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The Specialty Debate: PAs Have Questions; NPs Have Answers

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What is relevant to this particular article is that the consensus model expressly states, “Competence at the specialty level will not be assessed or regulated by boards of nursing but rather by the professional organizations.” In other words, as explained by Nancy Chornick, PhD, RN, CAE, Director of Practice for NCSBN, specialty recognition will be “out of the purview of legal recognition.”

Chornick goes on to say, “It’s important for NPs to understand that this is not a value issue. Certification is very valuable. It’s just that we’ve taken it out of the purview of licensure. In this way, we will assure that APRNs have a broad scope of practice, and then they’re free to specialize in whatever areas they want.”

Addressing Concerns
While the nursing community has reached a consensus, that doesn’t mean there weren’t questions and concerns along the way. What may be interesting to some is that it was the regulatory bodies—the state boards of nursing—that were most concerned about the potential limitations of specialty certification.

As APRNs—particularly clinical nurse specialists and NPs—started to specialize more, they would go to the boards of nursing and indicate their desire to be licensed in their specialty. “From my point of view, this put those nurses at a disadvantage, because those nurses then must practice within that scope,” Chornick says. “For instance, if they’re specialized—just to carry it to an extreme—in conditions of the right thyroid lobe, then they have a lot of constraints.”

The pitfalls are twofold. Based on her experiences, Mary Smolenski, EdD, FNP, FAANP, CAE, Director of Certification for the American Nurses Credentialing Center (ANCC), says, “NPs aren’t opposed to recognizing the certification in a particular area. But when it gets down to the fact that, gee, now you can’t work in derm unless you go off and get another certification, that’s where the problem arises.”

A narrow scope of practice could mean a decreased number of job opportunities, if an opening in the particular specialty is not readily available. But an even greater concern on the part of the NCSBN is that “individuals who have a very narrow scope of practice then don’t have the education or evaluation for a broader area,” Chornick says. “So it’s really a patient safety issue. You need to be educated and evaluated and work within a certain scope.”

That said, NPs’ primary education, licensure, and certification provide a platform that can be expanded at the practitioner’s choice. “Anything you can add to your basic licensure that ... shows you met a certain standard in a particular area adds to your recognition in that specialty,” Smolenski says. “You don’t want to be mandated to have that level of certification. But the fact that you have it, and you can say, ‘I do have this specialty knowledge,’ to me is a plus, not a minus.”

Looking Beyond Examination
While stating that “preparation in a specialty area of practice is optional,” the consensus model does “strongly recommend” certification in a specialty, if one is chosen. The model also provides a certain amount of leeway in how this additional knowledge and training are acquired and assessed:

“Competency in the specialty areas could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (eg, portfolios, examinations, etc).”

Since professional organizations would monitor specialty practice under the model, Chornick explains, “the profession would establish standards and decide what type of marker, so to speak, or designation would be appropriate for that person.”

Obviously, as a representative of ANCC, Smolenski appreciates the value of examination. But there are practical limitations to how many exams can be offered.

“Theoretically, you can develop an exam for anything,” she observes. “But from a business standpoint and a psychometric standpoint, you can’t—because if you’re trying to develop an exam that means anything, that the public can have faith in, you have to have certain numbers of people [to take it].”

Chornick also cites the expense of certification as a rationale for looking at other methods. “Licensure requires examination, so by allowing the specialties to have the profession in charge, they don’t need the examination,” she says. “A lot of specialties were unable to afford the development of a certification exam, so this will allow for alternative methods.”

For example, ANCC has started looking at portfolios for specialty recognition. Smolenski is already working with some nursing specialty groups to create online portfolios. The advantage is the breadth of information that can be made available to review boards or employers: Individuals might include case studies, articles, and presentations they have authored; a list of committees they’ve participated in; a complete history of work experience; and even a list of procedures they’ve learned, as well as how many times they’ve performed them and who supervised them.

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