In the fall of 2013, the American Nurses Credentialing Center (ANCC), the world's largest nurse credentialing organization and a subsidiary of the American Nurses Association (ANA), would, for the first time, award to those who are eligible and who meet the required content for portfolio assessment, the Emergency Nurse Practitioner-Board Certified (ENP-BC) credential (ANCC, 2013). The evolution of the ENP-BC has been a long time coming. This journey has led to a portfolio certification that would commence in the fall of 2013. So, how did we get there?
BRIEF HISTORY
Professional Organizations
The Emergency Nurses Association (ENA) was formed in 1970, recognizing the practice of emergency nursing and emergency care. The ENA in collaboration with national ex-perts completed a review of literature and published the first scope of practice and standards of practice for nurse practitioners (NPs) in the ED in 2000. In 2006, the ENA established an NP Validation Work Team to explore and delineate competencies (i.e., the behaviors, knowledge, and skills) necessary for an NP both to competently practice in emergency care and to recommend a validation mechanism (e.g., examination, portfolio, peer review). In 2010, the ENA published the first NP Delphi Study: Competencies for Practice in Emergency Care in the Journal of Emergency Nursing (ENA NP Validation Work Team, Hoyt, et al., 2010). In addition, in 2011, the ANA formally recognized emergency nursing as a specialty practice. The ANA also approved the ENA's scope of practice and standards of practice documents. However, the Board of Certification for Emergency Nurses determined that validation of ENPs was not financially feasible.
In 1985, the American Association of Nurse Practitioners (AANP) was formed. In 1965, the NP role was established initially for the pediatric population in underserved areas and soon evolved in the primary care area. The evolution of the NP role in the specialty of emergency care developed soon after the NP role was established. Nurse practitioners had been practicing in emergency care for nearly five decades, but until 2010, ENP competencies were not established to verify NPs' ability to perform in the emergency setting.
The National Organization of Nurse Prac-titioner Faculties (NONPF) established entry-level core competencies for all NPs (NONPF, 2006). The ENA recognized these core competencies as the foundation for all NP practices and added 60 ENP-specific competencies in 2010. The ENP competencies have been endorsed by the ANA and the NONPF. The NONPF has since updated its core competencies (NONPF, 2012).
Academia
There has never been a mandated structure or curriculum for ENP education. Many ENPs are acute care NPs who only work in adult emergency departments (EDs). There are pediatric NPs (PNPs) who work in pediatric EDs. And, family nurse practitioners (FNPs) are the most common emergency providers because of their expanded scope. The portfolio, although not an entry-level certification, allows all population-based NPs who practice in EDs the opportunity for ENP board certification. The Competencies for Nurse Practitioners in Emergency Care provide the blueprint for credentialing as an ENP, regardless of the original educational curriculum and core certification (ENA NP Validation Work Team, Hoyt, et al., 2010).
In the 1980s, when NP education was accomplished by on-the-job training or a form of apprenticeship led to the acquisition of a certificate in the content area, there was a certificate ENP program in Pennsylvania and then in Virginia. The education and scope of NPs nationally became increasingly regulated. Standard curricula and licensure requirements were promulgated by the American Association of Colleges of Nursing (AACN) and various state boards of nursing. Competencies were established collaboratively with specialty organizations and the NONPF in 2002 for primary care NPs and in 2004 for acute care NPs.
The modern ENP academic program was established in 1994 during the same era that the Acute Care Nurse Practitioner (ACNP) established its scope, standards, and competencies. A handful of ENP programs developed nationally, and depending on the state, education, and certifications, the graduate was licensed as an ENP or ACNP. The ENP was allowed to sit for the ACNP certification examination offered by the National Certification Corporation as long as the educational program incorporated all the competencies for the ACNP and content specific to emergency care.
At the same time, the ENP curriculum was evolving based on research and employer requests for broader utilization of the ENP in EDs that were increasingly used as an entryway to primary care. The need for ENPs both to see children and to be able to navigate primary and acute care needs shifted the baseline certification and education to the primary care FNP pathway in 2000.
Later, some academic programs changed the focus to FNP programs and included the critical care components in the emergency content whereas other programs opted to keep the content in acute care and forego the pediatric and women's health spectrum. At least one program requested that NP students complete both the acute care and family academic programs. There was no structure or framework for the establishment of a specific ENP curriculum.
