Policy Paper on Consensus Model for APRN Regulation ...



Policy Paper on Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education

Amy Higgins, Stephanie Kimbrel, and Diane Morris

Washburn University

Policy Paper on Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education

Problem Identification

Advanced Practice Registered Nurses (APRNs) have been practicing in various capacities for years; however, a consensus on the components involved in the regulation of APRNs has been argued for some time. Disagreements on uniform state regulations are limiting the accessibility of the high quality, cost-effective care APRNs can provide. Much of the debate involved in defining the APRN profession has involved credentialing, education, scope of practice, and the actual title of APRNs. The evolving landscape of healthcare and patient demographics give APRNs the opportunity to assume a more prominent role in the delivery of care and prove the impact of APRN care on patient outcomes (Stanley, 2009). Currently, there is a lack of uniformity across states in defining the APRN role, including advanced practice education, licensing, and credentialing requirements.

Background

The APRN role has been in existence since the 1940s (Rose & Regan-Kubinski, 2010). Early APRN roles were not clearly defined or regulated. In the early 1990s, official certification examinations were beginning to be utilized by state boards of nursing, as a requirement for APRN licensure. The first position statement was written in 1993. It identified the need for certifications as a piece of the regulation for advanced nursing practice (Rose & Regan-Kubinski, 2010). Prior to that time, an APRN may simply have meant a nurse who was very experienced and skilled in her area of practice, without regard to specific education, licensure or certification. After the publication of this position statement, increased attention was directed at the structure and accreditation of APRN educational programs. A second position statement was published in 2002, which detailed several regulatory concerns regarding the APRN certification examination. March 2004 brought about the convention of a group called The Alliance for APRN Credentialing, which was comprised of 14 organizations who discussed a consensus process to address the issues related to advanced practice education and credentialing. A smaller group was then put in charge of developing the future model for APRN regulation. This Alliance APRN Consensus Work Group met routinely from 2004 to 2008. In 2007, this group joined efforts with the NCSBN APRN Advisory Committee to produce complementary recommendations that would together guide future regulation, thus giving rise to the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (LACE) (Stanley, 2009). Their goal is to have this model fully implemented by 2015 (ANA, 2008).

The LACE Consensus Model recognizes four APRN roles: certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), certified nurse-midwife (CNM), and certified nurse practitioner (CNP) (ANA, 2008). The model also states that all APRNs will be educated in one of these four roles, in addition to at least one of six population foci: family, adult-gerontology, pediatrics, neonatal, women’s health, or mental health (Stanley, 2009). Education for APRNs will consist of completion of a graduate-level program in one of the four roles with successful passage of a national certification exam. The LACE model further outlines the requirement of every APRN graduate program to have core courses in comprehensive pathophysiology, health assessment, and pharmacology. The educational programs will also include appropriate clinical and didactic experiences. The LACE model now sets forth more specific guidelines for graduate programs and requires that these programs be knowledgeable of the various states’ regulations regarding the practice of APRNs (Chornick, 2008).

All education programs must now be accredited, according to the LACE model. Accreditation of educational organizations is a voluntary, self-regulating, nongovernmental process which assures a basic level of education (Chornick, 2008). The Commission of Collegiate Nursing Education and the National League for Nursing Accreditation are the only two accrediting groups responsible for this process.

Whereas accreditation applies to an organization, licensure applies to an individual. Licensure is the granting of authority to practice (ANA, 2008). Each APRN graduate must meet individual state licensure eligibility (Chornick, 2008). APRNs will be licensed as independent practitioners who are able to practice in one of the four previously discussed APRN roles within at least one of the six population foci. An APRN may then specialize in more focused areas within his/her population focus but can no longer be educated, certified, and licensed solely within that more narrow scope of practice (Stanley, 2009).

Ethical Factors

From an ethical standpoint, it is important for the public to trust that any APRN providing care is educated, certified, and licensed within his/her scope of practice. This will ensure patients that they are receiving safe and equitable care from providers with the title of APRN. Creating and implementing a timely consensus for APRNs is critical to assure the public about the consistency and quality of their healthcare providers (Yoder-Wise, 2010).

Political and Legal Factors

Politically, APRNs need an effective consensus model to more clearly define the profession and to move forward in healthcare as a united front with agreement on the regulations of the profession across all 50 states. As health care reform begins to change the delivery of care to individuals in our country, the APRN profession needs to be ready to speak as a unified voice about what care APRNs can contribute and why the professional development plan is essential (Yoder-Wise, 2010).

