Background
As advanced practice nursing was being recognized as a distinct role from registered nursing, boards of nursing began to look for assessment methods to evaluate advanced practice registered nurse's (APRNs') competency to practice. In the absence of a national licensure examination, many boards of nursing started to use available advanced practice certification examinations.
Today, most boards of nursing use APRN certification as a prerequisite for practice. On the basis of 2007 data (National Council of State Boards of Nursing [NCSBN]), 45 boards of nursing (out of 57 jurisdictions in the United States and its territories) use APRN certification examinations as one of the requirements for advanced practice licensure for nurse practitioners, and 38 boards of nursing use APRN certification examinations for clinical nurse specialists.1 With the adoption of the APRN Uniform Requirements, the number of boards using certification examinations promises to increase.2 The APRN Uniform Requirements were developed to serve as a foundation for the APRN Compact. Included in the APRN Uniform Requirements is the criterion of "being currently certified by national certifying body in the APRN specialty appropriate to educational preparation." Thus, for a state to be able to join the APRN Compact, it must require APRN nurses to take a national certification examination.
However, the use of APRN certification examinations as a basis for licensure has caused confusion among APRNs and APRN stakeholders regarding the difference between certification and licensure. Some nurses have assumed that by taking an APRN certification examination, they are entitled to practice as an APRN. Boards of nursing have reported cases of APRNs neglecting to apply to their board of nursing for licensure and, instead, practicing as an APRN after successfully taking an APRN certification examination. The intent of this article is to clarify the role of APRN certification examinations in the licensure process and to identify regulatory issues that APRNs should be aware of.
Licensure
Licensure results from the enactment of a nurse practice act by state legislatures to regulate nursing. Laws governing individual healthcare providers are enacted through state legislatures. After enacting a nurse practice act, a state legislature delegates authority to a state agency, such as a board of nursing, to enforce it. The state agency is authorized to promulgate regulations to implement the nurse practice act for the purpose of protecting the public health and safety. The nursing license is the end product of this process. Because the primary purpose of licensure is public protection and safety, the major stakeholder for licensure is the public.3
Individuals are required to have a license to practice as a nurse. Licensure authorizes a legal scope of practice for a nurse, provides legal use of a title, and includes standards of practice. The title given to an individual (eg, registered nurse [RN], licensed practical nurse, etc) indicates that he/she has completed eligibility requirements to obtain the title and authorizes him/her to be able to practice within a specific scope of practice. If nurses fail to practice within the prescribed scope, they are subject to disciplinary actions by boards of nursing.
Examinations used for licensure must be based on established testing standards and criteria to be legally defensible and psychometrically sound. Licensure examinations measure entry-level practice to prevent unnecessary barriers to individuals aspiring to practice and the minimal competency level necessary for the protection of the public. In addition, they meet specific testing practices such as being in compliance with the American Disabilities Act. Examination items are reviewed for content validity, currency, and cultural bias, and examinations are evaluated for psychometric performance. Passing standards must be established using established psychometric methodology and be reevaluated periodically. Examination security must be maintained. Due process must be in place, as well as confidentially for nonpublic candidate data. A retake policy must be established. It should be noted that many certification programs do use varying degrees of these criteria in their certification programs; however, all of these criteria are mandatory for licensure examinations. National Council Licensure Examination-Registered Nurse (NCLEX-RN) and the National Council Licensure Examination-Practical Nurse (NCLEX-PN) are the nursing licensure examinations for RN and licensed practical/vocational nurses. There is no advanced practice licensure examination that parallels the NCLEX-RN and NCLEX-PN.
Certification
By contrast, certification is usually a voluntary process by which individuals take an examination in a specialty area for the purpose of professional recognition. For instance, RNs can take certification examinations in the areas of oncology nursing, emergency department nursing, or informatics. Successful candidates certified in these specialty areas use specific initials after their names to signify excellence in these specialty areas. The certification process provides nurses with a mechanism to distinguish themselves from other nurses.
