Chapter 4: Nursing

Licensure and
Certification
Presented by: Harlie Silberman, Daelyn Lazor, Alyssa
Crump, and Summer Khatib
Pins & Registries
Over the years health personnel have had special insignias to mark their title, such as:
- The nursing cap: often worn around the world years past, but not seen as often in today's
society.
- School of nursing pins: The pins emblems and text symbolizes the philosophy beliefs and
aspirations of a particular nursing program. This pin not only shows their achievements, but
knowledge in how to properly take care of the community that are in need of medical attention.
- White coat ceremonies: Often white coat ceremonies are seen for the right of passage for
medical student however in 2014 nursing schools in 43 states plus the District of Columbia
were given the opportunity to offer a white coat ceremony for nurses. Student typically often
received their nursing pins at these white coat ceremony.

Registry:
● Florence Nightingale started a system of keeping record of students that successfully graduated
from St. Thomas’s school of nursing in England. This record is known as the registry of
graduate nurses. We still continue this tradition today. Although, now state and international
agencies also have a list of nurses practicing in their jurisdictions.
Purpose of Licensure
When nursing programs began to multiply and grow, variations developed among the programs

- Things such as: entry criteria, and educational programs were structured to meet specific
employers needs.

No longer was a simple registry of nurse graduates sufficient to ensure the level of competency
regardless of the school in which nurses were educated at.

Graduate nurses, physicians, and hospitals met to resolve this dilemma of distinguishing between
untrained or lesser individuals from people who went through training to provide proper nursing
care.

They came to the outcome of requiring licensure of nurses in the United States; primary purpose was
to actively protect the public from the dangers of anyone calling him or herself a nurse
Early Licensure Activities
In 1867, Dr. Henry Wentworth Acland encouraged licensure of English nurses. Not until 1896 were
attempts made to implement licensed nurses in the United States.

As prior to the late 1800’s, each nursing program established and molded their training to their own
specific institution. As these programs varied based on the needs of the hospital, the availability of
physicians and nurses for training new students and as well as resources devoted specifically to
nursing training. An overall consensus was assumed that all nurses needed consistent minimum
standards to provide safety for the public and improve mobility of nurses among institutions. The
ANA (American Nurses Association) was a big advocate in developing these standards for the whole
profession of nursing.

However, their attempt to initiate this new training failed due to lack of broad-based support.
Early Licensure Activities
In 1901, the International Council of Nurses decided that each nation and state examine and license its nurses

By 1903, North Carolina, New Jersey, New York, and Virginia were the first to institute permissive licensing.
As these were voluntary, all nurses were not required to become registered .

Standards:

- Minimum of 2 years of training

- State boards were established with rules for examinations as well as revocation of the license → did not pass,
did not receive title of RN

These regulations protected the public from unskilled nurses, and as well as provide legal sanctions to protect title of
RN.

In 1923, all states had instituted examinations permissive license

- Each state's content varied in length and format including written, oral, and practice components.
Early Licensure Activities
As there was a lot of widespread variety regarding nursing practice acts - the ANA & The National
Council of State Boards of Nursing eventually designed a template for states to follow. These
practice acts have been revised and will continue to be revised as nursing evolves.

This model practice act includes many sections: definition of nursing, scope of practice for RN,
descriptions of advanced practice nursing, requirements for prescriptive authority of nurses, nursing
education, compact guidelines, and process for disciplinary actions against nurses who violate
sections of the act

Eventually from these model acts, each state and jurisdiction has developed a unique practice act,
but they all still address all sections described in the overall model act.
Mandatory Licensure
New York was the first state to require mandatory licensure but was put in
place until 1947. During this time, nursing groups also moved to standardize
nursing licensure testing procedures.

After WW1, the ANA formed the NCSBN. This newly formed NCSBN
council advocated standardized examination for licensure. The first State
Board Test Pool Examination in 1950, instituted by National League of
Nursing.

