The Journal for Nurse Practitioners - JNP 99www.npjournal.org

ABSTRACTNursing’s leading professional organizations, after meeting for over 4 years, have reachedconsensus on a model for future advanced practice registered nurse (APRN) regulation.This landmark document, the collaborative work of the APRN Consensus Work Groupand the National Council of State Boards of Nursing APRN Committee, establishes clearexpectations for licensure, accreditation, certification, and education for all APRNs andwill shape future APRN practice.

Keywords: APRN education,APRN regulation, certification, consensus model, licensure

Reaching Consensus on a Regulatory Model: What Does This Mean for APRNs?

Joan Stanley

February 2009100 The Journal for Nurse Practitioners - JNP

Meeting regularly for the past 4 years, nursing’sleading professional organizations have crafteda new model for future advanced practice reg-

istered nurse (APRN) regulation. In the broader sense,regulation encompasses licensure, accreditation, certifica-tion, and education, commonly known as LACE.ThisAPRN regulatory model, the product of the AdvancedPractice Nursing Consensus Work Group, comprised oforganizations representing each of these regulatory enti-ties, and the National Council of State Boards of Nursing(NCSBN) APRN Committee, will shape future APRNpractice and establish clear expectations for each of thecomponents of LACE.1

APRNs, numbering over 240,000, play an essentialrole in meeting the nation’s burgeoning health careneeds.2 The growing demand for health care services,the changing population demographics, and growingshortages of health profes-sionals, particularly primarycare physicians, all demandan increased number ofAPRNs that are expertlyprepared, are allowed topractice to the full extent oftheir knowledge and skills,and are readily accessible topatients in all settings.Thechanging landscape of healthcare and population demo-graphics provides APRNsthe opportunity to assume a more prominent role incare delivery and demonstrate the impact of APRNpractice on patient outcomes. Currently, however, thereis no uniformity across states in defining what anAPRN is, what advanced practice nursing and educa-tion encompasses, and licensing and credentialingrequirements.These realities lead to potential confusionamong the public, weakens the APRN position in thepublic policy arena and health care community, andlimits access to APRNs across states and settings.

HOW DID THIS HISTORIC AGREEMENT COME ABOUT? As far back as 1993, NCSBN adopted a position paperon the licensure of advanced practice nursing, whichincluded model legislation and administrative rules. In2003, the NCSBN APRN Advisory Committee (knownthen as the APRN Advisory Panel) began work on adraft APRN vision paper, which was completed and dis-

seminated in 2006 to a broad audience of stakeholdersfor feedback. Response from boards of nursing, nationalorganizations, and individual APRNs was sizeable andvaried.The NCSBN APRN Advisory Panel continued towork to respond to the concerns of the APRN commu-nity and to craft a future vision for APRN regulation.

In March 2004, in response to the growing concernand dialogue surrounding the lack of uniformity acrossthe country regarding how advanced practice nursingwas defined, what constituted an APRN specialty or sub-specialty, and varied credentialing requirements from stateto state, the American Association of Colleges of Nursing(AACN) and the National Organization of Nurse Practi-tioner Faculties (NONPF) proposed that the Alliance forAPRN Credentialing (The Alliance for APRN Creden-tialing, comprised of 14 organizations, was convened byAACN in 1997 to discuss issues related to nursing educa-

tion, practice, and credential-ing.) convene a nationalconsensus process to addressthese and other issues sur-rounding APRN regulation.In June 2004, an invitationto participate in a nationalAPRN consensus confer-ence was sent to 50 organi-zations, identified as havingan interest in advanced prac-tice nursing. Based on therecommendations from this

first APRN Consensus Conference, a smaller representa-tive work group was charged with the development of afuture model for APRN Regulation.The Alliance APRNConsensus Work Group, made up of 23 organizationdesignees, met regularly from 2004 to 2008 to craft anational consensus statement on APRN regulation.

