Abstract
Nursing's leading professional organizations, after meeting for over 4 years, have reached consensus on a model for future advanced practice registered nurse (APRN) regulation. This landmark document, the collaborative work of the APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Committee, establishes clear expectations for licensure, accreditation, certification, and education for all APRNs and will shape future APRN practice.

Introduction
Meeting regularly for the past 4 years, nursing's leading professional organizations have crafted a new model for future advanced practice registered nurse (APRN) regulation. In the broader sense, regulation encompasses licensure, accreditation, certification, and education, commonly known as LACE. This APRN regulatory model, the product of the Advanced Practice Nursing Consensus Work Group, comprised of organizations representing each of these regulatory entities, and the National Council of State Boards of Nursing (NCSBN) APRN Committee, will shape future APRN practice and establish clear expectations for each of the components of LACE.[1]

APRNs, numbering over 240,000, play an essential role in meeting the nation's burgeoning health care needs.[2] The growing demand for health care services, the changing population demographics, and growing shortages of health professionals, particularly primary care physicians, all demand an increased number of APRNs that are expertly prepared, are allowed to practice to the full extent of their knowledge and skills, and are readily accessible to patients in all settings. The changing landscape of health care and population demographics provides APRNs the opportunity to assume a more prominent role in care delivery and demonstrate the impact of APRN practice on patient outcomes. Currently, however, there is no uniformity across states in defining what an APRN is, what advanced practice nursing and education encompasses, and licensing and credentialing requirements. These realities lead to potential confusion among the public, weakens the APRN position in the public policy arena and health care community, and limits access to APRNs across states and settings.

How Did This Historic Agreement Come About?
As far back as 1993, NCSBN adopted a position paper on the licensure of advanced practice nursing, which included model legislation and administrative rules. In 2003, the NCSBN APRN Advisory Committee (known then as the APRN Advisory Panel) began work on a draft APRN vision paper, which was completed and disseminated in 2006 to a broad audience of stakeholders for feedback. Response from boards of nursing, national organizations, and individual APRNs was sizeable and varied. The NCSBN APRN Advisory Panel continued to work to respond to the concerns of the APRN community and to craft a future vision for APRN regulation.

In March 2004, in response to the growing concern and dialogue surrounding the lack of uniformity across the country regarding how advanced practice nursing was defined, what constituted an APRN specialty or subspecialty, and varied credentialing requirements from state to state, the American Association of Colleges of Nursing (AACN) and the National Organization of Nurse Practitioner Faculties (NONPF) proposed that the Alliance for APRN Credentialing (The Alliance for APRN Credentialing, comprised of 14 organizations, was convened by AACN in 1997 to discuss issues related to nursing education, practice, and credentialing.) convene a national consensus process to address these and other issues surrounding APRN regulation. In June 2004, an invitation to participate in a national APRN consensus conference was sent to 50 organizations, identified as having an interest in advanced practice nursing. Based on the recommendations from this first APRN Consensus Conference, a smaller representative work group was charged with the development of a future model for APRN Regulation. The Alliance APRN Consensus Work Group, made up of 23 organization designees, met regularly from 2004 to 2008 to craft a national consensus statement on APRN regulation.

Despite the tremendous amount of work to develop consensus around what the future of APRN regulation should look like, at a fourth APRN Consensus Conference in fall 2006, co-hosted by the American Nurses Association (ANA) and AACN, agreement was reached that future APRN practice would best be served if the parallel work of the APRN Consensus Process and the NCSBN APRN Advisory Committee could come together and, at a minimum, produce complementary recommendations that would guide future regulation. To achieve this goal, seen as a somewhat daunting task at the time, the APRN Joint Dialogue Group, a subgroup of the APRN Work Group and the NCSBN Advisory Committee, began meeting in January 2007. As this Joint Group continued to meet, agreement in many significant areas was reached, and it was finally decided that one joint paper, which reflected the work of both groups could and would be developed.