From a legal perspective, a consensus model is required to outline the scope of practice for each of the four APRN roles. As the APRN profession attempts to maximize the existing scope of practice, there is potential to do so by expanding: amendments to state nurse practice acts, judicial decisions, and federal enactments (Watson & Hillman, 2010).

Further, agreement among states is needed to align the prescriptive authority of APRNs. Currently, APRNs have some degree of prescriptive authority in all 50 states; however, these varying degrees of authority cause much confusion among consumers. Legislative changes are needed to expand APRN prescription privileges in all states to include:

• Authority to prescribe without physician involvement

• Authority to prescribe with physician collaboration

• Written protocol required to prescribe

• Authority to prescribe controlled substances (Watson & Hillman, 2010)

A consensus regarding prescriptive authority is needed to bring uniformity in scope of practice and alleviate confusion among healthcare consumers.

Additional liability issues that exist for APRNs include:

• Unlicensed practice of medicine

• Failure to adequately diagnose

• Negligence in the delivery of healthcare

• Conduct exceeding physician-delegated authority—resulting in harm

• Conduct exceeding scope of practice –resulting in harm

• Failure to refer appropriately (Guido, 2010).

Essentially, APRNs have dual legal liability including nurse adherence to the state nurse practice act and the APRN’s requirement to national specialty certification and/or secondary licensure requirement. If APRNs continue to expand practice roles, there will likely be an increase in the APRNs level of accountability and liability (Watson & Hillman, 2010).

Issue Statement

How can the LACE model be expeditiously implemented in all states to ensure that the APRN profession continues to grow and meet the demands of changing healthcare, while increasing the APRN scope of practice and assuring that licensure, accreditation, certification, and education are uniform across all 50 states?

Stakeholders

There are a variety of stakeholders with regard to the LACE consensus model. The most obvious stakeholder is the APRN, both existing and newly graduating. Existing APRNs have a definite stake in the implementation of the consensus model and a grandfather clause does allow for any APRN who is already practicing to continue to do so in the state he/she is currently licensed (ANA, 2008). Once the LACE model is fully implemented, it will allow APRNs to move from one state to another and be able to obtain licensure, if certain criteria are met.

Individual states and state legislatures represent another group of stakeholders. In order for the LACE model to promote uniformity among APRN regulation, states must meet the new Uniform APRN Requirements in order to enter into the APRN compact which will facilitate interstate APRN practice (Chornick, 2008). To achieve the expectations of the consensus model, every state must agree to the same terms, definitions, and conditions outlined in the LACE document (Yoder-Wise, 2010).

As mentioned earlier, the consumers or “patients” are certainly a stakeholder in the LACE consensus model. Assuring the public consumers that the quality and consistency of care they receive from an APRN is essential and makes consumers a definite stakeholder (Yoder-Wise, 2010). The American Association of Retired Persons (AARP) in Hawaii commented that consumers of all ages need access to primary care and chronic care management, so that people with diabetes, hypertension, and other chronic ailments can lead productive and health lives. They also stated that APRNs should be able to practice to their full extent and be reimbursed for the care they provide to help fill the gap in primary care (Mathews et al., 2010).

Nursing education programs have a pronounced role as stakeholders with regard to the LACE consensus model. Once implemented, the LACE model will require all APRN education programs be accredited to ensure that each program meets the minimum curriculum guidelines, as well as clinical and didactic experiences. Graduate nursing programs will need to re-visit their current curriculum to meet these new standards and be more abreast of the various states regulations, until interstate uniformity is reached (Chornick, 2008).

Policy Objectives

The policy objectives for the LACE model are aimed at creating uniformity among the states with regard to APRN licensure, accreditation, certification, and education. While there is much debate about how to carry out this policy change, several steps need to be taken to achieve this goal:

• Nurses should practice to the full extent of education and training.

• Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

• Nurses should be full partners, with physicians and other health care professionals

• Effective nursing workforce planning and policy making require better data collection and improved information structure (Oleck et al., 2011).

While these objectives are not exclusive for APRNs, they most certainly apply to the LACE consensus model’s objectives for reaching uniformity for the profession.

Policy Alternatives

One possible policy alternative would be to follow the recommendation of The American Association of Colleges of Nursing (AACN) for all master’s level APRN programs to be changed to doctorate of nursing practice (DNP) by 2015 (Watson & Hillman, 2010). This recommendation is not included in the LACE consensus model. Implementation of this alternative would have a huge impact on existing APRN educational programs both organizationally and financially.