Despite the tremendous amount of work to developconsensus around what the future of APRN regulationshould look like, at a fourth APRN Consensus Confer-ence in fall 2006, co-hosted by the American NursesAssociation (ANA) and AACN, agreement was reachedthat future APRN practice would best be served if theparallel work of the APRN Consensus Process and theNCSBN APRN Advisory Committee could cometogether and, at a minimum, produce complementaryrecommendations that would guide future regulation.Toachieve this goal, seen as a somewhat daunting task at thetime, the APRN Joint Dialogue Group, a subgroup of the

Currently, however, there is nouniformity across states in

defining what an APRN is, whatadvanced practice nursing andeducation encompasses, andlicensing and credentialing

requirements.

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APRN Work Group and the NCSBN Advisory Com-mittee, began meeting in January 2007.As this JointGroup continued to meet, agreement in many significantareas was reached, and it was finally decided that onejoint paper, which reflected the work of both groupscould and would be developed.

WHAT IS THE NEW APRN REGULATORY MODEL? The new APRN Regulatory Model sets forth require-ments for future APRN licensure, certification, educa-tion, and accreditation of APRN education programs.Under this regulatory model, 4 APRN roles are recog-nized: certified registered nurse anesthetist (CRNA), cer-tified nurse-midwife (CNM), clinical nurse specialist(CNS), and certified nurse practitioner (CNP).Thesefour roles are given the title Advanced Practice Regis-tered Nurse (APRN), which is protected and can legallyonly be used by individualslicensed in 1 of these 4 roles.Under the new model, allAPRNs will be educated in 1of these 4 roles in addition toat least 1 of 6 population foci:individual across thelifespan/family, adult-geron-tology, pediatrics, neonatal,women’s health/gender-related, or psych/mentalhealth. Nurse practitioners(NPs) will be licensed solely by the state board of nursingas an APRN, CNP and in one population.This will bethe designation on one’s license and what individuals willbe required to use as the legal credential (for example,Jane Smith,APRN, CNP).The individual has the optionand may indicate the population-focus as well.

In the model, key defining characteristics of anAPRN include the completion of a graduate-level edu-cation program in 1 of the 4 roles; successful passage of anational certification examination that tests the APRN,role, and population-focused competencies; knowledgeand skills to provide direct care to individuals as well as acomponent of indirect care; and educational preparationto assume responsibility and accountability for healthpromotion, assessment, diagnosis, and management ofpatient problems, including the use and prescription ofpharmacologic and non-pharmacologic interventions.

The definition of an APRN stipulates that all APRNsmust have the educational preparation to assume the

management of patient problems including the prescrip-tion of pharmacologic agents.This means that all APRNeducation programs must provide the necessary contentand experiences to prepare the graduate to prescribepharmacologic agents. It does not mean that all APRNsmust assume the responsibility for prescribing pharmaco-logic agents in their practice after graduation.

Under this new model,APRN education consists ofbroad-based graduate education, including 3 separatecomprehensive, graduate-level courses in advanced physi-ology/pathophysiology, health assessment, and pharma-cology known as the APRN core, as well as appropriateclinical and didactic experiences that prepare the gradu-ate with the specific nationally recognized APRN roleand population-focused competencies.All APRN educa-tion programs, including master’s and doctoral degree-granting programs and post-master’s and post-doctoral

certificate programs, will beaccredited. In addition, allAPRN education programswill be pre-approved by theaccrediting body prior toadmitting students.

Graduates of all APRNeducation programs must beeligible for national certifi-cation and will sit for a cer-tification examination rec-ognized by state licensing

bodies. Certification examinations will assess the nation-ally recognized competencies of the APRN core, role,and at least one population-focus area of practice.APRNcertification programs will continue to be accredited by anational certification accrediting body (the AmericanBoard of Nursing Specialties (ABNS) or the NationalCommission for Certifying Agencies (NCCA)) and willrequire a continued competency mechanism.

APRNs will be licensed as independent practitionersfor practice in 1 of the 4 APRN roles within at least 1 ofthe 6 population foci.APRNs may specialize in a morenarrowly focused area within the population-focus butcannot be educated, certified, and licensed solely withinthat more narrow area of practice. In addition, this special-ized preparation cannot expand the individual’s practicebeyond the role and population in which they are edu-cated and certified. For example, a CNP educated as anadult-gerontology NP could obtain additional specialtyknowledge and skills either as part of their original APRN

The new APRN Regulatory Modelsets forth requirements for

future APRN licensure,certification, education,

and accreditation of APRNeducation programs.

