Introduction

There are three major ways we regulate our profession, its members, and their performance--namely, licensure, certification, and accreditation. The differences among these processes can be confusing. They have different purposes, unique philosophies, and diverse legal standings.

Licensure

Let's begin with licensure. A registered nurse (RN) or licensed practical nurse (LPN)sometimes called a licensed vocational nurse) -- is individually licensed in a particular by testing that validates she/he has acquired the basic knowledge required for safe practice. Licensure does not purport to do more than that. The philosophy is one of protecting the client, public, from harm. This testing aims to eliminate those not qualified for minimal safe performance; it does not recognize exceptional performance (although the test is scored).

A nurse must be licensed in a state in order to work as an RN or LPN (barring special circumstances not to be elaborated here). The exams for these two levels are separate and distinct, as are the qualifications that must be completed before a candidate sit for the test. Licensure in general is a granted to the states, not the federal government. Of course, nursing has conveniently gotten around this fact by, among other things, creating the Council of State Boards of Nursing. This body has allowed for national uniformity in testing and related criteria (between and among states) whiletechnically skirting the fact that each state is legally free to write its own licensure rules and examinations. This coordination has meant that a nurse could move from New Hampshire to Tennessee without the trauma faced, for example, by a lawyer making the same move. As a nurse who is old enough to remember the early insanities of each state having different requirements, I appreciate these efforts. I remember, for example, classmates who moved (even in my earlier days nurses were peripatetic), yet couldn't sit for licensure in the new state because their school program had offered 1,040 hours of psychiatric nursing instead of the 1,250 hours required in the new state. (Don't hold me to the hours, but the type of problem was typical.) The solution to such problems wasn't easy: the nurse would have to find some school willing to take him or her as a part-time student for more experience in the area judged inadequate. It was a numbers game of ultimate frustration that our present system avoids.

Historically, there have been few "hot" issues concerning licensure, at least since licensure became a fact. There always have been, of course, various arguments concerning what crimes and misdemeanors can cost one a license, as well as issues of who should or should not serve on the administrative boards. On the national scene, however, there have been few historical proposals to change who gets licensed for what.

As always happens in a situation of upgrading (in this case to licensure), there has to be some accommodation for those who getcaught in the middle of such an historical change.

RN licensure was well established in each state when I graduated and started working (circa 1958), but I can remember when there were still "waivered" LPNs, that is, people who worked as practical nurses but had not had the requisite education. As always happens in a situation of upgrading (in this case to licensure), there has to be some accommodation for those who getcaught in the middle of such an historical change. So the waivered LPNs were given their licenses by the grandfathering mechanism. Employers, of course, knew who had earned the license and who was waivered, and sometimes waivered LPNs were payed less, and not all institutions hired them.

The Lysaught report (1981) by the National Commission for the Study of Nursing and Nursing Education, sponsored by the Kellogg Foundation, was another (almost) challenge to licensure. Lysaught and the Commission recommended two separate licenses, one in acute, one in distributive care. The Commission thought that nursing had grown too big for a single license (by this they meant that the total content of nursing had expanded beyond what could be contained in a single curriculum). The nursing profession decided to pass on that one, although the report looks more interesting now that we're in an era when much nursing delivery is moving out of acute, episodic care into what Lysaught called distributive care.

The next big fluff concerning licensure was -- and still is twenty years later -- the proposal to make two RN licenses, one for 2-year nurses and one for 4-year degree-holding nurses, with the latter credential bearing the label, "professional." This licensure change never came about for many reasons, one of which was the rigidity of the proposers who did not want to waiver in as "professionals," nurses who didn't then hold the 4-year credential. Ironically, if there had been a little more accommodation, by now most of those waivered RNs would be retired and the issue would be finished. Instead, we are still arguing the same issue in our professional organizations. No profession in the history of this nation, incidentally, has managed to bootstrap its credentials without using the waivering mechanism. I don't know why the advocates of "no waivering" thought nursing could be different. Anyone who can count could tell that the 2-license plan would not happen without waivering, as long as nurses without the 4-year degree outnumbered those with it.

Another perennial issue is that of institutional licensure. This proposal recommends that an institution be allowed to create its own job descriptions and license employees for them. The proposition has always been fought tooth and nail by nurses. (Not surprisingly, the proposal never suggests that institutional licensure apply to physicians, only to nurses and "lower level" personnel.) Fortunately, we live in an era when people no longer trust the beneficence of institutions, so perhaps institutional licensure as an issue is dead for a while.

The newest issue is that of licensure for the nurse practitioner, an issue which is steadily being settled, one state at a time, with a few states still being controlled by medical interests that hope to stop or restrain the inevitable nurse practitioner tide. (On this issue, don't move to California.) But, once again, because licensure is a state's right, the licensure requirements differ from state to state. Will we ever have a Council of State Boards of Nurse Practitioners? Who knows.