Another policy alternative includes the specialists’ model which has been criticized as being restrictive in its focus, uneconomical and at variance with the World Health Organization whom advocates for the preparation of general nurses (Fealy et al., 2009). In restricting registrants to a specialized area, it decreases workplace mobility. Despite this, there have been calls to return to specialists’ model because the generic comprehensive model does not prepare APRNs in some specialty areas. The generic model prepares graduates with a more broad and comprehensive knowledge base. The generic model assumes that a generalist practitioner can assess the needs of all patients, regardless of age and healthcare setting. Graduates are prepared with beginner-practitioner competencies that can differentiate, integrate, and generalize from knowledge gained. It also presupposes that branching into specialists’ area will occur after initial registration (Fealy et al., 2009).

Evaluation Criteria

The criteria for evaluation of a policy alternative includes: the likelihood of ongoing funding, size and availability of funding stream, ability to meet current and future demands, and political feasibility.

Analysis for Option 1- Do Nothing

Criterion 1: Likelihood of Ongoing Funding

Pro: With health care reform and the need for accessible healthcare providers money is being poured into primary care education including increasing the number of APRN’s. The Patient Protection and Affordable Care Act has allotted $200 million program to educate more APRN’s in primary, preventive, and chronic care management (Carlson, 2010). This is an addition other federal funding by the government such as: Title VII, Title VIII, and Medicare education funding.

Con: The United States Health Care system is failing. Healthcare costs continue to rise without the ability of the American people or government to afford these changes. The increasing costs will continue to bring close examination of government spending and needed healthcare system changes. If changes are not made to increase the accessibility of ARNP care, then funds could be diverted from graduate nursing education to other means of providing primary care and prevention.

Criterion 2: Size and Availability of Funding Stream

Pro: The Title VIII Nursing Workforce Development programs administered by the Health Resources and Services Administration (HRSA) are the primary source of Federal funding for nursing education. They include major grants such as the Advanced Nursing Education Grants which provide nursing schools, academic health centers, and other entities funds to enhance education and practice for masters and post-masters nursing programs (American Nurses Association, 2011). According to the FY 2011 Appropriations: Senate (see Appendix B), funding for nursing education, retention and workforce has greatly increased from $137,000 to $64,438 million, under Title VIII Advanced Education Nursing grant (Nursing, 2010).

Con: Difficulty exists in fully examining the amount of monies allotted to nursing education. However, the majority of these funds are discretionary. In negotiations for FY 2011 Continuing Resolution (CR) H.R. , the House opted to cut the Nursing Workforce Development Programs and Health Professions Programs by $145.1 million, which represents a decrease of 29% in the funding over the FY 2010 (American Nurses Association, 2011).

Criterion 3: Ability to Meet Current and Future Demand

Pro: The great need for primary care providers is evident. It is apparent that APRN’s can help to fill this hole. There are 50 million uninsured Americans (AlterNet, 2011) that will have health insurance after the Health Care Reform Act is implemented. As the number of insured individuals rises, there will be an even larger shortage of providers. A solution to this problem is APRN’s.

Con: Currently there is a decrease in the accessibility to APRN’s. If no change is made then the function of an APRN will not be fully utilized. The need for APRN’s to function to the full scope of their abilities and practice, with equality in reimbursement, is essential in alleviating this shortage.

Criterion 4: Political Feasibility

Pro: President Obama supports the need for APRNs and nursing education important components in the Health Care Reform plan. The President’s February 2011 FY 2012 budget includes a 28.4% increase, with $313 million allotted for the Title VIII nursing education provisions. With the planned Health Care Reform changes, our aging population of baby boomers, and an increase in national health care needs, our government is realizing the benefit of care that an APRN can provide in addressing the shortage of healthcare providers.

Con: Without an appropriate strategy, the APRN could be lost in the mix of Healthcare reform. If the APRN profession lacks a uniform message, a united front and effort by the nursing community to lobby for APRN’s the medical society may pull rank and protect their monopoly on providing primary care.

Analysis of Option 2: APRN to DNP Program

Criterion 1: Likelihood of ongoing funding

Pro: Current funding for APRN programs and faculty has been discussed in the first option. This applicable to the DNP option as well.