February 2009102 The Journal for Nurse Practitioners - JNP

education program or through additional education orexperiences in an area such as adult oncology or cardiovas-cular health, but could not specialize in an area involvingthe care of children. Competence in the specialty will beregulated by the professional organizations, not boards ofnursing; however, professional certification to demonstratecompetence in the specialty is strongly recommended.

WHAT DOES THIS MEAN TO CURRENTLY LICENSEDAPRNS?This new model, once fully implemented, has significantand exciting implications for all APRN practice, includingindependent practice, regulation solely by boards of nurs-ing, and standardization of licensure requirements. Morespecifically, this new regulatory model will allow APRNslicensed in one state to move to any other state and obtaina license to practice if certain criteria are met.A grandfa-thering clause in the model allows practicing APRNs tocontinue to practice in the state of their current license. Inaddition, the model allows an APRN to practice throughendorsement in another state if the APRN maintains anactive practice in the APRN role and population, main-tains current and active certification or recertification inthe role and population, has met the educational require-ments that were in effect in that state when the APRNcompleted his/her education program, and any other cri-teria established by the state. This means that if the othercriteria for licensure are met, the APRN seeking licensurein another state will not have to meet these new educa-tional criteria, which include the 3 separate APRN coursesif they graduated from an APRN program prior to theadoption of this new model in that state. For example, ifthis new model with these comprehensive, broad-basededucation requirements is adopted by a state board in 2010and an individual had graduated from an NP master’sdegree program prior to 2010, he or she would not haveto meet the new education requirements. However, if anNP graduates in 2011 from a program that does not meetthe new education requirements and seeks a license topractice in that state, he/she would not be eligible.

As of 2007, 7 states did not require national NP certifi-cation to practice, and an additional 3 states requirednational certification, but not in all cases.3 Therefore, onesignificant implication for practicing NPs, or all APRNs, isthat if an NP who is not nationally certified moves toanother state and seeks a license to practice, that NP wouldhave to obtain certification in the role and population to beeligible for a license in the new state. For this reason, all NPs

are strongly encouraged to obtain national certification fromone of the certification entities recognized by state boards.In the future, all NPs will be required to sit for national cer-tification prior to becoming licensed.

HOW WILL THE MODEL IMPACT NP EDUCATION,CERTIFICATION, AND LICENSURE?In addition to the implications for currently practicingNPs, other key elements of the model will have signifi-cant impact on NP education, certification, and NPpractice. One of the most notable is the educationalpreparation and certification of NPs across the entireadult population. Preparation and certification of theAdult-Gerontology CNP must include care of theyoung to the older adult, and across the continuum ofcare from the well adult to the frail elderly adult.Thisbroadened focus will require education programs to pro-vide students with the necessary didactic and clinicalexperiences to ensure they are prepared with the depthof knowledge and skills of the current Adult and Geron-tology NP. Likewise, certification bodies will expandassessment across this broadened focus and scope ofpractice.After extensive national dialogue, the decisionto define the population as Adult-Gerontology wasmade to increase the number of NPs and other APRNshighly prepared to care for the growing older popula-tion. (AACN, in collaboration with the NYU HartfordInstitute, has received funding from the John A. HartfordFoundation to oversee a national consensus-process tovalidate competencies for this new Adult-GerontologyNP and for the Adult-Gerontology CNS.)

Faculty in an NP education program will need toassess the current curriculum to ensure that the 3 com-prehensive courses included in the APRN Core (healthassessment, physiology/pathophysiology, and pharmacol-ogy) meet the criteria described in the model. In addi-tion, faculty must ensure that graduates are broadly pre-pared with the nationally defined role and population-focused competencies. Programs may continue to providemore specialized education preparation; however, thismust be done only in addition to the broader preparationin the role and population. Didactic and clinical experi-ences must prepare the graduate to provide care acrossthe entire scope of the identified role and population.Education programs must also ensure that graduates areeligible to sit for national certification in the role andpopulation-focused area of practice. Under the newmodel, the APRN’s education, certification, and license

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must all be congruent and in the same role and popula-tion-focused area of practice.