Certification examinations are developed by private organizations and are not subject to the same level of legal scrutiny as that of a licensure examination. Certification organizations, being accountable only to themselves, are free to establish criteria in the interest of their members.4 They are not accountable to the public. The title used by an individual after successful completion of a certification examination does not carry any type of legal status. It does not embellish one's licensure or procure additional rights.
The public can rightfully assume that the use of certified professionals will increase the probability of more proficient care. However, by virtue of a certification examination being private and voluntary, it cannot be used by state as a public protection mechanism. Since the certification is voluntary and private, there are no legal requirements that the individual must be certified to be practice. Some qualified individuals may elect not to be certified. Therefore, the public cannot make the assumption that the competence of a certified individual differs from that of an individual who is not certified.
Blurred Distinctions
The difference between licensure and certification seems very distinct in many healthcare roles. For instance, the distinction between RN licensure examinations and RN certification examinations is clear. Before practicing as an RN, candidates must apply to a board of nursing and submit evidence that they have completed requirements. Requirements for licensure can vary from state to state but usually include successful completion of an approved nursing education program and the NCLEX-RN. Registered nurse certification programs are taken after individuals have been granted their registered nursing license. Registered nurse licensure is a prerequisite for achieving nursing certification.
However, the distinction between certification and licensure becomes blurred when certification and licensure have overlapping roles, as in the case of advanced practice nursing. There is no national APRN licensure examination, and in lieu of one, most boards of nursing use APRN certification examinations as one of several requirements for entry into APRN practice. Therefore, APRN certification, if used for licensure, is no longer voluntary but instead mandatory for practice. The previous distinctions between certification and licensure have subsequently become blurred, and questions arise regarding the meaning of APRN certification examinations. How have the stakeholders changed? What is the purpose of APRN certification examinations? Advanced practice registered nurses ask if they are licensed after taking their APRN certification examination.
The use of APRN certification examinations by boards of nursing to make APRN licensure decisions has major ramifications for both certification programs and boards of nursing. Traditional certification programs are accountable solely to their members. However, with the advent of APRN certification examinations being used by boards of nursing as a measure of APRN competence, the stakeholders for APRN certification programs now include the public. The purpose of public protection, which is inherent in licensure examinations, has been extended to the certification programs developing APRN examinations for licensure, and APRN certification programs used for licensure now must meet the public safety goal of licensure examinations. Instead of being free to develop examinations based on their own specifications, they must meet the regulatory specifications of high-stake licensure examinations that are legally defensible and psychometrically sound. The APRN certification program must determine the degree to which it is willing to assume the obligation to meet the public protection needs of the licensure boards. Only those certification programs willing to make the necessary changes can be used for licensure.
The APRN certification examination must be directed toward measuring the essential competencies in the professional APRN role. Evidence of the job-related knowledge, skills, and abilities required for entry-level practice must be identified and incorporated into the examination process. Identification of the knowledge, skills, and abilities to be included in the examination is based on a job analysis study. Questions on the examinations are confined to those with a direct relationship to public safety.
Traditional certification programs also have the option of determining the breadth of their examination and determine who is eligible to take their examination. A too broad or too narrow scope would be inappropriate for an APRN examination used for licensure. Advanced practice registered nurse examinations used as a basis for licensure may only consist of job-related knowledge and skills and use a pass/fail at the point of the minimum essential level for safety and effectiveness. In addition, the certifying body must ensure that the individual meets specific qualification criteria such as ensuring that the educational background of the individual is consistent with the APRN certification examination.
Although boards of nursing use APRN certification examinations, they must retain the ultimate responsibility of determining if an APRN certification examination meets the board's regulatory criteria to protect the public. This authority cannot be relinquished to certification programs.5 Boards of nursing must be assured that the examination is psychometrically sound and legally defensible for use as a basis for licensure through established criteria aimed at the evaluation of examination content, procedures, and scoring process. Even after approving an examination for licensure purposes, it is the duty of the board of nursing to continue to monitor the examination to ensure that it continues to meet their standards.
