In my opinion, whether we call it certification or licensure, we must raise the bar in care delivery by credentialing direct patient care providers, including assistive staff.

Over the past 30 years, the healthcare system has been challenged to redefine the scope and nature of the services it offers to the public. Faced with the paradox of medical and technological advances and an environment of soaring expenses and declining reimbursement, many hospitals re-engineered the clinical workforce who provided patient care services. "Nursing substitutes" were created from narrower, task-specific roles into a more global, multi-skilled role. The newly designed "nursing assistant roles" incorporated the former jobs of EKG technicians and phlebotomists and were intended to decrease the need for higher cost professional nurses. The philosophy was to give the nurses an "extra pair of hands" to assist in providing the physical needs of patients, such as feeding, bathing, toileting, and ambulating. In principle, nurses would no longer be responsible for these activities; their focus instead would shift to medication delivery, procedures, and documentation required to generate revenue for the hospital. Some professional nursing lines were converted to create the case management/care coordination role, taking nurses further away from the bedside to focus on decreasing resource use and length of stay.

There is no formal educational requirement for nursing assistants. In fact, many hospitals have different levels and titles associated with assistive nursing positions. Nurses must act in a supervising capacity for the unlicensed assistive personnel to whom they delegate patient care, although the nurses know little about their training or competency. In their joint statement on delegation, the American Nurses' Association and the National Council of State Boards of Nursing stated that delegation of care is authorized to professional nurses within their state licensure and that there is a need for appropriate supervision of assistive personnel. They also stated that within the scope of individual and organizational accountability, staff nurses should have access to competence information about the person to whom the RN is delegating care (ANA & NCSB, 2005).

Early legislation to support licensure/certification of assistive staff occurred in 1987, when the federal government passed the Medicare Omnibus Reconciliation Act (Kelly, 1989). This law mandated a certified nursing assistant registry for each state to regulate care rendered in nursing homes, home care, and long-term care facilities to ensure that humane and safe care would be provided for the chronically ill elderly and handicapped. This was 20 years ago, yet there is still no regulation of unlicensed assistive personnel who provide complex care for patients in hospitals. Some states (such as Florida) have made nursing assistant licensure a priority goal, defining measures to achieve licensure or challenge examinations and setting up a path for professional discipline and reporting (Florida Department of Health, 2006). Wyoming has a clear outline of curriculum requirements, accreditation of training programs, and guidelines for acquiring and maintaining licensure as a nursing assistant (Wyoming State Board of Nursing, 2006). In New York State, hairstylists, cosmeticians, manicurists, and even pet groomers are licensed. Licensure/certification is required for laboratory technicians, massage therapists, physical and occupational therapy assistants, and many fitness center employees. All of these occupations offer services to the healthy community; we must consider licensure/certification of our nursing assistants as a necessity for patient/consumer safety.

All patients deserve competent and humane care; regulation is needed to ensure that caregivers have accountability and responsibility for their educational preparation and professional behavior. The Institute of Medicine (2003) report on "Keeping Patients Safe" is a narrative on why we must act on this legislation now. Processes for transition of current unlicensed assistive personnel toward licensure can be met within institutional educational offerings. States that already have a testing process can participate in planning a standardized national examination.

We can't go back in time, but we can move forward and raise the bar to achieve excellence in our hospital care. Nurses need to be assisted by a team of staff who are "licensed to care."

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