What Is the New APRN Regulatory Model?
The new APRN Regulatory Model sets forth requirements for future APRN licensure, certification, education, and accreditation of APRN education programs. Under this regulatory model, 4 APRN roles are recognized: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), and certified nurse practitioner (CNP). These four roles are given the title Advanced Practice Registered Nurse (APRN), which is protected and can legally only be used by individuals licensed in 1 of these 4 roles. Under the new model, all APRNs will be educated in 1 of these 4 roles in addition to at least 1 of 6 population foci: individual across the lifespan/family, adult-gerontology, pediatrics, neonatal, women's health/gender-related, or psych/mental health. Nurse practitioners (NPs) will be licensed solely by the state board of nursing as an APRN, CNP and in one population. This will be the designation on one's license and what individuals will be required to use as the legal credential (for example, Jane Smith, APRN, CNP). The individual has the option and may indicate the population-focus as well.

In the model, key defining characteristics of an APRN include the completion of a graduate-level education program in 1 of the 4 roles; successful passage of a national certification examination that tests the APRN, role, and population-focused competencies; knowledge and skills to provide direct care to individuals as well as a component of indirect care; and educational preparation to assume responsibility and accountability for health promotion, assessment, diagnosis, and management of patient problems, including the use and prescription of pharmacologic and non-pharmacologic interventions.

The definition of an APRN stipulates that all APRNs must have the educational preparation to assume the management of patient problems including the prescription of pharmacologic agents. This means that all APRN education programs must provide the necessary content and experiences to prepare the graduate to prescribe pharmacologic agents. It does not mean that all APRNs must assume the responsibility for prescribing pharmacologic agents in their practice after graduation.

Under this new model, APRN education consists of broad-based graduate education, including 3 separate comprehensive, graduate-level courses in advanced physiology/pathophysiology, health assessment, and pharmacology known as the APRN core, as well as appropriate clinical and didactic experiences that prepare the graduate with the specific nationally recognized APRN role and population-focused competencies. All APRN education programs, including master's and doctoral degree-granting programs and post-master's and post-doctoral certificate programs, will be accredited. In addition, all APRN education programs will be pre-approved by the accrediting body prior to admitting students.

Graduates of all APRN education programs must be eligible for national certification and will sit for a certification examination recognized by state licensing bodies. Certification examinations will assess the nationally recognized competencies of the APRN core, role, and at least one population-focus area of practice. APRN certification programs will continue to be accredited by a national certification accrediting body (the American Board of Nursing Specialties (ABNS) or the National Commission for Certifying Agencies (NCCA)) and will require a continued competency mechanism.

APRNs will be licensed as independent practitioners for practice in 1 of the 4 APRN roles within at least 1 of the 6 population foci. APRNs may specialize in a more narrowly focused area within the population-focus but cannot be educated, certified, and licensed solely within that more narrow area of practice. In addition, this specialized preparation cannot expand the individual's practice beyond the role and population in which they are educated and certified. For example, a CNP educated as an adult-gerontology NP could obtain additional specialty knowledge and skills either as part of their original APRN education program or through additional education or experiences in an area such as adult oncology or cardiovascular health, but could not specialize in an area involving the care of children. Competence in the specialty will be regulated by the professional organizations, not boards of nursing; however, professional certification to demonstrate competence in the specialty is strongly recommended


This new model, once fully implemented, has significant and exciting implications for all APRN practice, including independent practice, regulation solely by boards of nursing, and standardization of licensure requirements. More specifically, this new regulatory model will allow APRNs licensed in one state to move to any other state and obtain a license to practice if certain criteria are met. A grandfathering clause in the model allows practicing APRNs to continue to practice in the state of their current license. In addition, the model allows an APRN to practice through endorsement in another state if the APRN maintains an active practice in the APRN role and population, maintains current and active certification or recertification in the role and population, has met the educational requirements that were in effect in that state when the APRN completed his/her education program, and any other criteria established by the state. This means that if the other criteria for licensure are met, the APRN seeking licensure in another state will not have to meet these new educational criteria, which include the 3 separate APRN courses if they graduated from an APRN program prior to the adoption of this new model in that state. For example, if this new model with these comprehensive, broad-based education requirements is adopted by a state board in 2010 and an individual had graduated from an NP master's degree program prior to 2010, he or she would not have to meet the new education requirements. However, if an NP graduates in 2011 from a program that does not meet the new education requirements and seeks a license to practice in that state, he/she would not be eligible.