Another area of the model that received extensiveattention and dialogue was the scope of NP practice fromwell care to acute care. Scope of practice is not defined bysetting but by patient care needs. Pediatric andAdult/Gerontology CNPs will continue to be preparedwith acute care and/or primary care competencies. Signifi-cant overlap exists between the competencies delineated forthe acute care and primary care NP. Under the model, aCNP can be prepared with either or both of these sets ofcompetencies. If preparedacross both the acute care andprimary care NP roles, theCNP must be prepared withthe nationally recognized com-petencies of those roles andmust obtain certification inboth the acute and primarycare CNP roles. However, a CNP should not be restrictedfrom practicing in a setting, such as an outpatient setting oran acute care setting, based on the type of setting, but ratherthe CNP should be allowed to practice across settings andshould be based on the needs of the individual patient.

As nursing practice evolves and health care needs ofthe population change, provisions are made in the modelfor the emergence of new roles or population foci. How-ever, the emergence of a new role or population must becarefully considered, and a national process and criteriafor this to occur are clearly delineated in the model.

IMPLEMENTATION OF THE MODELThe targeted timeline for full implementation of themodel is 2015.All involved in the development of thisnew regulatory model recognize, however, that imple-mentation will be sequential and will require changes byall LACE entities. Some of the changes will be imple-mented immediately while others, such as changes instate laws and regulations governing APRN practice will,by necessity, occur over time.

Endorsement by APRN organizations is currentlyunderway.Names of endorsing organizations will be listedin the report beginning November 2008.Due to varyingprocesses and meeting schedules, additional organization’snames will be added on a rolling basis after that date.Cur-rently, endorsing organizations include AACN;ANA;NCSBN,NONPF;Academy of Medical-Surgical Nurses;American Academy of Nurse Practitioners;American Acad-

emy of Nurse Practitioners certification Program;AmericanAssociation of Critical-Care Nurses;American Associationof Critical-Care Nurses Certification Corporation;Ameri-can Association of Legal Nurse Consultants;AmericanBoard of Nursing Specialties;American College of NursePractitioners;American Holistic Nurses Association;Ameri-can Nurses Credentialing Center;American PsychiatricNurses Association;Association of Faculties of PediatricNurse Practitioners;Commission on Collegiate NursingEducation;Dermatology Nursing Certification Board;Emergency Nurses Association;Gerontological Advanced

Practice Nurses Association;Hospice and Palliative NursesAssociation;National Associa-tion of Clinical Nurse Spe-cialists;National Association ofOrthopedic Nurses;NationalAssociation of Pediatric NursePractitioners;National Board

for Certification of Hospice and Palliative Nurses;NationalCertification Corporation;National Gerontological NursingAssociation;National League for Nursing;National Leaguefor Nursing Accrediting Commission, Inc.; Nurse Practi-tioners in Women's Health;Nurses Organization of VeteransAffairs;Oncology Nursing Certification Corporation;Oncology Nursing Society;Orthopedic Nurses Certifica-tion Board; Pediatric Nursing Certification Board;WoundOstomy and Continence Nurses Society; and the WoundOstomy and Continence Nursing Certification Board. Inaddition to these organizational endorsements, at the 2008NCSBN Annual Meeting held August 2008, delegates over-whelmingly adopted a new APRN Model Act and Rulesand new Education Model Rules that are consistent withthe Consensus Model for APRN Regulation.

The Joint Dialogue Group continues to meet to dis-cuss the formation of a permanent LACE structure thatwill provide guidance for implementation. Critical char-acteristics of this structure include inclusiveness, trans-parency, and flexibility that will allow timely decisionmaking, representation of all components of LACE andall 4 APRN roles, and ongoing communication amongall entities.

In addition to the development of a national LACEstructure, each individual state board of nursing, school ofnursing, certification entity, and accrediting body willneed to examine what changes are needed and whatactions they specifically need to undertake to make thismodel a reality. Reluctance to make necessary changes by

The targeted timeline for full implementation of the

model is 2015.