NCLEX-RN - development began in 1982 with the first distribution of this

well known exam still taken by nurses today.
Purpose of Nurses Practice Act
Each act begins with a purpose - all nurse practice acts include 2 essential
purposes: each act includes statements that refer to protecting the health and
safety of the citizens in the jurisdiction. The act describes qualifications and
responsibilities of those individuals covered by these regulations

*The act delineates those excluded from the practice of nursing*

(1) These provisions also ensure the protection of the public.

(2) To protect the title of a registered Nurse

- This title is reserved for those meeting the requirements to practice

nursing
 Nursing & the Scope of Practice
Nursing is defined as of utmost importance because it delineates the scope of practice for nurses within
the state

However, some states describe nursing as a process that includes nursing diagnosis, whereas other
states list broad areas of nursing activities.

Depending on the jurisdiction, definitions of nursing and advanced practice nursing are within one
definition and other states define them separately.

As nursing practice becomes more complex and sophisticated, states may revise their nurse practice acts.
Nurses are accountable for knowing the definition and scope of practice within their jurisdictions and
practice accordingly. May include: labor laws, and performing in ways that are beyond the legal
definition of nursing → could lose their privilege of practicing nursing
Licensure Requirements
Entry into Practice Licensure:

Candidates for licensure must submit evidence of a graduation as defined by each state including high school and an
accredited nursing school.

Other requirements include:

- Transcript of coursework, diploma, or a letter from the dean

- A statement regarding the applicant's mental & physical status
- A review of criminal background
- A statement from the nursing school attesting eligibility of candidate for licensure

The most important part, regardless of state requirements, all candidates have to successfully complete and pass the
NCLEX-RN before they can practice nursing.
Licensure Requirements
As more and more nurses are practicing in multiple jurisdictions or states, it is now required for the
individual to be knowledgeable of current licensure requirements in all states that he or she wishes
to practice in.

Steps to do so:

- Apply for a licensure by endorsement - submit a letter to the second state board of nursing
- Evidence for new licensure is similar to that for initial licensure
- Proof of nurses current license
- Follow if state is not participating in the Nurse Licensure Compact (NLC)

** If your states is designated as a compact state (which is the agreement with other states
allowing nurses to practice within the state without additional license), the nurse should
contact the state board of nursing and determine appropriate procedures for initiating nursing
practice in that jurisdiction
Licensure Requirements
Advanced Practice Nursing Licensure:

