May 11, 2006
Donna Dorsey, MS, RN, FAAN
President
National Council of State Boards of Nursing
111 E. Wacker Drive, Suite 2900
Chicago, IL 60601-4277
Dear Ms. Dorsey:
The Boards of Directors of the American Association of Critical-Care Nurses (AACN) and the
AACN Certification Corporation have reviewed the draft Vision Paper: The Future Regulation of
Advanced Practice Nursing developed by the National Council of State Boards of Nursings’
APRN Advisory Panel. We appreciate the opportunity to provide input on the document.
We agree with the premise that there is inconsistency in the regulation of APRN practice among
the states, and that these inconsistencies may lead to confusion among employers and
consumers of APRN services, as well as difficulties in interstate mobility for practitioners. We
can also understand that it is frustrating and time consuming for Boards of Nursing to be
confronted with an increasing array of groups seeking recognition for specialty practice.
However, we believe that the documented value of nurse practitioner and clinical nurse
specialist practice vastly outweighs the need to restructure a process that is working well to
protect and meet the needs of patients and families in order to address these emerging
regulatory issues.
Advanced Practice in Acute and Critical Care – Evolution of Specialty Practice
The Acute Care Nurse Practitioner (ACNP) and the Clinical Nurse Specialist certified in acute
and critical care (CCNS) are examples of advanced practice specialties which evolved in
response to changes in the healthcare environment and the increasingly complex needs of
patients along the dynamic continuum of acute and critical illness. In the past, as the specialty
evolved, the educational program for the Adult Nurse Practitioner did not keep pace with the
competencies needed for the care of the acute and/or critically ill patient. Too, the examination
program did not test for mastery of the required content. Similarly, Clinical Nurse Specialists
educated in Medical-Surgical programs were not receiving necessary content to deal with the
complexities of acutely/critically ill patients, and patient safety was not being assured by testing
competencies through the Medical/Surgical CNS certification examination. In response to these
trends, the ACNP certification program was developed jointly by AACN Certification Corporation
and the American Nurses Credentialing Corporation (ANCC) in 1996. AACN Certification
Corporation additionally launched the CCNS certification program in 1999.
Based on this experience, AACN believes that there must remain opportunities for specialties to
evolve. However, this evolution must take place in a logical sequence. We fully support the
NCSBN Criteria for APRN Certification Programs, including the requirements that education
programs must offer a graduate degree with a concentration in the advanced nursing practice
specialty the individual is seeking. Also, all individuals, without exception, seeking a national
certification must complete a formal didactic and clinical advanced practice program meeting the
educational requirements as delineated in the NCSBN Criteria. We believe that all specialty
certification programs must meet these criteria before being accepted for advanced practice
designation. We believe that this process is currently working and could continue as a key
component to assist in the designation of current and emerging specialties. The national APRN
Consensus Work Group has made significant progress in identifying key components of the
evolution of specialty practice, which will only serve to facilitate the goals of the NCSBN. AACN
believes that in order to provide for patient safety and optimal patient outcomes, specialty
practice should be limited to that practice based on an educational program that prepares the
practitioner to provide comprehensive care for the patient. Specialty practice should not be
limited to a disease entity, such as Heart Failure, or a body system, such as Cardiovascular;
these are examples of subspecialties.
Clinical Nurse Specialist as APRN
The acute and critical care CNS practices in any setting in which patient care requirements
include complex monitoring and therapies, high-intensity nursing intervention, or continuous
nursing vigilance within the full range of high-acuity care. The acute and critical care CNS is
particularly suited to achieving optimal outcomes in more complex, uncertain, and resourcelimited situations.1 The acute and critical care CNS is educated in advanced health/physical
assessment, advanced physiology and pathophysiology, advanced pharmacology, and across
all body systems in order to be prepared to provide comprehensive care to these patients. The
role of the CCNS is distinctly different from the ACNP. The two roles have often been blurred by
how they are interchangeably used in the marketplace due to the lack of sufficient supply of
adequately educated and certified acute and critical care clinical nurse specialists.
The acute and critical care CNS plays a crucial role in assuring positive patient outcomes for this
patient population through the three spheres of influence; the patient/family, nursing personnel,
and organizational systems, and may be found in inpatient areas or in settings such as heart
failure clinics. Care is provided using a collaborative model involving patients, families, nurses,
other healthcare providers, and administrators. Their services are reimbursable by Medicare
and their practice has demonstrated cost savings and improved patient outcomes such as
decreased hospital readmissions.
The role of the Clinical Nurse Specialist is evolving as the needs of patients become more
complex due to such issues as increased longevity, multiple co-morbidities, poly pharmacy, lack
of insurance and dwindling community resources. We are deeply troubled by the APRN Panel’s
forced separation of a vital category of essential practitioners, the Clinical Nurse Specialists, into
two divisions, the “traditional” and the “nontraditional” CNS, and then recommending that one
division simply transition to the NP category, when data from job analyses indicate the existence
of the very real and unique role of the CNS who provides more extensive services to individual
patients and communities of patients. These services include differential diagnosis, ordering of
tests, and prescription of interventions, medications and equipment. This CNS role evolved very
directly in response to dynamic patient and system needs. The CNS serves a unique role in
integrating care across the continuum. One of the key elements in CNS practice is to create
environments, through mentoring and systems changes, that empower nurses to develop caring
practices, alleviate patient suffering, facilitate ethical decision making for themselves and their
patients/families, respond to diversity, and serve as a strong patient advocate. The CNS assists
patients and families to navigate a complex healthcare system. From a systems perspective,
this environment encompasses the continuum of acute/critical care from tertiary care to home
care and all systems and agencies of the practice environment. So too, this environment calls
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for CNS practice competencies along the continuum from the RN to the APRN level. Therefore,
toward the goal of public protection, the CNS role should have advanced practice designation by
the Boards of Nursing.