Con: The average cost of a Master in Nursing (MSN) is approximately $24,000 in the state of Kansas. A Doctoral of Nursing Practice (DNP) degree would be an additional $15,000-$20,000. Instead of $24,000 to become an APRN, the cost would be closer to $40,000. This would take additional money away from the discretionary funding of the Title VIII program to help support advanced nursing education creating one doctoral APRN instead of two master degree APRNs. This makes the goal of becoming an APRN more difficult to obtain for an individual attempting to pay for or use school loans. Additionally, it increases the amount of time dedicated to a longer program. Would the salary made by an APRN after receiving a DNP make up for the money spent on school? This may also increase the number of faculty members needed to staff DNP programs. Nursing educational programs are already experiencing shortages of faculty and this would no doubt be made worse, as PhD faculty would now be required.

Criterion 2: Size and Availability of Funding Stream

Pro: The size and availability of the Funding Stream is currently quite large and accessible to those organizations supporting further education of nurses into the APRN role. Kathleen Sebelius, Health and Human Services Secretary, states “We cannot build a healthier America if our country continues to face a growing health professions shortage, a well-trained and diverse workforce is critical to meeting future health care demands and to reforming the nation’s health care system.” Sebelius announced that $159.1 million would be appointed to support the healthcare workforce and training, which would build on the multimillion dollar investments made under the Affordable Care Act and Recovery to strengthen and grow our primary care workforce (U.S> Department of Health & Human Services, 2010). The Act has reauthorized Title VIII and enacted new laws, such as the removal of the 10% cap previously imposed on support for the doctoral students. It has created an individual nurse faculty loan fund, in addition to the Nurse Faculty Loan Programs awarded to schools of nursing. Both programs will place priority of the funding doctoral students (American Association Colleges of Nursing, 2011).

Con: The size and availability of funding will decline with the implementation of DNP. A DNP will cost more money for the future APRN to obtain, requiring more financial hardship, more money for institutions to provide for the faculty to teach at this level ,and more money to fund this program with a decrease in the numbers of APRNs graduating.

Criterion 3: Ability to Meet Current and Future Demand

Pro: Currently the demand outweighs the supply; the future demand will only increase. With the Affordable Care Act and Recovery the effort is being made to increase the supply to meet the increasing demands of the American people who are in need of primary, preventative and chronic care management.

Con: With the implementation of DNP as a requirement to practice for those entering a program after 2015, who are not already grandfathered in, will decrease the number of graduating APRNs throughout the United States. The prevalence of DNP programs are less and these programs are not able to take on as many students, thus decreasing the supply, while the demand will continue to rise.

Criterion 4: Political Feasibility

Pro: The changing demands of the nation’s complex healthcare environment necessitate the highest level of scientific knowledge and practice expertise to assure positive patient outcomes. A call for action has been made by the National Academy of Sciences for nursing to develop a non-research clinical doctorate program to prepare expert practitioners, following in the direction of other health professions such as Medicine (MD), Dentistry (DDS), Pharmacy (PharmD), Psychology (PsyD), Physical Therapy (DPT) and Audiology (AudD) (American Association of Colleges of Nursing, 2011). This will gain support and respect for the nursing community helping to redefine their role. DNP will allow for stronger lobbying for nursing education and less opposition by others in the health profession.

Con: Significant funding is required for this change to produce the amount of needed primary health care providers. In the current economic decline, discretionary monies may be diverted from nursing education to fund other needs. Again organizations such as the American Medical Association or major hospitals, who have great lobbying power, could arrange road blocks to the succession of DNP, for fear of their own financial burdens.

Option 3: Specialists’ Model

Criterion 1: Likelihood of ongoing funding

Pro: The Specialists’ model allows for focus on a specialized area such as gerontology or pediatrics. Woman’s health and pediatrics are among several of the known health disparities in our county. This particular model suggests having APRNs specialize in these areas of care to decrease disparities. Funding on this model will likely continue with the Affordable Care Act and Recovery. The Act along with other healthcare organizations attempt to focus on decreasing health disparities in the United States, by utilizing specialists in these areas to help reduce provider gaps.

Con: As stated earlier, this model does not allow for workforce mobility. Additionally, accessibility to care remains a problem. Opponents of the generic comprehensive preparation have charged advocates with having ulterior motives related to managerial concerns with cost effectiveness and ease of staff deployment while others point to the risk of inequality in the classroom and in practicum. With the initial training is also fails to provide sufficient knowledge and skills to offer higher quality care within specialty fields. There is great concern of particular importance in areas of children and the intellectual disability (Fealy et al., 2009). The cost effectiveness of the model is also questionable. Making major policy changes that do not result in improved cost effectiveness or greater access to care will have limited acceptance, resulting in a decrease in funding.

