The title of Advanced Practice Nurse (APN) encompasses the roles of Nurse Anesthetists, Nurse Midwives, Nurse Practitioners (NPs), and Clinical Nurse Specialists (CNSs). Only the Clinical Nurse Specialist group has always required Master's level nursing education. Wound Ostomy Continence (WOC) nurses who are pursuing advanced practice education typically follow either the NP or CNS pathway via a graduate level APN program. Once the Master's level education has been completed, most WOC-APNs will seek advanced level licensure from their state Board of Nursing (SBON).
The individual SBON licensure requirements for APNs currently vary widely from state to state, making the path for recognition of some advanced practice WOCNs convoluted and/or inaccessible. Because there is no Advanced Practice Certification Examination for the WOCN specialty, some states will not consider APN licensure for the WOCN who has completed graduate education unless their educational track has prepared them to sit for a different advanced practice specialty exam (e.g. geriatrics, oncology, or medical-surgical nursing). If the APN intends to practice solely in the WOCN specialty area, one must consider if certification in these more general areas is truly appropriate. If the purpose of APN licensure requirements is to ensure advanced knowledge and clinical skills for consumer protection, one must question if certification in medical-surgical nursing (or another more general nursing area) really measures advanced nursing competency in wound, ostomy, and continence care.
Some states also permit alternative options to certification by exam, and will allow the individual who has completed the Master of Science program to submit a professional portfolio for consideration as a reflection of advanced practice knowledge and competency. Many of the states allowing this alternative option require additional supervised hours of practice prior to awarding an APN license. A limited number of states will allow the WOC-APNs to obtain prescriptive authority with evidence of appropriate pharmaco-therapeutic education and experience, while others do not. Some WOCNs may pursue graduate education in the Nurse Practitioner tracks, then sit for Adult or Family Nurse Practitioner exams despite their intent to function in solely the WOC-APN role after graduation. This choice may be made simply to avoid the frustration that many CNSs have experienced in obtaining APN licensure.
The Uniform Advanced Practice Registered Nurse Licensure/Authority to Practice Requirements, or Interstate APRN Compact Agreement, approved by the National Council of State Boards of Nursing (NCSBN), is now being examined at the State levels (the APRN Compact Agreement document can be accessed via the NCSBN web-site at: http://www.ncsbn.org; addresses for individual state Boards of Nursing are also available at this site). The effort by the NCSBN to move toward standardization of APN licensure requirements across the country is a positive step in concept. It is, however, problematic to small nursing specialty groups as the requirements stipulate that, effective by 2005, alternatives to APN certification by exam will no longer be accepted. This creates a barrier to practice for many CNS practitioners who have no available APN examination for their specialty area of practice. The cost of developing a certification exam ranges from seventy to ninety thousand dollars, making this option financially prohibitive for small nursing specialty groups like WOC nursing.
Correspondence from the NCSBN to WOCNCB has further stated that the development of a means for Advanced Practice certification in our specialty would not meet the proposed regulatory requirement for a "broad scope of preparation." The NCSBN cited the "narrow scope of practice" in Wound Ostomy Continence as a nursing "subspecialty," noting that they did not wish to de-value our specialty knowledge for which advanced level certification would be viewed as "value added." One wonders how many other nursing specialty groups will be categorized in this way. It is important to remember that the NCSBN does not set the regulatory requirements for licensure, but has developed the proposal for acceptance into legislation at the state level. Input from all stakeholders is vital for a workable solution!!
The Wound, Ostomy, and Continence Nursing Certification Board (WOCNCB) is pursuing options to best meet the needs of our Advanced Practice certificants. The feasibility, validity, and reliability of alternative means of APN certification, including professional portfolio or a core exam with additional specialty focus measures, is being explored as an alternative mechanism for practice-based evidence of competency. The concerns of WOCNCB regarding this issue have been expressed in writing to the NCSBN; this letter resulted in an invitation for WOCNCB to participate in the NCSBN/APN Roundtable held this Spring in Chicago. The informal networking with other attendees and formal dialogue with NCSBN representatives was a hopeful first step toward a workable solution to this issue. The National Association of Clinical Nurse Specialists and several nursing certifying bodies within the American Board of Nursing Specialties have expressed interest in collaboration with WOCNCB in making the solution a more feasible one for all groups involved. The Wound, Ostomy, and Continence Certification Board encourages all Advanced Practice Nurses to dialogue with their individual state Boards of Nursing concerning the Interstate APN Compact requirements currently being considered. The inability to obtain an APN license significantly impacts reimbursement for services, thus creating a barrier to nursing practice and to the delivery of care to specific patient populations. The WOCNCB takes certification seriously and is committed to identifying an optimal solution for all WOC-APNs. Dialogue with all interested stakeholders will continue, and communication on our progress will be available through the Journal of WOCN, the WOCNCB web-site (http://www.wocncb.org), and the WOCNCB newsletter, The Board's Bulletin. Stay tuned!!
Acknowledgements
The author wishes to express her thanks to Mary Walden (President of the WOCNCB), Cathyrn Vogeley (WOCNCB Financial Officer and Past Chair of the Advanced Practice Task Force), and Georganne Dixon (WOCNCB Executive Director) for their support in the completion of this guest editorial.
WHAT YOU CAN DO
1. Communicate your concerns about acceptance of the Interstate APN Compact Agreement to the NCSBN and your SBON, regardless of your current educational preparation and practice setting.
2. Stay informed of developments regarding this issue and continue to voice your opinions to decision-making stakeholders.
KEY POINTS
The APN Interstate Compact Agreement, as currently written, will have a significant impact for many Advanced Practice Wound Ostomy Continence Nurses in that it will:
* Alter reimbursement for WOC-APN services by Medicare/Medicaid and third party payers.
* Diminish Advanced Practice recognition/licensure for many WOC-APNs.
* Create barriers to practice and the delivery of WOC-APN care to our patient populations.