Running head: POLICY PAPER ON CONSENSUS MODEL FOR APRN
Policy Paper on Consensus Model for APRN Regulation: Licensure, Accreditation,
Certification, and Education
Amy Higgins, Stephanie Kimbrel, and Diane Morris
Washburn University
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POLICY PAPER ON CONSENSUS MODEL FOR APRN
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Policy Paper on Consensus Model for APRN Regulation: Licensure, Accreditation,
Certification, and Education
Problem Identification
Advanced Practice Registered Nurses (APRNs) have been practicing in various capacities
for years; however, a consensus on the components involved in the regulation of APRNs has
been argued for some time. Disagreements on uniform state regulations are limiting the
accessibility of the high quality, cost-effective care APRNs can provide. Much of the debate
involved in defining the APRN profession has involved credentialing, education, scope of
practice, and the actual title of APRNs. The evolving landscape of healthcare and patient
demographics give APRNs the opportunity to assume a more prominent role in the delivery of
care and prove the impact of APRN care on patient outcomes (Stanley, 2009). Currently, there is
a lack of uniformity across states in defining the APRN role, including advanced practice
education, licensing, and credentialing requirements.
Background
The APRN role has been in existence since the 1940s (Rose & Regan-Kubinski, 2010).
Early APRN roles were not clearly defined or regulated. In the early 1990s, official certification
examinations were beginning to be utilized by state boards of nursing, as a requirement for
APRN licensure. The first position statement was written in 1993. It identified the need for
certifications as a piece of the regulation for advanced nursing practice (Rose & Regan-Kubinski,
2010). Prior to that time, an APRN may simply have meant a nurse who was very experienced
and skilled in her area of practice, without regard to specific education, licensure or certification.
After the publication of this position statement, increased attention was directed at the structure
and accreditation of APRN educational programs. A second position statement was published in
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2002, which detailed several regulatory concerns regarding the APRN certification examination.
March 2004 brought about the convention of a group called The Alliance for APRN
Credentialing, which was comprised of 14 organizations who discussed a consensus process to
address the issues related to advanced practice education and credentialing. A smaller group was
then put in charge of developing the future model for APRN regulation. This Alliance APRN
Consensus Work Group met routinely from 2004 to 2008. In 2007, this group joined efforts with
the NCSBN APRN Advisory Committee to produce complementary recommendations that
would together guide future regulation, thus giving rise to the Consensus Model for APRN
Regulation: Licensure, Accreditation, Certification & Education (LACE) (Stanley, 2009). Their
goal is to have this model fully implemented by 2015 (ANA, 2008).
The LACE Consensus Model recognizes four APRN roles: certified registered nurse
anesthetist (CRNA), clinical nurse specialist (CNS), certified nurse-midwife (CNM), and
certified nurse practitioner (CNP) (ANA, 2008). The model also states that all APRNs will be
educated in one of these four roles, in addition to at least one of six population foci: family,
adult-gerontology, pediatrics, neonatal, women’s health, or mental health (Stanley, 2009).
Education for APRNs will consist of completion of a graduate-level program in one of the four
roles with successful passage of a national certification exam. The LACE model further outlines
the requirement of every APRN graduate program to have core courses in comprehensive
pathophysiology, health assessment, and pharmacology. The educational programs will also
include appropriate clinical and didactic experiences. The LACE model now sets forth more
specific guidelines for graduate programs and requires that these programs be knowledgeable of
the various states’ regulations regarding the practice of APRNs (Chornick, 2008).
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All education programs must now be accredited, according to the LACE model.
Accreditation of educational organizations is a voluntary, self-regulating, nongovernmental
process which assures a basic level of education (Chornick, 2008). The Commission of
Collegiate Nursing Education and the National League for Nursing Accreditation are the only
two accrediting groups responsible for this process.
Whereas accreditation applies to an organization, licensure applies to an individual.
Licensure is the granting of authority to practice (ANA, 2008). Each APRN graduate must meet
individual state licensure eligibility (Chornick, 2008). APRNs will be licensed as independent
practitioners who are able to practice in one of the four previously discussed APRN roles within
at least one of the six population foci. An APRN may then specialize in more focused areas
within his/her population focus but can no longer be educated, certified, and licensed solely
within that more narrow scope of practice (Stanley, 2009).
Ethical Factors
From an ethical standpoint, it is important for the public to trust that any APRN providing
care is educated, certified, and licensed within his/her scope of practice. This will ensure
patients that they are receiving safe and equitable care from providers with the title of APRN.
Creating and implementing a timely consensus for APRNs is critical to assure the public about
the consistency and quality of their healthcare providers (Yoder-Wise, 2010).
Political and Legal Factors
Politically, APRNs need an effective consensus model to more clearly define the
profession and to move forward in healthcare as a united front with agreement on the regulations
of the profession across all 50 states. As health care reform begins to change the delivery of care
to individuals in our country, the APRN profession needs to be ready to speak as a unified voice
POLICY PAPER ON CONSENSUS MODEL FOR APRN
about what care APRNs can contribute and why the professional development plan is essential
(Yoder-Wise, 2010).
From a legal perspective, a consensus model is required to outline the scope of practice
for each of the four APRN roles. As the APRN profession attempts to maximize the existing
scope of practice, there is potential to do so by expanding: amendments to state nurse practice
acts, judicial decisions, and federal enactments (Watson & Hillman, 2010).
Further, agreement among states is needed to align the prescriptive authority of APRNs.
Currently, APRNs have some degree of prescriptive authority in all 50 states; however, these
varying degrees of authority cause much confusion among consumers. Legislative changes are
needed to expand APRN prescription privileges in all states to include:

