Nurse Administrators and Understanding the Enigma of Nursing Regulation
For most of my 30-year career, the relationship I had with nursing regulation could be simply summarized as graduating from school, taking and passing a test, getting a license, and each year paying a fee to maintain that license. Even as a nursing administrator, I experienced minimal interaction with the Board of Nursing (Board), except for the few times I reported nurses for drug diversion. I believe I could safely say that most of my peers share a similar experience.
An enigma is something not easily understood and is sometimes hard to explain. Thus is nursing regulation-an enigma. Six years ago, I was appointed to the advanced practice seat on the state board. Like many regulatory novices, I thought I knew much more about regulation than I actually did. Luckily, through good mentoring, excellent regulatory resources, and the opportunity to complete a 4-year regulatory fellowship through Institute of Regulatory Excellence, National Council of State Boards of Nursing, today I have a working knowledge of regulation, but I am still far from being an expert.
Boards serve to protect the public through 4 major domains: (1) approving and enforcing educational standards, (2) licensing on the basis of psychometrically and legally defensible testing, (3) monitoring and decision making related to practice issues, and (4) using the disciplinary process to remove from practice those nurses who fail to maintain standards.
In crafting this edition, I selected contemporary topics that could provide greater understanding of regulatory issues and that could serve as useful resources to chief nursing officers (CNOs) and nursing administrators. National education standards are effectively established by the American Association of Colleges of Nursing and monitored by educational accreditation bodies. This work is commonly accepted by boards and is one domain not addressed in this edition. Other domains are grouped into articles that address discipline, contemporary issues, and public policy development impacted by nursing regulation.
Regarding discipline, James Raper, a nurse attorney and the current chairman of the Alabama Board, and I address the common concern among nursing administrators that the outcomes from board actions are not consistent with what nurse administrators think should happen, or would happen, to nurses whose violations are reported by the nurse administrator. Unhappiness with the outcome and the perception that reporting did not yield results pose a threat to sustained reporting by nurses and could limit the board's most important reporting relationships. We try to explain why this happens. The staff of the Ohio Board present examples of boundary violations that can be identified in many practice settings, and Patricia Dittman presents her work on identifying how impaired male nurses manipulate nursing systems to maintain access to drugs, whereas Linda Young from the South Dakota Board describes necessary educational support for workplace monitors when impaired nurses return to work.
Understanding the benefits of the Nurse Licensure Compact and the outcomes of its initial 5 years is presented by Laura Poe, executive director of the Utah Board and the first chair of the Nurse Licensure Compact administrators. Adoption of consensus statements related to pain management and examples of how regulation and practice partnered is presented by Nurse Attorney Vicki Sheets, and Shirley Brekken, executive director of the Minnesota Board. Margaret Walker, executive director of the New Hampshire Board, discusses the outcome of regulation's response to supporting approval of a new role to assist nurses in long-term care, the certified medication assistant. Reporting Nurse Practice Act violations requires some complex strategy because it can impact the integrity of the employment relationship. Navigating these complex regulatory requirements, while at the same time maintaining a "just culture" environment, is discussed by Joy Gorzeman, senior vice president and CNO for Trinity Health. Kelly Goudreau builds on addressing issues in the clinical environment by comparing roles and uses of the clinical nurse specialist and the comparatively new role, clinical nurse leader. As a mechanism to meet the needs of nurse administrators in understanding and developing relationships with boards, Marilyn Hudson presents the Oregon Board's Nurse Executive Orientation Program. CNOs, especially those new to the role, could use this tool to seek development of similar programs in other states.
An issue of major importance today, no longer limited only to teaching hospitals, is advanced practice registered nurse (APRN) credentialing in hospitals through the medical staff process. As nurse practice acts increasingly change to allow greater levels of autonomy and independence in APRN practice, appropriate mechanisms for credentialing are emerging. Tracy Klein, from a board perspective, and Ruth Kleinpell, Marilyn Hravnak, Barbara Hinch, and Jane Llewellyn present perspectives from regulation and practice on operationalizing this very important issue that impacts reimbursement for services and peer review and represents the ever-increasing autonomy and clinical contributions of advanced practice nurses in acute care hospitals.
The relationship between nurses in practice and nurses in regulation is important. Regulation relies heavily on those in practice for trend identification, practice changes and to be a source for violation reporting. Because of nursing's increasing globalization, cultural impact, variations in scopes of practice and multiple and complex educational systems, regulation must be present in contemporary nursing discussion and policy making.
I hope that nurse administrators find the content interesting, informative, and applicable to CNO practice and that it helps provide clarity, understanding, and meaning to regulatory issues that for many of us have been an enigma for years.
Randall Hudspeth, MS, APRN, CNS/NP, FRE, FAANP
Director, Professional and Specialty Practice, Saint Alphonsus Regional Medical Center, Boise, Idaho