As of 2007, 7 states did not require national NP certification to practice, and an additional 3 states required national certification, but not in all cases.[3] Therefore, one significant implication for practicing NPs, or all APRNs, is that if an NP who is not nationally certified moves to another state and seeks a license to practice, that NP would have to obtain certification in the role and population to be eligible for a license in the new state. For this reason, all NPs are strongly encouraged to obtain national certification from one of the certification entities recognized by state boards. In the future, all NPs will be required to sit for national certification prior to becoming licensed.

In addition to the implications for currently practicing NPs, other key elements of the model will have significant impact on NP education, certification, and NP practice. One of the most notable is the educational preparation and certification of NPs across the entire adult population. Preparation and certification of the Adult-Gerontology CNP must include care of the young to the older adult, and across the continuum of care from the well adult to the frail elderly adult. This broadened focus will require education programs to provide students with the necessary didactic and clinical experiences to ensure they are prepared with the depth of knowledge and skills of the current Adult and Gerontology NP. Likewise, certification bodies will expand assessment across this broadened focus and scope of practice. After extensive national dialogue, the decision to define the population as Adult-Gerontology was made to increase the number of NPs and other APRNs highly prepared to care for the growing older population. (AACN, in collaboration with the NYU Hartford Institute, has received funding from the John A. Hartford Foundation to oversee a national consensus-process to validate competencies for this new Adult-Gerontology NP and for the Adult-Gerontology CNS.)

Faculty in an NP education program will need to assess the current curriculum to ensure that the 3 comprehensive courses included in the APRN Core (health assessment, physiology/pathophysiology, and pharmacology) meet the criteria described in the model. In addition, faculty must ensure that graduates are broadly prepared with the nationally defined role and population-focused competencies. Programs may continue to provide more specialized education preparation; however, this must be done only in addition to the broader preparation in the role and population. Didactic and clinical experiences must prepare the graduate to provide care across the entire scope of the identified role and population. Education programs must also ensure that graduates are eligible to sit for national certification in the role and population-focused area of practice. Under the new model, the APRN's education, certification, and license must all be congruent and in the same role and population-focused area of practice.

Another area of the model that received extensive attention and dialogue was the scope of NP practice from well care to acute care. Scope of practice is not defined by setting but by patient care needs. Pediatric and Adult/Gerontology CNPs will continue to be prepared with acute care and/or primary care competencies. Significant overlap exists between the competencies delineated for the acute care and primary care NP. Under the model, a CNP can be prepared with either or both of these sets of competencies. If prepared across both the acute care and primary care NP roles, the CNP must be prepared with the nationally recognized competencies of those roles and must obtain certification in both the acute and primary care CNP roles. However, a CNP should not be restricted from practicing in a setting, such as an outpatient setting or an acute care setting, based on the type of setting, but rather the CNP should be allowed to practice across settings and should be based on the needs of the individual patient.

As nursing practice evolves and health care needs of the population change, provisions are made in the model for the emergence of new roles or population foci. However, the emergence of a new role or population must be carefully considered, and a national process and criteria for this to occur are clearly delineated in the model.

The targeted timeline for full implementation of the model is 2015. All involved in the development of this new regulatory model recognize, however, that implementation will be sequential and will require changes by all LACE entities. Some of the changes will be implemented immediately while others, such as changes in state laws and regulations governing APRN practice will, by necessity, occur over time.