Nurse Practitioners as Specialists
“A nurse is a nurse is a nurse” is a common misperception about the RN, which in many
instances has led to inappropriate nursing assignments and unsafe patient care. We fear that
the generic education scheme outlined in the vision paper for the NP would lead to similar
misconceptions and practice placement for these broadly educated NPs. To this point, AACN
has received multiple complaints and expressed concerns about patient safety from Family
Nurse Practitioners and Adult Nurse Practitioners who find they are being pressured to function
as Acute Care Nurse Practitioners, without being educated to do so.
Advanced practice nursing is specialty practice as evidenced by the practice of the CRNA, who
ensures safe passage of patients throughout the perioperative process, and the CNM, who
primarily cares for patients during labor and birth. These specialties evolved because of the
needs of patients. Both of these APRN specialties have been deemed satisfactory for
regulatory purposes in the Vision Paper.
It seems inconsistent, therefore, that the other nine2 well-established NP specialties would not
continue to be recognized for advanced practice designation in the vision paper as well. These
NP specialties have nationally developed and accepted educational criteria, standardized core
and specialty competencies and curricula which are reviewed by federally approved
accreditation agencies, and graduates sit for nationally accredited certification examinations
offered by certification programs which have met the NCSBN’s Criteria for Evaluating APRN
Certification Programs. What additional standards are the CRNA and CNM specialties meeting
that the NP specialties are not?
The consistency in NP education programs is assured through utilization of the National Task
Force’s Criteria for Evaluation of Nurse Practitioner Programs (2002) and the American
Association of Colleges of Nursing’s The Essentials of Master’s Education for Advanced
Practice Nursing (1996). Specialty competencies are standardized through use of the nationally
validated Domains and Core Competencies of Nurse Practitioner Practice (2002), and the
Specialty Competencies. Although analogous documents do not yet exist for CNS programs,
the development of these through a national validation process that has been outlined by the
APRN Consensus Work Group is beginning. This process will be co-facilitated by the American
Nurses Association and the American Board of Nursing Specialties. We believe that this
process will bring about a similar uniformity in CNS programs as has occurred with NP
programs. This will decrease the burden on Boards of Nursing and certification programs in
terms of having to individually and meticulously validate educational content of CNS certification
applicants.
Patient Safety and the Generic APN
The needs of patients on the acute-critical care continuum are complex and require a high
degree of knowledge and expertise not readily acquired in a broad based educational
curriculum. It is unlikely that the graduate of a generic NP educational program, as proposed in
the vision paper, would possess the knowledge, skills and abilities to adequately care for this
vulnerable patient population, even following a residency program. What safeguards would
exist to prevent these generic NP graduates from being employed in positions requiring
diagnosis and treatment of acutely or critically ill patients if Boards of Nursing only require
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education as a generalist for licensure? As with RNs, specialty organizations can only
recommend certification for nurses caring for a given patient population. What incentives then
would exist for a generic NP to obtain specialty certification? Our experience with voluntary
CCNS specialty certification has revealed that there is little incentive to obtain certification
beyond a mandated requirement by the Board of Nursing or employer.
We recognize that regulatory issues are difficult and complex, and that Boards of Nursing would
prefer to be out of the business of approving specialty certifications. However, we would urge
Boards of Nursing not to abandon the regulation of advanced practice nursing by sanctioning
the licensure of a lower level generalist and leaving the further definition, education and
utilization of specialists to the pressures of the marketplace. We feel that this would leave
consumers of APRN services with no recourse for resolution of practice issues, and would result
in an even greater fragmentation of services and level of confusion than currently exists.
AACN stands ready to collaborate in any way needed to facilitate further dialogue on the
regulation of advanced practice nursing and to share our experiences in the development of new
specialty practices. The AACN Synergy Model for Patient Care is based on the belief that
optimal patient outcomes result when patient needs are matched with nurse competencies. We
believe that this is also the best model for advanced practice regulation; the comprehensive
education and psychometrically validated competencies of the advanced practice nurse must
match patient needs.
Sincerely,
Debbie Brinker, RN, MSN, CCRN, CCNS
President
American Association of Critical-Care Nurses
Judy Verger, RN, MSN, CCRN, CRNP
Chair
AACN Certification Corporation
American Association of Critical-Care Nurses. (2002). Standards of Practice and Professional Performance for the
Acute and Critical Care Clinical Nurse Specialist. Aliso Viejo, CA.
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Nurse practitioner specialties that currently meet the NCSBN Criteria for APRN Certification Programs (2002)
include: adult, family, gerontology, pediatric, women’s health, adult-acute care, pediatric-acute care, psych/mental
health and neonatal.
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