Issues
The use of APRN certification examinations by boards of nursing can be an efficient mechanism for boards of nursing to demonstrate an individual's capabilities to promote public protection. However, the use of APRN certification examinations as a basis for entry into advanced practice by boards of nurses raises several issues. Some APRN certification programs have changed many aspects of their certification examinations to enable their examinations to be used by boards of nursing such as directing the examination at entry-level competency as opposed to testing excellence and determining the appropriate breadth of the examination based on a job analysis study of newly graduated APRNs in a specialty area. However, not all APRN certification programs have subscribed to the regulatory criteria required for licensure examinations. These examinations are not suitable for regulatory purposes. Boards of nursing very carefully review APRN examinations before determining which APRN certification programs meet their licensure requirements. Reasons that a board of nursing may not approve an APRN certification examination could include the following: the examination is not designed to measure entry-level abilities or it does not evaluate the skills and abilities needed to do the job. From a measurement perspective, they may not be constructed psychometrically in a manner appropriate for legal recognition. The content may not be consistent with the legal scope of practice, or the specialty area can be inappropriate.
To assist boards of nursing in determining if an APRN examination meets licensure requirements, the NCSBN Advanced Practice Committee has developed APRN Certification Program Criteria for consideration by boards of nursing.6 The criteria include the following areas:
* national in scope
* testing administration
* educational requirements
* testing methodologies
* represents entry-level APRN practice
* essential knowledge, skills, and abilities
* examination items
The complete list of criteria for certification programs, "Requirements for Accrediting Agencies and Criteria for Certification Programs," can be found on NCSBN's Web site at http://www.ncsbn.org.
Although these criteria are available for the consideration of boards of nursing, each board of nursing must review available APRN certification examinations to determine if they are appropriate for their specific jurisdiction. A list of the APRN certification examinations that are acceptable by a board of nursing can often be found in their nurse practice act or rules. Another way of determining what APRN certification examinations are accepted in your state is to call the state board of nursing. A list of boards of nursing and their contact information can be found on NCSBN's Web site. Students interested in being advanced practice nurses should investigate whether the APRN certification examination they intend to take is approved by their state board of nursing.
A trend of focusing on narrow specialties has occurred among nurse practitioner education programs and certification examinations. This trend toward narrow specialties has decreased the flexibility of nurse practitioners to practice in a variety of settings and has compromised their ability to practice safely. Nurse practitioners educated in, for instance, a disease entity have a very narrow scope of practice. This becomes a limiting factor when the practitioner is faced with a wide variety of health disorders in practice. To practice beyond treating that specific disease entity could mean that the nurse practitioner has gone beyond his/her scope of practice. The nurse practitioner with a narrow subspecialty is also limited in his/her ability to change to another specialty practice, which may decrease a practitioner's flexibility in changing work settings. In addition, many boards of nursing do not accept APRN certification examinations with a narrow focus, resulting in one's inability to practice in other states. Individuals interested in becoming nurse practitioners are advised to only consider a broad APRN educational preparation (eg, adult health, psychiatric mental health, pediatrics, etc) and corresponding APRN certification examination for licensure purposes. Advanced practice registered nurse subspecialty education and certification examinations can be taken after licensure for a value-added purpose.
New graduates can be confused regarding the meaning of APRN certification examinations. Successful completion of a board approved APRN certification examination is used by boards of nursing as only one criterion for licensure. Other criteria may include a review of educational credentials, criminal background check, and so forth. All of the criteria must be evaluated by the board of nursing before the approval of the APRN's licensure application. It is important for the APRN to understand that only after APRNs are licensed by a board of nursing can they practice legally as an advanced practice nurse.
Summary
The use of APRN certification examinations for licensure purposes can cause confusion among APRNs. Advanced practice registered nurses need to be aware of the regulatory issues associated with APRN examinations such as the fact that not all examinations are accepted by boards of nursing for purposes of obtaining licensure. Another important point is that a person who successfully takes an APRN certification examination is not licensed until he/she applies to the board of nursing and is notified by the board of nursing that he/she is licensed.
REFERENCES