Endorsement by APRN organizations is currently underway. Names of endorsing organizations will be listed in the report beginning November 2008. Due to varying processes and meeting schedules, additional organization's names will be added on a rolling basis after that date. Currently, endorsing organizations include AACN; ANA; NCSBN, NONPF; Academy of Medical-Surgical Nurses; American Academy of Nurse Practitioners; American Academy of Nurse Practitioners certification Program; American Association of Critical-Care Nurses; American Association of Critical-Care Nurses Certification Corporation; American Association of Legal Nurse Consultants; American Board of Nursing Specialties; American College of Nurse Practitioners; American Holistic Nurses Association; American Nurses Credentialing Center; American Psychiatric Nurses Association; Association of Faculties of Pediatric Nurse Practitioners; Commission on Collegiate Nursing Education; Dermatology Nursing Certification Board; Emergency Nurses Association; Gerontological Advanced Practice Nurses Association; Hospice and Palliative Nurses Association; National Association of Clinical Nurse Specialists; National Association of Orthopedic Nurses; National Association of Pediatric Nurse Practitioners; National Board for Certification of Hospice and Palliative Nurses; National Certification Corporation; National Gerontological Nursing Association; National League for Nursing; National League for Nursing Accrediting Commission, Inc.; Nurse Practitioners in Women's Health; Nurses Organization of Veterans Affairs; Oncology Nursing Certification Corporation; Oncology Nursing Society; Orthopedic Nurses Certification Board; Pediatric Nursing Certification Board; Wound Ostomy and Continence Nurses Society; and the Wound Ostomy and Continence Nursing Certification Board. In addition to these organizational endorsements, at the 2008 NCSBN Annual Meeting held August 2008, delegates overwhelmingly adopted a new APRN Model Act and Rules and new Education Model Rules that are consistent with the Consensus Model for APRN Regulation.

The Joint Dialogue Group continues to meet to discuss the formation of a permanent LACE structure that will provide guidance for implementation. Critical characteristics of this structure include inclusiveness, transparency, and flexibility that will allow timely decision making, representation of all components of LACE and all 4 APRN roles, and ongoing communication among all entities.

In addition to the development of a national LACE structure, each individual state board of nursing, school of nursing, certification entity, and accrediting body will need to examine what changes are needed and what actions they specifically need to undertake to make this model a reality. Reluctance to make necessary changes by any of these entities of LACE will create undo barriers to obtaining desirable outcomes.

One of the most significant outcomes realized through the creation of a uniform regulatory model and through the creation of a permanent LACE structure is the increased transparency and communication among all 4 regulatory components. The outcome from this change will be an increased understanding of each others' roles, standards, and processes, which also should lead to decreased duplication in efforts, eg, the setting of education standards and education program review.

Setting clear, common standards for APRN education, certification, and licensure across all states will protect the individual APRN from being denied a license to practice because his/her education program did not provide the necessary clinical experiences or coursework. This will also protect the APRN who becomes certified by one national certification body from being denied a license to practice when he/she moves to another state.

The Consensus Model for APRN Regulation also creates added protection for the public by ensuring that all APRNs are educated broadly with comprehensive preparation 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 prepared in a narrow area of practice can they (the state board) be assured that the APRN is prepared to provide a broader scope of services or care to that patient population when needed. Establishing standardized education and certification requirements for APRN licensure eliminates this uncertainty and concern.

A common definition for advanced practice and for regulatory requirements across all states has the potential to have a significant impact on APRN utilization and practice. A uniform definition makes the collection of workforce data possible. Without common licensing and credentialing requirements, obtaining accurate counts of all APRNs and identifying practice settings is difficult. This is particularly true for NPs due to the multiple certifications, specialties, licensing requirements, and titles used. Health professions workforce data are used by policy makers to craft national health care policy and make federal and state funding allocations.

Acting as a unified front strengthens the APRN community's opportunity to attain the goals set forth in the APRN Regulatory Model, including independent APRN practice, licensure solely under the regulation of state boards of nursing, uniformity of licensure/certification/education requirements across all states, increased flexibility to practice to the full scope of the APRN knowledge and skills, and increased accessibility to APRN services.

The outcomes and implications for APRN education, certification, accreditation, and licensure described here are based on the assumption that the model will be fully implemented over time. The impact of the model and the individual requirements outlined will also be dependent upon the interpretation by the many individuals and organizations that will be tasked with their implementation. The members of the APRN Consensus Work Group, the NCSBN APRN Advisory Group and the organizations they represent worked diligently to craft a model and language that clearly delineates the consensus vision and specific requirements for this vision. LACE will provide an ongoing mechanism for communication among all of the components as they work towards 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.