Authority to prescribe without physician involvement

Authority to prescribe with physician collaboration

Written protocol required to prescribe

Authority to prescribe controlled substances (Watson & Hillman, 2010)
A consensus regarding prescriptive authority is needed to bring uniformity in scope of practice
and alleviate confusion among healthcare consumers.
Additional liability issues that exist for APRNs include:

Unlicensed practice of medicine

Failure to adequately diagnose

Negligence in the delivery of healthcare

Conduct exceeding physician-delegated authority—resulting in harm

Conduct exceeding scope of practice –resulting in harm

Failure to refer appropriately (Guido, 2010).
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Essentially, APRNs have dual legal liability including nurse adherence to the state nurse practice
act and the APRN’s requirement to national specialty certification and/or secondary licensure
requirement. If APRNs continue to expand practice roles, there will likely be an increase in the
APRNs level of accountability and liability (Watson & Hillman, 2010).
Issue Statement
How can the LACE model be expeditiously implemented in all states to ensure that the
APRN profession continues to grow and meet the demands of changing healthcare, while
increasing the APRN scope of practice and assuring that licensure, accreditation, certification,
and education are uniform across all 50 states?
Stakeholders
There are a variety of stakeholders with regard to the LACE consensus model. The most
obvious stakeholder is the APRN, both existing and newly graduating. Existing APRNs have a
definite stake in the implementation of the consensus model and a grandfather clause does allow
for any APRN who is already practicing to continue to do so in the state he/she is currently
licensed (ANA, 2008). Once the LACE model is fully implemented, it will allow APRNs to
move from one state to another and be able to obtain licensure, if certain criteria are met.
Individual states and state legislatures represent another group of stakeholders. In order
for the LACE model to promote uniformity among APRN regulation, states must meet the new
Uniform APRN Requirements in order to enter into the APRN compact which will facilitate
interstate APRN practice (Chornick, 2008). To achieve the expectations of the consensus model,
every state must agree to the same terms, definitions, and conditions outlined in the LACE
document (Yoder-Wise, 2010).
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As mentioned earlier, the consumers or “patients” are certainly a stakeholder in the
LACE consensus model. Assuring the public consumers that the quality and consistency of care
they receive from an APRN is essential and makes consumers a definite stakeholder (YoderWise, 2010). The American Association of Retired Persons (AARP) in Hawaii commented that
consumers of all ages need access to primary care and chronic care management, so that people
with diabetes, hypertension, and other chronic ailments can lead productive and health lives.
They also stated that APRNs should be able to practice to their full extent and be reimbursed for
the care they provide to help fill the gap in primary care (Mathews et al., 2010).
Nursing education programs have a pronounced role as stakeholders with regard to the
LACE consensus model. Once implemented, the LACE model will require all APRN education
programs be accredited to ensure that each program meets the minimum curriculum guidelines,
as well as clinical and didactic experiences. Graduate nursing programs will need to re-visit their
current curriculum to meet these new standards and be more abreast of the various states
regulations, until interstate uniformity is reached (Chornick, 2008).
Policy Objectives
The policy objectives for the LACE model are aimed at creating uniformity among the
states with regard to APRN licensure, accreditation, certification, and education. While there is
much debate about how to carry out this policy change, several steps need to be taken to achieve
this goal:

Nurses should practice to the full extent of education and training.