On the whole, because of our contrived uniformity from state to state, basic licensure (for RNS and LPNs) is relatively simple. This will be true until some state decides to lead a change, probably that of dividing RN licensure into two or more separate licenses (e.g., acute versus episodic,baccalaureate versus other, or some new proposal on the scene). As to issues, the practitioner license is evolving, at different speeds and with different rules, from state to state; but essentially, the movement has been toward giving practitioners more extensive authority and more power to work independently of physicians. Some states, such as New Jersey, extend relatively comprehensive powers to all advanced practice nurses (clinical nurse specialists and nurse practitioners).

Certification

Nurse certification, like licensure for RNs, involves individual testing, in this case testifying to status achieved by a nurse in some given specialty. If licensure has its eye on minimal performance, certification is oriented toward the other end of the spectrum, testifying to the nurse's achievement of a special competence. Most certification programs are limited to nurses but there are some certification programs open to health or human services professionals from diverse fields.

Almost all graduates of nursing master's specialty programs (especially practitioner programs), want the status afforded by certification. However, unlike licensure, it is up to the individual to decide whether or not to take a certification exam. Although many jobs may only be open to nurses holding desired certifications, the certification process is voluntary.

Certification programs in nursing have grown like Topsy, (I count over 30 of them without even working at it), mostly through individual specialty organizations but now through ANA and the American Nurses Credentialing Center as well. Many, but not all, of the certification programs are designed for nurse practitioners; some are open to clinical nurse specialists as well. Many certifications involve "broad" specialties, in areas such as midwifery, anesthesia, orthopaedics, and oncology. Other certificate programs are very narrow, such as those in areas of enterostomal care and intravenous therapy.

For a long time, this country ignored the British system, which relied heavily on the certification process. Of course the British system often used certification in lieu of academic credentials, and our system has not gone that direction.

We are in the throes of a love affair with certification in this country, and virtually every RN has a string of (possibly) inexplicable certification initials following her signature. As specialty nursing has replaced general nursing, certification has become a powerful card in the competition for jobs.

The certificate has become very important but it is more likely to be combined with higher education than substituted for the lack thereof. Most major certification programs today require graduation from a related academic program (usually master's level) before allowing the candidate to sit for the certification examination.

There are, however exceptions to this rule. Narrow certifications, like intravenous therapy, obviously don't comprise the core of specialty master's programs. Some few certification programs prefer to employ the principle of testing only for knowledge acquired. These programs measure what the candidate knows rather than where and how the knowledge was acquired.

We are in the throes of a love affair with certification in this country, and virtually every RN has a string of (possibly) inexplicable certification initials following her signature. As specialty nursing has replaced general nursing, certification has become a powerful card in the competition for jobs.

Issues in certification chiefly involve quality control and who has the right to certify in a given area. In some cases, nurses may choose among certifying agencies. More interesting is the overall question of when will it all stop? How many specialties will emerge? How many will the market support? Should there be any overall policy regulating certification? At present, certification serves as a good check on the quality of nurse practitioner programs, among which there is still much (if unacknowledged) quality differential.

Accreditation

Accreditation, unlike the RN/LPN testing in licensure and RN certification, evaluates and judges institutions rather than individuals. Most accreditation programs testify to the institution's achievement, rather than merely guaranteeing safety. Accreditation, like nurse certification, is voluntary -- but not quite. For example, if a service institution wants to collect Medicaid bills, it will have to have accreditation. Hence, while accreditation is "voluntary," an institution might go broke for the privilege of not volunteering. Similarly, in nursing master's education, most programs will not admit a nurse who graduated from an unaccredited program, even if the program was licensed by the state.

In nursing practice, we have long been familiar with Joint Commission on Accreditation of Hospitals, later revised to Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the change corresponding to the broadening of the accrediting target from merely hospitals to other health care delivery systems.

In nursing, our chief accrediting body over the years has been the National League for Nursing (NLN).

Accreditation, like nurse certification, is voluntary -- but not quite. For example, if a service institution wants to collect Medicaid bills, it will have to have accreditation. Hence, while accreditation is "voluntary," an institution might go broke for the privilege of not volunteering.

The NLN parent organization accredits (through independent arms) both home health organizations under the Community Health Accreditation Program (CHAP) and nursing education through the NLN Accrediting Commission (NAC). We'll look at the home health accreditation process first.

Acquiring of deemed status for this new accrediting function brought NLN into direct competition with JCAHO (there is no monopoly on the coveted deemed status). JCAHO's deemed status allowed them to accredit home health care programs long before the NLN developed itscompetitor, CHAP. The League's argument for creating the competitive organ was that a nursing organization was better prepared to do this sort of accreditation than an organization in which nursing held little clout, certainly true of JCAHO, which has always preserved power (in the form of full membership) in the hands of physicians and administrators -- in spite of active participation of nurses atlower levels of JCAHO.