Criterion 2: Size and Availability of Funding

Pro: In 2011, Title VIII, the Advanced Education Nursing Grants, received a funding increase of $137,000, bringing the overall advanced nursing education grant to $64.438 million.

Con: The primary focus of the Affordable Care Act and Recovery includes preventative, primary, and chronic care management, not on specialties. Funding will most likely be granted to those students entering primary care, rather than those with a specialty focus.

Criterion 3: Ability to Meet Current and Future Demands

Pro: Current health disparities exist among specialized populations, such as children and woman’s health. By having APRN specialists who focus on these underserved populations, the current and future demands of these shortage areas in healthcare can be reduced.

Con: The shortage of primary health care providers has increased health disparities in America. Currently, the greatest health disparities are based on racial and geographic populations (Sack, 2005). These gaps and specialized populations, such as children and woman’s health can be benefited greatly by a practitioner who offers broader care. A specialist is not a feasible alternative within regions where a lack of access to appropriate medical care exists. To meet the current and future demands of our country, it is more cost effective to develop primary care providers who can provide healthcare services to any child, woman, or human, regardless of age or race.

Criterion 4: Political feasibility

Pro: The focus of children and women’s health is to reduce health disparities and create a healthier America. Support for specialized APRNs will dependent upon the specialty. With the nation’s growing elderly population , an APRN specializing in gerontology would be widely accepted and supported by organizations such as AARP, who are a powerful lobbying group.

Con: Current focus on health is within the primary care arena, not specialties. In fact, emphasis on healthcare reform does not support specialty care. Rather, focus on the whole person to with particular attention to preventing major diseases is the goal. Political support is geared toward the areas of primary care and prevention, not specialties.

Comparison of Alternatives and Results of Analysis

| | |Alternatives | | |

| |Do Nothing Option |DNP’s |Specialists’’ |LACE |

|Criteria | | | | |

| Substantive Funding Stream |++ |+++ |+ |+++ |

|Likelihood of Ongoing Funding |+ |++ |+ |++ |

| Ability to Meet Current/Future |- |- |- |++ |

|Demands | | | | |

| Political Feasibility |+ |++ |- |+ |

| |4+/1- |7+/1- |2+/2- |8+/0- |

|Score for Each Alternative |3 |6 |0 |8 |

Analysis and comparison of the Consensus Model: LACE and the three afore mentioned alternatives, (as seen in the matrix above) affirms that the Consensus Model: LACE exhibits the greatest ability to increase safe, equitable, and accessible healthcare. The alternative DNP comes in close with six points; however, would have a huge impact of nursing educational programs. Alternative 1, Do Nothing alternative scores positively but not strongly, as it has major weaknesses in meeting current and future demands. Alternative 3, the Specialists alternative, scored poorly, positives negated by negatives. It shows major weaknesses in both current and future demand and political feasibility (Mason and Leavitt, 2007).

After analyzing and comparing the LACE consensus model with the alternatives, it is apparent that the LACE model is seemingly the most feasible policy to address the APRN profession. As the LACE model is implemented across all states, it will ensure that the APRN profession continues to grow and meet the demands of changing healthcare. The LACE model also ensures the APRN’s scope of practice is utilized to its fullest extent. It also will assure that licensure, accreditation, certification, and education are uniform across all 50 states for APRNs, creating more accessible healthcare to meet the increasing demands of the nation.

References

AlterNet. (2011). Number of Uninsured Americans Soars to 50 Million. Retrieved May 2011, from AlterNet:

American Association of College of Nursing. (2011, Febuary). AACN Applauds president Obama's FY 2012 Budget Proposal Calling . Retrieved May 2011, from American Association of College of Nursing Calling for Increase in Nursing Education and Research:

American Nurses Association. (2008). Consensus model for APRN regulation: licensure, accreditation, certification & education. Retrieved from

American Nurses Association. (2011, April 29). President Obama' FY 2012 Budget, FY 2011 Continuing Resolution, Possible Government Shutdown...OH MY! Retrieved May 2011, from Capitol Update:

Carlson, J. (2010). Groups Hail Funding for Nurse Training. Healthcare Business News.

