A Message from the President: LACE
APNA has worked with other nursing specialties to develop the APRN Consensus Model and the elements of it known as LACE (Licensure, Accreditation, Certification and Education). We continue to attempt to keep the membership informed as well as providing opportunities for input. We are aware of concerns and angst over this matter. We will address the concerns in several sections:
We ask that you read all the material as we believe many concerns are the result of misunderstandings or not having the full facts.
Relationship of Licensure and Certification
It is important to stress the relationship between licensure and certification. Licensure is how a member of a profession is granted the ability to practice. State agencies and the legislature define advanced practice nursing, decide who can practice and the scope of that practice, and determine the requirements for licensure.
Certification concerns the evaluation of an individual’s knowledge, skills and abilities in a specialty. For most states, one requirement for advanced-practice licensure is certification. Licensure and certification, however, are separate processes.
This is the most easily misinterpreted aspect of the ANCC letter to all certified PMH APRNs. APNA was concerned when we saw the language used by ANCC that said they were “retiring certifications,” since we anticipated that this language would lead to misunderstanding and unnecessary distress by persons holding these certifications. The fact is that active credentials were not retired and those credentials remain valid and will remain so as long as the certificate holder is recertified. It is not the credential; it is the exam that is retiring!
Some background material on certification exams may be helpful in understanding the ANCC decision to retire the PMH-CNS exams. Although some APNA members are under the impression that the ANCC made this decision as a result of the recommendation of the APNA/ISPN LACE Taskforce, it is more accurate to say that both the ANCC decision and the LACE Taskforce recommendations were influenced by the same data about numbers taking the various PMH-APRN certification exams.
States require that national certifying bodies, such as ANCC, must be able to establish that their exams are legally defensible and psychometrically valid. I have been told by ANCC that establishing psychometric validity requires 300 persons per year taking the exam. Given the significant national increase in PMHNP programs and decrease in PMH-CNS programs, the number of PMH-CNS graduates has been dwindling. Since 2000, the number of new candidates passing the PMH-CNS exam has fallen by an average of 41 per year. The trend was such that by 2015, regardless of the Consensus Model, the number of persons applying for PMH-CNS certification would not be sufficient for the ANCC to support the exams’ psychometric validity. It is important that PMH-APRN certification never be called into question since this erodes the credibility of the profession, particularly as we move to expand the scope of PMH-APRN practice.
There have been a number of issues raised in regard to possibilities that might prevent someone from meeting the requirements for recertification, which could lead to the loss of the individual’s credential if they were unable to retake a certifying exam. It is agreed that anything is possible but it is unlikely that there would be enough people in this situation to maintain a test’s validity if it were offered. To bring this issue to the attention of ANCC, we need data to support that clinical practice hours can be reduced without compromising the integrity of the recertification process. Even with such data, that is not available and frankly would be hard to obtain, ANCC still has to demonstrate to its accrediting bodies, the American Board of Nursing Specialties (ABNS) and the National Certifying Corporation (NCC) that reduction in required hours is acceptable. We must also bear in mind that the ABNS and NCC are very specific about relationship of the specialty organizations with the certifying agency. They must remain independent.
Returning to School
A second area that is being misinterpreted and at time misrepresented is the notion that PMH-APRNs must return to school to become an NP or to obtain lifespan content. This is not the case and it is APNA’s position that all those currently certified are qualified now and will continue to be qualified to practice as long they maintain their credential. However, if someone of their own volition wishes to seek additional education, APNA is committed to helping those people navigate the system to obtain that education and subsequent certification. Our zeal to offer this type of information should not be interpreted as APNA taking a position that additional education is required.
Moving From One State to Another
This is perhaps the least understood and one of the concerns particularly among newly certified who anticipate that a move from state to state is probable in their career. This is a licensing issue and not a certification matter. Licensing, as noted above, is the province of each individual state. The impetus for this aspect of the model is the lack of uniformity in the nurse practice acts. Portability of one’s APRN license is the problem and the model seeks to resolve it.
The directors of the state boards of nursing collectively belong to the National Council of State Boards of Nursing (NCSBN). The language in the Consensus Model on Grandfathering was provided by the NCSBN. It is important to note the two aspects of the Grandfathering provision. One aspect deals with those who continue to practice within their state. The other and apparently not appreciated aspect is the endorsement of an APRN from a different state. This deals with those who choose to move. Here is the specific language:
However, if an APRN applies for licensure by endorsement in another state, the APRN would be eligible for licensure if s/he demonstrates that the following criteria have been met:
- current, active practice in the advanced role and population focus area,
- current active, national certification or recertification, as applicable, in the advanced role and population focus area
- compliance with the APRN educational requirements of the state in which the APRN is applying for licensure that were in effect at the time the APRN completed his/her APRN education program, and
- compliance with all other criteria set forth by the state in which the APRN is applying for licensure (e.g. recent CE, RN licensure).
If we ever want to have portability it is essential that we incorporate the grandfathering language into nurse practice acts.
APNA is actively engaged in the LACE Network and is in dialogue with the other nursing organizations in addressing the grandfathering provisions.
Loss of Psychotherapy
APNA recognizes that PMH-APRN roots are in the CNS role and that the PMHNP role evolved from it. The APNA / ISPN Task Force on Implementation of LACE and APNA Board of Directors were very specific in their recommendations that PMH-APRN programs continue to incorporate teaching and clinical training in psychotherapy. We recognize that market forces have led to medication management becoming a greater focus of PMH-APRN practice, so the Task Force and Board want to strongly communicate that psychotherapy is an essential skill set and should remain a major treatment modality in PMHNP practice.
There is a perception that the Consensus Model is causing the demise of the PMH-CNS role and with it psychotherapy. In fact, the shift from PMH-CNS to PMHNP graduate programs began in the 1990s and was a market driven phenomenon, not something precipitated by the Consensus Model. A milestone in recognition of this trend occurred in 2000 when PMH-NP certifications became available from ANCC. The numbers of PMHNP graduates taking the PMHNP exam has steadily grown, from zero in 2000 to 762 in 2011. Eighty–nine percent of the certificates issued for PMH-APRNs are for PMH-NPs. As noted in the previous section on retiring exams, the number of people taking the adult and child CNS exams are not sufficient to establish psychometric validity for either exam.
As for the future of psychotherapy, the ANCC has always required supervised clinical training in at least two psychotherapeutic modalities for PMHNP graduates to be able to sit for the PMHNP exam. Schools will be expected to continue to teach psychotherapy, and it is to be hoped that experienced PMH-CNS practitioners will support psychotherapy clinical training opportunities for PMHNP students. Although psychotherapy has always been one of many components of PMH-APRN practice, there is a rich tradition of psychotherapy practice by PMH-APRNs that will continue as long as PMH-APRNs embrace it.
APNA Strategies to Seek Member Input
The development of the Consensus Model dates back to 2005. During this time, APNA has used a number of strategies to communicate information about the Consensus Model to the membership and to solicit member input, including:
- a section of the Website devoted to information on LACE and the Consensus Model
- The LACE Implementation Task Force presented its recommendations at the October 2010 Conference and engaged in a lively discussion with members attending. This was followed by posting of the recommendations and rationale to all members with a request for feedback
- APNA has encouraged ANCC to notify all members at least two years in advance of changes.
Beth Phoenix, PhD, RN, CNS