Nurses should achieve higher levels of education and training through an improved
education system that promotes seamless academic progression.
POLICY PAPER ON CONSENSUS MODEL FOR APRN
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Nurses should be full partners, with physicians and other health care professionals

Effective nursing workforce planning and policy making require better data collection
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and improved information structure (Oleck et al., 2011).
While these objectives are not exclusive for APRNs, they most certainly apply to the LACE
consensus model’s objectives for reaching uniformity for the profession.
Policy Alternatives
One possible policy alternative would be to follow the recommendation of The American
Association of Colleges of Nursing (AACN) for all master’s level APRN programs to be
changed to doctorate of nursing practice (DNP) by 2015 (Watson & Hillman, 2010). This
recommendation is not included in the LACE consensus model. Implementation of this
alternative would have a huge impact on existing APRN educational programs both
organizationally and financially.
Another policy alternative includes the specialists’ model which has been criticized as
being restrictive in its focus, uneconomical and at variance with the World Health Organization
whom advocates for the preparation of general nurses (Fealy et al., 2009). In restricting
registrants to a specialized area, it decreases workplace mobility. Despite this, there have been
calls to return to specialists’ model because the generic comprehensive model does not prepare
APRNs in some specialty areas. The generic model prepares graduates with a more broad and
comprehensive knowledge base. The generic model assumes that a generalist practitioner can
assess the needs of all patients, regardless of age and healthcare setting. Graduates are prepared
with beginner-practitioner competencies that can differentiate, integrate, and generalize from
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knowledge gained. It also presupposes that branching into specialists’ area will occur after initial
registration (Fealy et al., 2009).
Evaluation Criteria
The criteria for evaluation of a policy alternative includes: the likelihood of ongoing funding,
size and availability of funding stream, ability to meet current and future demands, and political
feasibility.
Analysis for Option 1- Do Nothing
Criterion 1: Likelihood of Ongoing Funding
Pro: With health care reform and the need for accessible healthcare providers money is
being poured into primary care education including increasing the number of APRN’s. The
Patient Protection and Affordable Care Act has allotted $200 million program to educate more
APRN’s in primary, preventive, and chronic care management (Carlson, 2010). This is an
addition other federal funding by the government such as: Title VII, Title VIII, and Medicare
education funding.
Con: The United States Health Care system is failing. Healthcare costs continue to rise
without the ability of the American people or government to afford these changes. The
increasing costs will continue to bring close examination of government spending and needed
healthcare system changes. If changes are not made to increase the accessibility of ARNP care,
then funds could be diverted from graduate nursing education to other means of providing
primary care and prevention.
Criterion 2: Size and Availability of Funding Stream
Pro: The Title VIII Nursing Workforce Development programs administered by the
Health Resources and Services Administration (HRSA) are the primary source of Federal
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funding for nursing education. They include major grants such as the Advanced Nursing
Education Grants which provide nursing schools, academic health centers, and other entities
funds to enhance education and practice for masters and post-masters nursing programs
(American Nurses Association, 2011). According to the FY 2011 Appropriations: Senate (see
Appendix B), funding for nursing education, retention and workforce has greatly increased from
$137,000 to $64,438 million, under Title VIII Advanced Education Nursing grant (Nursing,
2010).
Con: Difficulty exists in fully examining the amount of monies allotted to nursing
education. However, the majority of these funds are discretionary. In negotiations for FY 2011
Continuing Resolution (CR) H.R. , the House opted to cut the Nursing Workforce Development
Programs and Health Professions Programs by $145.1 million, which represents a decrease of
29% in the funding over the FY 2010 (American Nurses Association, 2011).
Criterion 3: Ability to Meet Current and Future Demand
Pro: The great need for primary care providers is evident. It is apparent that APRN’s can
help to fill this hole. There are 50 million uninsured Americans (AlterNet, 2011) that will have
health insurance after the Health Care Reform Act is implemented. As the number of insured
individuals rises, there will be an even larger shortage of providers. A solution to this problem is
