standards of Practice.^13-15 In addition, other population and specialty competencies guide APRN practice. Maintaining national certification in an APRN role and population focus that matches one’s formal education and transcript from the academic institution, through recertification programs, is an additional demonstration of competency as an APRN.

When searching for occurrence rates regarding the number of accumulated malpractice and adverse actions, licensure actions, civil judgments and criminal conviction reports submitted against NPs, one must place them in a context with other practitioners such as MDs and DOs. Pearson has performed such an analysis in Table 3 of her 2009 report in The American Journal for Nurse Practitioners on NP legislation and healthcare issues.¹⁶ Overall, Pearson finds that NPs have much lower occurrence rates based on the National Practitioners Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB) reports. In the 10 states (plus DC) in which NP practice is independent of physician involvement, no research has shown a higher incidence of malpractice on the part of NPs compared with other practitioners.^6,16-18 Thirteen states do not require national certification; however, to protect APRNs as well as the public, this situation must change by 2015, the year proposed for full implementation of the Model Act. APRNs will continue to practice under a second license, as mentioned earlier.

How do the Consensus Model and the Model Act help me?
Implementation of the Model Act may provoke anxiety, but regulations are in place to protect NPs. As stated earlier, if NPs remain in their state, the Model Act may not affect them. In addition, NPs have a property right to their APRN license/recognition. Their license or permit to practice as an APRN is protected by Amendment 14—due process.¹⁹ The license or permit cannot be revoked or suspended without proper notification and hearing.¹⁹ Professional license laws always have such criteria listed as procedural protection in administrative procedure law. Procedural protections are appropriate and justified because licenses give people the ability to earn a living in their chosen profession, such as nursing. The protected status of the license of a nurse is firmly established.

A grandfather clause or waiver is a statement in a licensing act that addresses how persons who are currently licensed will maintain that license when new qualifications are enacted into law.20 The clause or waiver is a standard feature that allows such persons to continue to practice the profession when new criteria are enacted into law. This concept is more than 100 years old and is related to the 5th and 14th Amendments. The US Supreme Court has ruled that a license to practice a profession is a property right and that Amendment 14 extends the due process requirement to state law.²⁰
Endorsement is a different issue for APRNs. For APRNs to gain the right to practice in a new state, they must meet the current terms of the state. One state need not recognize the “property right” granted by another state. To gain endorsement under the Model Act, APRNs must:

Be in good standing in their current state;

Meet current requirements of the new state;

Submit an application to the new state;

Pay a fee to the new state;

Have completed an accredited APRN program in one role and one population focus; and

Have current national certification in the same role and population focus as the formal education.

 

Without endorsement, APRNs may not practice in a new state. A grandfathering clause or waiver that allows APRNs to practice in their current state does not cover them in a new state in which practice may be desired. If all goes according to plan, one of the greatest advantages of the Consensus Paper and Model Act will be that, by 2015, all 50 states and territories will adopt these recommendations and mobility will be granted for future APRNs who meet the Consensus Model and Model Act criteria.

How will the Model Act affect Ms Smith and Mr Jones?
The Model Act will have different implications for individual NPs, as illustrated by reviewing the scenarios presented earlier. Ms Smith lives in State A, where she is a pediatric nurse practitioner in pediatric oncology, without national certification. She practices at an academic institution in State A. She is moving to State B, which will not recognize her as a CNP because she lacks national certification. What must Ms Smith do to get certified? Ms Smith needs to examine her transcript to make sure that she has three distinct graduate-level courses in pharmacology, physical assessment, and advanced pathophysiology (the 3 P’s), as well as 500 clinical hours in one of the six population foci to sit for the National Certification examination before she can practice in State B. Mr Jones is a palliative care NP. He is practicing in State C but wishes to move to State D. Will he be allowed to practice in State D? To practice in State D, Mr Jones will need to be licensed in one of the six population foci. Palliative care is not one of these foci; instead, palliative care will be considered a specialty. Mr Jones will need to return to school to receive education in one of the six populations in order to practice in a new state.

Conclusion
The Consensus Model and subsequent Model Act represent a beneficial change for all APRNs. These entities will assure quality preparation for practice and will promote a better understanding of what constitutes a nurse practitioner. In the current era of healthcare reform, NPs will play a crucial role as healthcare providers. By embracing the Model Act, NPs can assure the public that they are united and prepared to meet the challenges of a changing healthcare system.

Barbara A. Boland is an adult nurse practitioner at an internal medicine practice at the University of Pennsylvania Health System and the University of Pennsylvania School of Nursing in Philadelphia. June Treston is an advanced senior lecturer and associate director of the family health nurse practitioner program, Victoria A. Weill is an advanced senior lecturer and associate director of the pediatric nurse practitioner program, and Ann L. O’Sullivan is a professor of primary care nursing and program director of the family and pediatric nurse practitioner programs, all at the University of Pennsylvania School of Nursing in Philadelphia. The authors state that they have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References

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