March 30, 2006
Nancy Chornick, PhD, RN, CAE
Director of Practice and Credentialing
National Council of State Boards of Nursing
111 E. Wacker Drive Suite 2900
Chicago, IL 60601-4277
Dear Dr. Chornick,
The American Nephrology Nurses Association (ANNA), representing 12,000 registered nurses is pleased to respond to the preliminary draft of the VISION document formulated by the National Council of State Boards of Nursing. ANNA has been an active participant in the APN stakeholder meetings hosted by ANA and the AACN in 2004 and 2005. Our membership includes a relatively small but very active and important cadre of advanced practice nurses both nurse practitioners and clinical nurse specialists. Four of our current nine members of our Board of Directors are APNs.
We have distributed the draft to our leadership for comment. We have received many thoughtful responses with varied reactions and concerns. None disagreed with the 12 premises for APRN regulation and there was great support for the majority of the recommendations. There was unqualified support for the independence from physicians in both licensure and oversight as well as for the freedom to practice across state lines that would be made possible by a licensure compact between all states. Divergence of opinion was evident, however, in the proposal re the categories and education tracks.
There was little discussion or disagreement about the nurse anesthetists or midwives. Several responders agreed that the overall proposal for the simplification of the nurse practitioner role was appropriate but there was concern over the deletion of the CNS role, even though there was general agreement that the role is poorly defined and highly variable. Many feel that deleting the CNS role devalues and even negates the considerable contribution that CNSs make to nursing and patient care. The other major concern was the incorporation of the DNP track as alternative educational preparation to the Masters degree. This prompted comments that it was both inappropriate and would lead to the same confusion of educational preparation that we have for the RN licensure.
ANNA recognizes the huge amount of thoughtful work that has gone into the creation of this document and applauds NCSBN for their courage to elucidate their vision. We are in wholehearted agreement with your statement:
The challenge of the future lies in creating these areas of clarity while ensuring minimal competency to protect the public without disenfranchising those currently practicing or currently committed to study in areas identified as less broad in nature.
And it is because we join you in wanting to meet this challenge that we offer the following comments for your consideration.
ANNA has experienced first hand the ongoing divisiveness created by the entry in practice (EIP) quagmire because we have taken the position that the BSN is the EIP for RNs and we have made that the eligibility criterion for our certification for nephrology nursing. We applaud NCSBNs attempt to avoid the same fate for entry into advance practice (EIAP). We agree that the VISION gives nursing a unique opportunity to not make the same mistake twice. However we believe the VISION can be improved upon.
We think that nursing must simplify the EIAP to one core education model, exam, and licensure that includes all APNs whether they plan to be CRNAs, CNMs, NPs, or CNSs. There are some who are concerned that this is the medical model. However, we know that all other professions including pharmacists, lawyers, physical therapists, among others, have one uniform educational preparation only nursing doesn't, at any level.
Therefore we think there should be one Masters level core course that covers all the requisite knowledge required for advanced practice nursing including nursing theories, pathophysiology, assessment, pharmacology etc building on the BSN (might encourage more RNs to get BSN too) followed by a state licensing exam and giving the credential of APRN. ANNA doesnt believe it necessitates an internship even though we have had mixed response to that piece of the VISION. Then, (and only then) the APRN can choose specialty training and certification in whatever mode of APN or specialty he/she desires. The majority of specialties already have certification in place but the beauty of the single core model is that this is something the public, other professions, and all of nursing can relate to. It will reinforce all the good evidence we have about APN safe and effective care and additionally it will provide clear direction for potential nurses of the future who need clarity on why nursing is a great profession for the talented, intelligent, caring individual. This model should also reassure other health professions such as medicine that we are not trying to impinge on their practice but rather assure them that nursing can be practiced safely and effectively at an advanced level independent of, but collaborating with, other health care professionals.
But what about the grandfathering of existing APNs? How do we take all the APNs currently practicing and funnel them back through this very tight entry model? Simple - we don't. We do, instead, what should have been done with school integration back in the 1960s - we pick a year - 2015 say and start there. The Masters level Nursing Core Curriculum and exam would be in place for all BSN prepared RNs thereafter who wish to attain APN licensure. They must complete both the Masters and the exam prior to any specialization and certification - period! This way you don't dismiss any specialty or APN model - including the DNP, the CNL etc. The attempt to grandfather into a simpler model puts us at risk for devaluing some segment of our nursing population and we must avoid that at all costs. It is time for nursing to come together and find common ground for the future of nursing and the magnificent role it could and should play in health care.
In ANNA, we are all so tired of having to explain who we are and what we do and having to prove ourselves by having the majority of the alphabet after our names. APRN at least could guarantee a universally recognized entry level of education and preparation yes, like an MD does for physicians or a JD does for lawyers - and like those professions, it comes with no other guarantee of specialization, experience, personal commitment, talent or skill - but it would be a great place to start.
Thank you again for the invitation for us to comment on this exciting and courageous work. It seems to us that you have responded to the gentle exhortation that Gretta Styles issued at the first APN stakeholders meeting for the profession of nursing to come to consensus on this most important issue. Such a consensus would be a worthy tribute to her vision and hopes for nursing.
Suzann Van Buskirk, BSN, RN, CNN
Lesley C. Dinwiddie, MSN, RN, FNP, CNN
Immediate Past President