APRN’s.
Con: Currently there is a decrease in the accessibility to APRN’s. If no change is made
then the function of an APRN will not be fully utilized. The need for APRN’s to function to the
full scope of their abilities and practice, with equality in reimbursement, is essential in alleviating
this shortage.
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Criterion 4: Political Feasibility
Pro: President Obama supports the need for APRNs and nursing education important
components in the Health Care Reform plan. The President’s February 2011 FY 2012 budget
includes a 28.4% increase, with $313 million allotted for the Title VIII nursing education
provisions. With the planned Health Care Reform changes, our aging population of baby
boomers, and an increase in national health care needs, our government is realizing the benefit of
care that an APRN can provide in addressing the shortage of healthcare providers.
Con: Without an appropriate strategy, the APRN could be lost in the mix of Healthcare
reform. If the APRN profession lacks a uniform message, a united front and effort by the nursing
community to lobby for APRN’s the medical society may pull rank and protect their monopoly
on providing primary care.
Analysis of Option 2: APRN to DNP Program
Criterion 1: Likelihood of ongoing funding
Pro: Current funding for APRN programs and faculty has been discussed in the first
option. This applicable to the DNP option as well.
Con: The average cost of a Master in Nursing (MSN) is approximately $24,000 in the
state of Kansas. A Doctoral of Nursing Practice (DNP) degree would be an additional $15,000$20,000. Instead of $24,000 to become an APRN, the cost would be closer to $40,000. This
would take additional money away from the discretionary funding of the Title VIII program to
help support advanced nursing education creating one doctoral APRN instead of two master
degree APRNs. This makes the goal of becoming an APRN more difficult to obtain for an
individual attempting to pay for or use school loans. Additionally, it increases the amount of
time dedicated to a longer program. Would the salary made by an APRN after receiving a DNP
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make up for the money spent on school? This may also increase the number of faculty members
needed to staff DNP programs. Nursing educational programs are already experiencing
shortages of faculty and this would no doubt be made worse, as PhD faculty would now be
required.
Criterion 2: Size and Availability of Funding Stream
Pro: The size and availability of the Funding Stream is currently quite large and
accessible to those organizations supporting further education of nurses into the APRN role.
Kathleen Sebelius, Health and Human Services Secretary, states “We cannot build a healthier
America if our country continues to face a growing health professions shortage, a well-trained
and diverse workforce is critical to meeting future health care demands and to reforming the
nation’s health care system.” Sebelius announced that $159.1 million would be appointed to
support the healthcare workforce and training, which would build on the multimillion dollar
investments made under the Affordable Care Act and Recovery to strengthen and grow our
primary care workforce (U.S> Department of Health & Human Services, 2010). The Act has
reauthorized Title VIII and enacted new laws, such as the removal of the 10% cap previously
imposed on support for the doctoral students. It has created an individual nurse faculty loan fund,
in addition to the Nurse Faculty Loan Programs awarded to schools of nursing. Both programs
will place priority of the funding doctoral students (American Association Colleges of Nursing,
2011).
Con: The size and availability of funding will decline with the implementation of DNP.
A DNP will cost more money for the future APRN to obtain, requiring more financial hardship,
more money for institutions to provide for the faculty to teach at this level ,and more money to
fund this program with a decrease in the numbers of APRNs graduating.
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Criterion 3: Ability to Meet Current and Future Demand
Pro: Currently the demand outweighs the supply; the future demand will only increase.
With the Affordable Care Act and Recovery the effort is being made to increase the supply to
meet the increasing demands of the American people who are in need of primary, preventative
and chronic care management.
Con: With the implementation of DNP as a requirement to practice for those entering a
program after 2015, who are not already grandfathered in, will decrease the number of
graduating APRNs throughout the United States. The prevalence of DNP programs are less and
these programs are not able to take on as many students, thus decreasing the supply, while the
demand will continue to rise.
Criterion 4: Political Feasibility
Pro: The changing demands of the nation’s complex healthcare environment necessitate
the highest level of scientific knowledge and practice expertise to assure positive patient