- These nurses must obtain separate nursing licensure in addition to

licensure for entry into practice
- State requirements vary; so advanced practice nurses should contact the
state board of nursing to determine the criteria and procedures
Renewal of Licensure
- License is usually valid for 2-3 years
- Other specific requirements and information is included in each nurse
practice act necessary to renew a nursing license
Mandatory Continuing Education
- Is requirements for renewal of licensure in the section on license renewal.
- Nurses are required to stay competent of not only new and upcoming information but the
basics that they need everyday to practice nursing.
● California was the first state to mandate continuing education for renewal of
licensure in 1976. Many more states have instituted the same requirement, the
number of hours ranging from 20-40 hours over a 2-3 year period.
- Some areas are requiring specific continuing coursework in the areas of healthcare ethics, the
state nurse practice act, or other content specific to that jurisdiction.
● For example: topics on sexually transmitted diseases, HIV/AIDS and family
violence
● However, in other states, requirements are less strict regarding on what topic they
continue coursework on.
Role of Regulatory Boards to Ensure Safe Practice
Membership of the Board of Nursing
● The most important section of every nurse practice act is the assignment of nurses and
consumers to a regulating board, who administers the nursing practice act.
● This responsibility of administering the nursing practice act is usually assigned by the state
Board of Nursing.
● The nurse practice act summarizes specific guidelines for membership on the State Board.
● There are procedures designated in which members are appointed to the Board of Nursing.
● Members of the Board of Nursing are usually appointed by the governor’s office.
● Individuals that are interested in joining the board or organizations, such as the state's nurse’s
association, can submit individual’s names to the governor’s office to be considered for
membership on the board.
Role of Regulatory Boards to Ensure Safe Practice
Duties of the Board of Nursing
● The duties of Board of Nursing can be summarized in the Nurse practice
act or in other enabling laws.
● These other enabling administrative laws are designated as rules and
regulations for nursing practice.
● The Board of Nursing grants and renews nursing licenses, and takes
disciplinary acts when areas of the nursing act are violated.
● A major responsibility of the Board of Nursing is confronting any
concerns about nursing practice.
Role of Regulatory Board to Ensure Safe Practice
Duties of the Board of Nursing Continued:
● If a nurse violates or has a potential wrongdoing of the nurse practice act
or other administrative laws, then it is the responsibility of the board of
nursing to handle the situation. The nurse practice act states the due
process and procedures if a situation does occur.
● It is the responsibility of the board to assign disciplinary action such as:
○ Restriction of license
○ Suspension
○ Revocation of License
● Just as all nurses need to be aware of nurse practice acts, they also have
to be familiar with the state board’s role.
Special Cases of Licensure
Military and Government Nurses
● Many nurses are members of the military or they join the military nursing
services after graduation.
● The Veterans Administration and U.S. Public Health Service employ
thousands of nurses in multiple jurisdiction and out of the United States.
● Nurses do not need to get a license in each jurisdiction in which they
practice.
○ Once the NCLEX-RN examination is successfully completed in a state, a nurse is
considered an employee of U.S. Government and is able to practice in other jurisdictions
without additional licensure.
Special Cases of License
Internationally Educated Nurses
● Internationally educated nurses have become a crucial part of the U.S
registered nursing workforce.
○ In 2010 these international nurses came from Philippines, South Korea, India, Canada,
and Nigeria and were need in times of shortage in domestic supplies.
● The health workforce has received an increase in attention as a result of
the 2010 World Health Organization Global Code of Practice on
International Recruitment of Health Professionals.
○ This organization helps promote ethical principles in recruiting international personnel.
● When international nurses move to the U.S. they must show evidence of
completing original education program, demonstrate competency in
English and the ability to take and pass the NCLEX-RN.
Special Cases of Licensure
Internationally Educated Nurses Continued:
● These foreign nurses take an Exam given by the Commission on Graduate
Of Foreign Nursing Schools.
○ It is in English and tests knowledge required to practice in the U.S
● After completion of Exam, international nurses can apply for a license to
practice in the U.S.
● These regulations for international students are important for two things:
1.) The protection of the public
2.) Protection of the title RN
Special Cases of Licensure
International Practice
● Nurses interested in practice in other countries can contact either the
International Council of Nurses or the nursing regulatory board of the
country in which they want to practice.
● The International Council of Nurses is composed of worldwide
representatives in organized nursing and functions to assist nurses in
receiving licensure from other countries.
● Each country has their own laws and regulations that rules nursing
practice based on the practice of the U.S Nurse.
● Similar to foreign nurses, U.S nurses have to:
○ Prove their competency, be aware that they have submit educational documentations,
NCLEX-RN results, and proof of licensure and practice.
Revision of Nurse Practice Acts
Nurse practice acts are laws in each state that define responsibilities
of the nurse and scope of practice as well as the qualifications. The acts are
intended to protect patients from harm as a result of unsafe or incompetent
practice or unqualified nurses.

● Nurse practice acts are written and passed by legislators, many governmental agencies,
administrators, consumers, and special-interest groups seek to influence the legislation.
● the nurse practice act represent the aims and concerns not only of nurses but of many
individuals and multiple interest groups
● The people directly affected by the definition of nursing practice are physicians, dentists,
pharmacists, licensed practical nurses and other well educated medical professions.
Sunset Legislation
“Sunset laws” are laws that are founded in many states and are intended to
make sure that legislation is current and reflects the needs of the public.

● Multiple nurse practices contain these laws because if the act is not
renewed it is automatically revoked. The review is to ensure that revisions
are updated for nursing practicing and that they are consistent with what
the current nursing practices are.
● Other changes such as requirements for mandatory continuous of
education for license renewal.
● Nurses are responsible for being aware of the sunset laws regulations
affecting the nurse practice act in their state which they practice.
 Delegation of Authority to Others
•Guidelines for delegations have been developed by many nursing
organizations , including the ANA (American nurses Association) and NCSBN
(national council of state boards of nursing).
• Individual states establish legal definitions of appropriate delegation
practices. As a result of regulations differing in states each nurse must identify
the Regulations set by their state
•American Nurses Association (ANA) is a professional organization that
represents all Registered Nurses.
•National Council of State Boards Of Nursing (NCSBN) is an organization
whose membership consists of the board of nursing of each state or territory.
•Even though states differ in regulations, each Registered Nurse takes the
same standardized board test called the NCLEX.
Current Licensure Activities
Mutual Recognition Model