Currently, there are several emergency concentration programs for NPs in the United States with varied approaches to curriculum. Some are concurrent with FNP programs and add emergency-specific and critical care didactic and clinical content, whereas other programs prepare according to the acute care curriculum and are devoid of pediatric and women's health content. There is no one answer, and the eligibility for portfolio certification does not support model over another.
Consensus Model
In 2004, the ANA and the AACN held a series of advanced practice registered nurse (APRN) meetings. Several specialty organizations (e.g., ENA, AANP) were also present at these meetings. In 2006, the National Council of State Boards of Nursing and other nursing groups also held an APRN stakeholder meeting, and a joint effort was established between the groups.
In 2008, the APRN Consensus Model Document ("Consensus Model for APRN Regulation," 2008) offered various population foci (i.e., family/individual across life span, adult-gerontology, neonatal, pediatrics, women's health/gender-related, psychiatric-mental he-alth) for APRNs (i.e., NPs, clinical nurse specialists, certified nurse midwives, certified registered nurse anesthetists). Emergency care was considered an APRN "specialty," where the focus of practice was beyond one of the four APRN roles and population focus.
The evidence that ENPs were indeed unique providers had been validated, as the nation had established specific populations for licensure and certification, and the consensus model stated that it was up to the specialty organizations to further identify scope, standard, competency, and certification needs. The ENA collaborated with the ANCC, and it was agreed to develop a portfolio certification for ENPs.
ENP CERTIFICATION AND ELIGIBILITY
Certification
The term certification is a designation earned by an individual to validate possession of a specific body of knowledge and the qualification to perform a particular skill or behavior. "Certification is the formal recognition of the knowledge, skills, and experience demonstrated by the achievement of standards identified by the profession" ("Consensus Model for APRN Regulation," 2008, p. 7). The term certification is also used to specifically describe the granting of a particular title (ENP-BC) to a recipient from an approved agency (e.g., ANCC). "ANCC's Certification Program enables nurses to demonstrate their specialty expertise and validate their knowledge to employers and patients." (ANCC, 2013).
Eligibility
The individual applying for ENP-BC must have a valid licensure as an RN or APRN. In addition, the individual must have been awarded national certification and a master's, postgraduate, or doctoral degree in one of the following NP populations: acute care, adult, adult-gerontology acute care, adult-geronto-logy primary care, family, pediatric acute care, or pediatric primary care. This national certification does not have to be an ANCC certification. Furthermore, this certification it is not intended to meet requirements for APRN licensure.
In addition, within the past 3 years, the individual must have practiced the equivalent of 2 years full-time as an NP. Nurse practitioners are ineligible for this certification until they obtain at least 2,000 of advanced practice hours in the specialty area of emergency care. Also, these NPs must have completed 30 hr of continuing education (CE) in advanced emergency care. Finally, the NP must complete two additional professional development categories that include academic credits, presentations, publication or research, preceptorship, or professional service.
Therefore, the question persists, what education and skill should the NP have for entry-level practice in emergency are? The competencies are only a guideline; education often occurs via on-the-job training and or CE offerings. It is seldom a formal academic program.
DEMONSTRATING COMPETENCY
How does one demonstrate competency? Competency can be achieved through various pathways including a combination of (1) successful academic course completion (e.g., emergency care concentration); (2) CE course completion (e.g., advanced electrocardio-graphic interpretation); or (3) on-the-job instruction (e.g., minor procedures-suturing). Credentialing in a specialty area affords NPs an additional method by which they can demonstrate their competency. One thing is clear: There is work to be done in preparing NPs who wants to enter the ED whether their academic base is family or acute care. Employers must be aware that specialty-specific education must be completed to ensure quality care in the ED and that some clinical practice must be completed as a prerequisite for eligibility for ANCC ENP portfolio certification. It will be up to national organizations and grassroots advocates for the quality of ENPs to have a standard for preparation to practice in the specialty. It is time to call in the troops and continue the work of past NPs in emergency care who have helped us come this far.
-K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP, FAAN
Emergency Nurse Practitioner
St. Mary Medical Center
Long Beach, CA
-Elda G. Ramirez, PhD, RN, FNP-BC, CEN, FAEN
Associate Professor
University of Texas Health Science Center
Houston, TX
-Jean A. Proehl, RN, MN, CEN, CPEN, FAEN
Emergency Clinical Nurse Specialist
Proehl PRN, LLC
Cornish, NH
REFERENCES