outcomes. A call for action has been made by the National Academy of Sciences for nursing to
develop a non-research clinical doctorate program to prepare expert practitioners, following in
the direction of other health professions such as Medicine (MD), Dentistry (DDS), Pharmacy
(PharmD), Psychology (PsyD), Physical Therapy (DPT) and Audiology (AudD) (American
Association of Colleges of Nursing, 2011). This will gain support and respect for the nursing
community helping to redefine their role. DNP will allow for stronger lobbying for nursing
education and less opposition by others in the health profession.
Con: Significant funding is required for this change to produce the amount of needed
primary health care providers. In the current economic decline, discretionary monies may be
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diverted from nursing education to fund other needs. Again organizations such as the American
Medical Association or major hospitals, who have great lobbying power, could arrange road
blocks to the succession of DNP, for fear of their own financial burdens.
Option 3: Specialists’ Model
Criterion 1: Likelihood of ongoing funding
Pro: The Specialists’ model allows for focus on a specialized area such as gerontology
or pediatrics. Woman’s health and pediatrics are among several of the known health disparities
in our county. This particular model suggests having APRNs specialize in these areas of care to
decrease disparities. Funding on this model will likely continue with the Affordable Care Act
and Recovery. The Act along with other healthcare organizations attempt to focus on decreasing
health disparities in the United States, by utilizing specialists in these areas to help reduce
provider gaps.
Con: As stated earlier, this model does not allow for workforce mobility. Additionally,
accessibility to care remains a problem. Opponents of the generic comprehensive preparation
have charged advocates with having ulterior motives related to managerial concerns with cost
effectiveness and ease of staff deployment while others point to the risk of inequality in the
classroom and in practicum. With the initial training is also fails to provide sufficient knowledge
and skills to offer higher quality care within specialty fields. There is great concern of particular
importance in areas of children and the intellectual disability (Fealy et al., 2009). The cost
effectiveness of the model is also questionable. Making major policy changes that do not result
in improved cost effectiveness or greater access to care will have limited acceptance, resulting in
a decrease in funding.
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Criterion 2: Size and Availability of Funding
Pro: In 2011, Title VIII, the Advanced Education Nursing Grants, received a funding
increase of $137,000, bringing the overall advanced nursing education grant to $64.438 million.
Con: The primary focus of the Affordable Care Act and Recovery includes preventative,
primary, and chronic care management, not on specialties. Funding will most likely be granted
to those students entering primary care, rather than those with a specialty focus.
Criterion 3: Ability to Meet Current and Future Demands
Pro: Current health disparities exist among specialized populations, such as children and
woman’s health. By having APRN specialists who focus on these underserved populations, the
current and future demands of these shortage areas in healthcare can be reduced.
Con: The shortage of primary health care providers has increased health disparities in
America. Currently, the greatest health disparities are based on racial and geographic populations
(Sack, 2005). These gaps and specialized populations, such as children and woman’s health can
be benefited greatly by a practitioner who offers broader care. A specialist is not a feasible
alternative within regions where a lack of access to appropriate medical care exists. To meet the
current and future demands of our country, it is more cost effective to develop primary care
providers who can provide healthcare services to any child, woman, or human, regardless of age
or race.
Criterion 4: Political feasibility
Pro: The focus of children and women’s health is to reduce health disparities and create
a healthier America. Support for specialized APRNs will dependent upon the specialty. With the
nation’s growing elderly population , an APRN specializing in gerontology would be widely
accepted and supported by organizations such as AARP, who are a powerful lobbying group.
POLICY PAPER ON CONSENSUS MODEL FOR APRN
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Con: Current focus on health is within the primary care arena, not specialties. In fact,
emphasis on healthcare reform does not support specialty care. Rather, focus on the whole
person to with particular attention to preventing major diseases is the goal. Political support is
geared toward the areas of primary care and prevention, not specialties.
Comparison of Alternatives and Results of Analysis