● Most nurses are required to apply for licensure in each state in which
they practice
● In 1997 The Delegate Assembly of the NCSBN approved a resolution
endorsing a mutual recognition model of nursing licensure. Through this
model, individual state boards formed the NLC.
● Nurses practicing in an NLC state are responsible for following the laws
and regulations each state in which they practice, although they are not
required to apply for multiple individual state licenses.
Current Licensure Activities (Cont’d)
● Differences in practices requirements in different states may cause
nurses confusion as to their rights and responsibilities.
● The NLC is increasingly affecting all nurses
● Nursing students and graduates must remain apprised of changing
conditions.
● As changes occur frequently in this area, the most comprehensive and
current sources of information are the websites for the ANA, the
NCSBN, and the state boards of nursing for individual jurisdictions.
Continued Competency
Still following under the category of Current Licensure Activities:

● The primary purpose of nurses licensure is protection of the public. This

is the reasoning for mandatory continuing of education being used as a
strategy to ensure that nurses were competent to remain in practice
● These programs have continued for a number of years. However, a
growing number of nurses believe that more is required than just
attending seminars to demonstrate the degree of competence.
● There is increasing concern for patient safety and treatments in today’s
health care system. Models of continued competency are but one attempt
by professional nurses to ensure that patients receive safe, effective
nursing care. Something we can also work on is establishing program s of
certification of advanced practice nurses.
History of Certification
● There are several distinct differences between licensure and certification.
Licensure requires minimal levels of practice while certification recognizes
excellence in practice. Because of this, the requirements, background, and
opportunities differ.
● Development of nursing licensure was not legally required, it was more
recommended.
● To recognize the nurses who have completed addition education in clinical
practices, many graduate schools and nursing organizations offered
certification programs.
● In the 1970s advanced clinical courses were created as certificate programs.
● Licensure is administered through state boards for nursing, while certification
is awarded by nongovernmental agencies.
History of Certification
● In 1946, CRNA was the first field of nursing practice to certify advanced
practitioners.
● In 1961, the American College of Nurse - Midwives began certifying
midwives.
● In 1975, the American Nurses Association (ANA) held a national study
group at the University of Wisconsin in Milwaukee, to discuss program
standardization. 75 nursing organizations attended.
● This meeting resulted in the formation of the American Nurses
Credentialing Center. (ANCC) More than a quarter million nurses in 40+
areas of specialty practice have been certified by the ANCC since 1990.
More than 80,000 advanced practice nurses are currently certified.
History of Certification
● All advanced practice registered nurses (APRN’s) must be certified
through a nationally recognized nursing certifying body, and understand
the examinations offered will be used by state boards to grant APRNs
ability to practice.
● Certification was created to be voluntary.
● State agencies were not involved.
● This is still the case, although all states have requirements of
certifications for advanced practice nurses in all special roles.
Purpose of Certification
● Protection of the public
● Requirements for practice varies among states.
● All states require evidence of certification in the specialty area.
● Some require practice in the specialty before being awarded the
certification.
● All states require special provisions for prescribing medications.
Steps to Certification
● Become informed of specific requirements in chosen field.
● Examine roles and responsibilities in advanced practice nursing.
● Contact the ANCC & specialty organization to determine education,
experience, and examination requirements to become certified.
● Contact state boards in state wishing to practice.
Current Issues in Certification
● Nurses in advanced practice have different educational requirements to
receive their license.
● Reimbursement for nursing services.
● Which group will test and license nurses?
● Which organization will credential and regulate advanced practice
nursing?
● NCSBN believes it is the appropriate organization to do so.
 References
Cherry , B., & Jacob, S. R. (n.d.). Contemporary Nursing Issues, Trends, & Management (7th ed.).