After a long struggle, NLN (or technically, the independent arm) achieved deemed status. The competition between the two organizations (CHAP and JCAHO) was inevitable, but JCAHO is now recognizing CHAP accreditation for home health care components in integrated systems that come under the JCAHO purview.

The longer-standing function of accrediting nursing education organizations has been one of the NLN's chief reasons for being. The accreditation program covers all bases, accrediting programs for licensed practice nurses, diploma nurses, baccalaureate and master's level graduates. (There has been a power struggle for years concerning whether or not doctoral nursing programs should also be accredited. This issue, which has merits on both sides, has not yet been resolved.)

Recently NLN was dealt a blow when its deemed status as an accrediting agency for nursing education was threatened by the granting agency, the Department of Education (DOE). Part of NLN's effort to meet the objectives required by DOE in order to retain deemed status has involved creating the separate arm, the NLN Accrediting Commission (NLNAC).

Just as NLN offered JCAHO competition in home health accreditation, so the American Association of Colleges of Nursing (AACN) the organization of deans of baccalaureate and higher schools of nursing, has determined to offer NLN competition in the accreditation game. For decades, various members of AACN had proposed creating an accreditation service, and it was predictable that the group would take this period of NLN vulnerability as the time to propose its own accrediting process. AACN's present proposal for a "collaborative" accreditation process may end up threatening many or all of NLN's accrediting programs, not merely the baccalaureate and higher degree components. On the other hand, there is also talk about a cooperative venture between the two organizations, so time will tell what actually emerges. All these moves by the various organizations are typical of a health care environment like today's, that is, one run primarily by competition.

Issues in nursing education accreditation run the gamut from: "Do we really need it?" to "Does it have to take so much time and energy?" Ironically, it is often the more sophisticated programs (those most likely to pass with flying colors) that see the accreditation processes as redundant. For these programs, the process may be measured only by the lost opportunity costs of faculty and administrative time put into the extensive requirements of preparing a self-report. (AACN claims that shortening the process will be one of its chief aims.) On the other hand, some smaller or newer programs need the clout (or threat) of accreditation requirements to gain resources from the home institution.

Early in its professional development, nursing schools were well served by the accreditation process. It provided sound guidelines and clout with the home institutions; it weeded out failing programs that needed to be closed. In the present era, however, many schools of nursing are feeling over-regulated. State evaluation for nursing programs, general collegiate evaluation, and NLN evaluation together consume a heavy dose of scarce time of deans and faculties. Cost and time are big factors in an era of down-sizing -- a phenomenon that education has not escaped.

Backing away from the politics, one can ask the perfectly justifiable question of whether nursing still needs and profits from a specialized professional evaluation apart from state evaluation and academic accreditation of the home institution in which the nursing program is housed. The answer might lie in a careful assessment of what is gained collectively through accreditation at this time. One measure might be some study of the actual, contemporary changes that have taken place in nursing programs due to NLN accreditation. Nitty-gritty measures would serve to answer this question, items like: how many schools actually got bigger budgets, more nursing library books, or more faculty lines in order to meet accreditation standards? It would be interesting to have cost/benefit studies balancing what was gained versus what was lost in dean and faculty time for report preparation.

Whether school accreditation be under NLN or AACN, the question remains: Do we still benefit from a separate professional education accreditation process? Has the era of professional accreditation passed? Has accreditation been superseded by a focus on individual certification?

Summary

To date, we have relied on licensure, certification, and accreditation to maintain standards for the nursing profession (in practice and in education), both for the public and for the profession. What are your thoughts? I look forward to Online input to fill in the blanks and to correct any historical inaccuracies in my personal interpretation of the situation.

Author

Barbara Stevens Barnum, RN, PhD, FAAN
E-mail: barbbarnum@aol.com

Barbara Stevens Barnum's writings reflect her extensive experiences in both nursing education and nursing service. She is currently on faculty at the Columbia University School of Nursing, New York City. Since coming to Columbia University she has served both as Director, Division of Health Services, Sciences and Education at Teachers College and Chairman of the Department of Nursing Education. She is a recognized author in the areas of nursing management, theory and education and has consulted extensively in the national and international arenas. Her consultations include that of Consultant to the U.S. Air Forced Surgeon General. Dr. Barnum has also served as Director of Nursing staff Development at the University of Chicago Hospitals and Clinics and as Coordinator of Nursing Service Administration Program of the College of Nursing, University of Illinois at Chicago. She is past Editor of Nursing and Health Care and current Editor of Nursing Leadership Forum.

---