February 2009104 The Journal for Nurse Practitioners - JNP

any of these entities of LACE will create undo barriers toobtaining desirable outcomes.

HOW WILL A UNIFORM REGULATORY MODEL IMPACTAPRNS?One of the most significant outcomes realized throughthe creation of a uniform regulatory model andthrough the creation of a permanent LACE structureis the increased transparency and communicationamong all 4 regulatory components.The outcomefrom this change will be an increased understanding ofeach others’ roles, standards, and processes, which alsoshould lead to decreased duplication in efforts, eg, thesetting of education standards and education programreview.

Setting clear, common standards for APRN educa-tion, certification, and licensure across all states willprotect the individual APRN from being denied alicense to practice because his/her education programdid not provide the necessary clinical experiences orcoursework.This will also protect the APRN whobecomes certified by one national certification bodyfrom being denied a license to practice when he/shemoves to another state.

The Consensus Model for APRN Regulation alsocreates added protection for the public by ensuring thatall APRNs are educated broadly with comprehensivepreparation to provide care to a population of patients.One of the current concerns expressed by many state-licensing bodies has been that when individuals are pre-pared in a narrow area of practice can they (the stateboard) be assured that the APRN is prepared to provide abroader scope of services or care to that patient popula-tion when needed. Establishing standardized educationand certification requirements for APRN licensure elimi-nates this uncertainty and concern.

A common definition for advanced practice and forregulatory requirements across all states has the potentialto have a significant impact on APRN utilization andpractice.A uniform definition makes the collection ofworkforce data possible.Without common licensing andcredentialing requirements, obtaining accurate counts ofall APRNs and identifying practice settings is difficult.This is particularly true for NPs due to the multiple cer-tifications, specialties, licensing requirements, and titlesused. Health professions workforce data are used by pol-icy makers to craft national health care policy and makefederal and state funding allocations.

Acting as a unified front strengthens the APRN com-munity’s opportunity to attain the goals set forth in theAPRN Regulatory Model, including independentAPRN practice, licensure solely under the regulation ofstate boards of nursing, uniformity of licensure/certifica-tion/education requirements across all states, increasedflexibility to practice to the full scope of the APRNknowledge and skills, and increased accessibility toAPRN services.

The outcomes and implications for APRN educa-tion, certification, accreditation, and licensure describedhere are based on the assumption that the model will befully implemented over time.The impact of the modeland the individual requirements outlined will also bedependent upon the interpretation by the many individ-uals and organizations that will be tasked with theirimplementation.The members of the APRN ConsensusWork Group, the NCSBN APRN Advisory Group andthe organizations they represent worked diligently tocraft a model and language that clearly delineates theconsensus vision and specific requirements for this vision.LACE will provide an ongoing mechanism for commu-nication among all of the components as they worktowards full implementation.

For additional information or to download a copy of the Consensus Model for APRN Regulation:Licensure,Accreditation, Certification & Education(July 2008), go to http://www.aacn.nche.edu/Education/pdf/APRNReport.pdf.

References

1. APRN Consensus Work Group & National Council of State Boards ofNursing APRN Advisory Committee (2008). Consensus Model for APRNRegulation: Licensure, Accreditation, Certification & Education. Available at:http://www.aacn.nche.edu/. Accessed October 6, 2008.

2. U.S. Department of Health and Human Services Health Resources andServices Administration. The registered nurse population findings from theMarch 2004 national sample survey of registered nurses. Washington, DC:U.S. Department of Health and Human Services Health Resources andServices Administration; 2006;32.

3. Pearson LJ. The Pearson Report: a national overview of nurse practitionerlegislation and healthcare issues. Am J Nurse Pract. 2007;11(2):10-101.

Joan M Stanley, PhD, CRNP, FAAN, is the senior director ofeducation policy for the American Association of Colleges ofNursing in Washington, DC. She can be reached atjstanley@aacn.nche.edu. In compliance with national ethicalguidelines, the author reports no relationships with business orindustry that would pose a conflict of interest.

1555-4155/09/$ see front matter© 2009 American College of Nurse Practitionersdoi:10.1016/j.nurpra.2008.11.005