Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Institute of Regulatory Excellence (sponsored by NCSBN, Chicago, Illinois).
Correspondence: Randall Hudspeth, MS, APRN-CNS/CNP, FRE, FAANP, Cleveland Clinic Abu Dhabi, United Arab Emirates (firstname.lastname@example.org).
Disclaimer: The opinions expressed herein are those of the author and are not those of the National Council of State Boards of Nursing.
The author declares no conflict of interest.
NURSING REGULATION has grown in complexity and scope over the past 30 years since the council of state boards of nursing separated from the American Nurses Association (ANA) in 1979 and formed a separate organization as the National Council of State Boards of Nursing (NCSBN). In the ensuing time the state board test pool examination was replaced by the NCLEX examination for licensure and evolved to use computer adaptive testing techniques, multistate nurse licensure recognition evolved and multiple nursing organizations formed and developed standards of practice statements for specialty practice beyond the one developed by the ANA. Many of those standards have been endorsed by boards of nursing.
In the same 30 years nursing administration education evolved. Unlike nurses who chose to focus their education on advanced nursing practice in roles that have become commonly accepted as the 4 advanced practice registered nurse (APRN) roles, certified nurse anesthetist, certified nurse midwife, certified nurse practitioner, and clinical nurse specialist, nurse administrators had various pathways. In the 1980s, the trend turned toward Masters of Business Administration (MBA), or Masters of Public Administration (MPA), or Masters of Healthcare Administration (MHA), with many chief nurses having those degrees. Others took the more traditional MSN in education, administration, or an advanced practiced role and then migrated into nursing administration. Whatever the program, many of us lacked any specific content on the concepts of regulation, and specifically nursing regulation, unless we sought out those experiences as parts of independent projects.
Today, nursing administrators are impacted by both national and international practice issues. Chief nursing officers do not encounter every issue every day, but keeping abreast of contemporary ones that impact our own practice, our staffs, and our organizations is important. There are many issues, but these are the national and international ones that are currently discussed in multiple nursing venues that may or may not be included in a nursing administration graduate curriculum.
National Nursing Issues
1. Boards of nursing (BON) exist to protect the public; not to protect nursing interests. This is accomplished by working with nursing educators to establish nursing education curricula that is driven by practice, and then monitoring that education to see that the established standards are maintained. Then BONs administer entry-level licensure examinations to graduates of those programs and give a license to those who successfully pass the examination. Boards of nursing monitor ongoing nursing practice to evaluate scope changes and are involved in the natural progression of nursing practice. Finally, BONs remove from practice those nurses who violate the nurse practice act (NPA) and then work with the nurse to establish mechanisms to bring their practice back into compliance so that the nurse can return to the workforce. In addition to protecting the public, the profession also benefits by the BON's effective involvement in these 4 domains.
2. By monitoring and engaging with nurse stakeholder groups, nursing regulation establishes, and monitors nursing scope of practice. This is not done in isolation and nursing organizations have a major role in scope development, but at the end of the day, scope of practice is a legal issue granted to members of a profession by the people through the state's legislative process and the BON is task with monitoring and enforcing it.
3. Chief nursing officer specific responsibilities are sometimes designated in a NPA. States that have this content included in the NPA hold the chief nursing officer (CNO) responsible for the quality of care provided and also to see that nurses under their supervision comply with the provisions of the NPA. This is usually linked to duty to report practice breakdown, appropriate utilization of staff, and establishing mechanisms to monitor staff licensure.
4. The CNO must be aware of safety to practice guidelines. These usually pertain to nurses who use chronic pain medications, are under a provider's care and who continue to work. They can also pertain to the impaired nurse who is returning to the workplace following recovery from addiction.
5. Nursing education partnerships and monitoring clinical experience contracting is essential. The nursing shortage has resulted in a proliferation of for-profit nursing schools that compete with state and private institutions for faculty and community resources, including clinical experience space and time. The CNO needs to be aware of community standards and resources before independently granting clinical time to schools that can result in too many students on site, an overwhelmed staff and poor experiences for students, and could impact the school's approval process by the BON.
6. The CNO is responsible for appropriate APRN use within a facility. Understanding APRN scope of practice, what the APRN is educated and licensed to do, and understanding the 2008 Consensus Document for APRN licensure, accreditation, certification, and education is important. The APRN must also have a current RN license and while the RN enjoys basically the same scope of practice in all states, the APRN scope of practice varies greatly from state to state.
7. Being knowledgeable about the national work that is focused on measurement of continued competence and the associated problems with effectively resolving this problem positions the CNO to better address competence evaluation within a facility.
8. Understanding licensure concepts helps the CNO to know that in the United States we have a national licensure system that is state based. This means that to be a nurse in this nation, you have to meet established criteria and be granted a license by a BON in a state, territory, or the District of Columbia. This is different than a federal licensure system whereby the license is granted by the federal government and is good throughout the country. Australia recently moved from a province or state-based system to a federal system.
9. Nurses who are impaired by alcohol, drugs, or other substances often enter into alternative to discipline programs that help them recover over time and regain their license. These program requirements vary between states and often the CNO is integral for the nurse to reenter practice.
10. The best resource a CNO can have for understanding the NPA within their state is the state's BON. Do not hesitate to call the office and speak with a practice consultant. They are there to assist you.
Global changes in nursing regulation are outside the realm of most US CNOs, but there is a big world of nursing and while many of the challenges are common, some issues are different and we need to be aware of them.
1. European nurses were impacted by the Bologna Process that has been agreed to by 47 participating countries and calls for more uniform standards for academic degrees and professional education. This has resulted in a greater migration away from hospital-based nursing education programs to universities and easier portability throughout Europe. In the 10 years since the initial agreement, implementation continues at variable stages but one outcome is that we are seeing more European nurses with university degrees and the emergence of graduate nursing education and advanced practice nursing.
2. The Ethical Nurse Recruitment position statement by the International Council of Nurses recognized that nurses as individuals have a right to migrate and to use their educations to better themselves and their families. At the same time it cautions nurse recruiters and employers to be cognizant of the health manpower needs of both the home country and the recruiting country and to use effective manpower strategies to better position development of home country workforces to avoid having to rely on an expatriate workforce or depletion of another country's nursing resources.
3. It is also important to recognize disciplinary processes beyond US borders. Judicious regulatory practices are often lacking due to inadequate resources, laws, or problem recognition. Thus, criminal background checks can fail to identify problem nurses who migrate from one country to another. When recruiting internationally, it is essential to know the recruiting agency, maintain ethical recruitment standards, and screen candidates thoroughly.
These issues can serve as a beginning list for information and study areas whereby nurses completing formal nursing administrative educational programs can increase their awareness. In an increasingly complex practice environment, it is essential that CNOs have a working knowledge of the regulatory process of the profession. Additional learning opportunities can be found on Web sites of state boards of nursing or at the NCSBN Web site: www.ncsbn.org.
© 2011 Lippincott Williams & Wilkins, Inc.