Alternatives
Do Nothing Option DNP’s
Specialists’’ LACE
Substantive Funding Stream
++
+++
+
+++
Likelihood of Ongoing Funding
+
++
+
++
Ability to Meet Current/Future
-
-
-
++
+
++
-
+
4+/1-
7+/1-
2+/2-
8+/0-
3
6
0
8
Criteria
Demands
Political Feasibility
Score for Each Alternative
Analysis and comparison of the Consensus Model: LACE and the three afore mentioned
alternatives, (as seen in the matrix above) affirms that the Consensus Model: LACE exhibits the
greatest ability to increase safe, equitable, and accessible healthcare. The alternative DNP comes
in close with six points; however, would have a huge impact of nursing educational programs.
Alternative 1, Do Nothing alternative scores positively but not strongly, as it has major
weaknesses in meeting current and future demands. Alternative 3, the Specialists alternative,
POLICY PAPER ON CONSENSUS MODEL FOR APRN
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scored poorly, positives negated by negatives. It shows major weaknesses in both current and
future demand and political feasibility (Mason and Leavitt, 2007).
After analyzing and comparing the LACE consensus model with the alternatives, it is
apparent that the LACE model is seemingly the most feasible policy to address the APRN
profession. As the LACE model is implemented across all states, it will ensure that the APRN
profession continues to grow and meet the demands of changing healthcare. The LACE model
also ensures the APRN’s scope of practice is utilized to its fullest extent. It also will assure that
licensure, accreditation, certification, and education are uniform across all 50 states for APRNs,
creating more accessible healthcare to meet the increasing demands of the nation.
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Guido, G. (2010). Legal and ethical issues in nursing (5th ed.). San Francisco: Pearson.
U.S> Department of Health & Human Services. (2010, August 5). HHS Awards $159.1
Million to Support Health Care Workforce Training. Retrieved May 2011, from
HHS.gov: http://www.hhs.gov/news/press/2010pres/08/20100805a.html
M. W., Mason, D. J., & Leavitt, J. K. (2007). Policy and Politics in Nursing and Healthcare.
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Mathews, B. P., Boland, M. G., & Stanton, B. K. (2010). Removing barriers to APRN practice in
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POLICY PAPER ON CONSENSUS MODEL FOR APRN
Appendix A
Organizations Participating in APRN Consensus Process
Accreditation Commission for Midwifery Education
American Academy of Nurse Practitioners
American Academy of Nurse Practitioners Certification Program
American Academy of Nursing
American Association of Critical Care Nurses
American Association of Critical Care Nurses Certification Program
American Association of Nurse Anesthetists
American Association of Occupational Health Nurses
American Board of Nursing Specialties
American College of Nurse Practitioners
American College of Nurse-Midwives
American Nurses Association
American Nurses Credentialing Center
American Organization of Nurse Executives
American Psychiatric Nurses Association
Association of Faculties of Pediatric Nurse Practitioners
Association of Rehabilitation Nurses
Association of Women's Health, Obstetric and Neonatal Nurses
Certification Board Perioperative Nursing
Commission on Collegiate Nursing Education
Council on Accreditation of Nurse Anesthesia Educational Programs
Division of Nursing, DHHS, HRSA
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Emergency Nurses Association
Hospice and Palliative Nurses Association
International Nurses Society on Addictions
International Society of Psychiatric-Mental Health Nurses
NANDA International
National Association of Clinical Nurse Specialists
National Association of Neonatal Nurses
National Association of Nurse Practitioners in Women's Health
National Association of Nurse Practitioners in Women's Health, Council on Accreditation
National Association of Pediatric Nurse Practitioners
National Association of School Nurses
National Board for Certification of Hospice and Palliative Nurses
National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties
National Conference of Gerontological Nurse Practitioners
National Council of State Boards of Nursing
National Gerontological Nursing Association
National League for Nursing
National League for Nursing Accrediting Commission
National Organization of Nurse Practitioner Faculties
36 APRN Joint Dialogue Group Report, July 7, 2008
POLICY PAPER ON CONSENSUS MODEL FOR APRN
Nurse Licensure Compact Administrators/State of Utah Department of Commerce/Division of
Occupational & Professional Licensing
Nurses Organization of Veterans Affairs
Oncology Nursing Certification Corporation
Oncology Nursing Society
Pediatric Nursing Certification Board
Sigma Theta Tau, International
Society of Pediatric Nurses
Wound Ostomy & Continence Nurses Society
Wound Ostomy Continence Nursing Certification Board
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POLICY PAPER ON CONSENSUS MODEL FOR APRN
Appendix B
24