Chornick, N. (2008, January-March). Advanced practice registered nurse educational programs and regulation: a need for increased communication. JONA’s Healthcare Law, Ethics, and Regulation, 10(1), 9-11.

Fealy, G. M., Carney, M., Drennan, J., Treacy, M., Burke, J., O’Connell, D., ... Sheerin, F. (2009). Models of initial training and pathways to registration: a selective review of policy in professional regulation. Journal of Nursing Management, 17, 730-738.

Guido, G. (2010). Legal and ethical issues in nursing (5th ed.). San Francisco: Pearson.

U.S> Department of Health & Human Services. (2010, August 5). HHS Awards $159.1

Million to Support Health Care Workforce Training. Retrieved May 2011, from :

M. W., Mason, D. J., & Leavitt, J. K. (2007). Policy and Politics in Nursing and Healthcare.

St. Louis: Saunders Elsevier.

Mathews, B. P., Boland, M. G., & Stanton, B. K. (2010). Removing barriers to APRN practice in the state of Hawai’i. Policy, Politics, & Nursing Practice, 11(4), 260-265.

Nursing Community. (2011). Testimony of the Nursing Community Tregarding Fiscal Year 2012 Appropriations for the Title VIII Nursing Workforce Development Programs, the National Institute of Nursing Research, and Nurse-Managed Health Clinics.

Nursing, A. A. (2010). FY 2011 Appropriations: Senate.

Oleck, L. G., Retano, A., Tebaldi, C., McGuinness, T. M., Weiss, S., Carbray, J., ... McCoy, P. (2011). Advanced practice psychiatric nurses legislative update: state of the states, 2010. Journal of American Psychiatric Nurses Association, 17(2), 171-188.

Rose, L., & Regan-Kubinski, M. (2010, December). Update on advanced practice registered nurse regulation: licensure, accreditation, certification and education. Archives of Psychiatric Nursing, 24(6), 440-441.

Sack, K. (2005, June 5). Research Finds Wide Disparities in Health Care by Race and Region. New York Times.

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Yoder-Wise, P. S. (2010). LACE: the consensus model and implications beyond advanced practice. The Journal of Continuing Education in Nursing, 41(7), 291.

Appendix A

Organizations Participating in APRN Consensus Process

Accreditation Commission for Midwifery Education

American Academy of Nurse Practitioners

American Academy of Nurse Practitioners Certification Program

American Academy of Nursing

American Association of Critical Care Nurses

American Association of Critical Care Nurses Certification Program

American Association of Nurse Anesthetists

American Association of Occupational Health Nurses

American Board of Nursing Specialties

American College of Nurse Practitioners

American College of Nurse-Midwives

American Nurses Association

American Nurses Credentialing Center

American Organization of Nurse Executives

American Psychiatric Nurses Association

Association of Faculties of Pediatric Nurse Practitioners

Association of Rehabilitation Nurses

Association of Women's Health, Obstetric and Neonatal Nurses

Certification Board Perioperative Nursing

Commission on Collegiate Nursing Education

Council on Accreditation of Nurse Anesthesia Educational Programs

Division of Nursing, DHHS, HRSA

Emergency Nurses Association

Hospice and Palliative Nurses Association

International Nurses Society on Addictions

International Society of Psychiatric-Mental Health Nurses

NANDA International

National Association of Clinical Nurse Specialists

National Association of Neonatal Nurses

National Association of Nurse Practitioners in Women's Health

National Association of Nurse Practitioners in Women's Health, Council on Accreditation

National Association of Pediatric Nurse Practitioners

National Association of School Nurses

National Board for Certification of Hospice and Palliative Nurses

National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties

National Conference of Gerontological Nurse Practitioners

National Council of State Boards of Nursing

National Gerontological Nursing Association

National League for Nursing

National League for Nursing Accrediting Commission

National Organization of Nurse Practitioner Faculties

36 APRN Joint Dialogue Group Report, July 7, 2008

Nurse Licensure Compact Administrators/State of Utah Department of Commerce/Division of Occupational & Professional Licensing

Nurses Organization of Veterans Affairs

Oncology Nursing Certification Corporation

Oncology Nursing Society

Pediatric Nursing Certification Board

Sigma Theta Tau, International

Society of Pediatric Nurses

Wound Ostomy & Continence Nurses Society

Wound Ostomy Continence Nursing Certification Board

Appendix B

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