Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education
Background: The Consensus Model was developed during 2004-2008 by a group of Advanced Practice Nursing (APRN) organizations including representation by several nurse practitioner organizations, clinical nurse specialists, nurse anesthetists and ACNM. The group, known as the Joint Dialogue Group, included accreditation and certification organizations, as well as membership organizations and the National Council of State Boards of Nursing (NCSBN). The document has been endorsed by 47 national nursing and nursing-related organizations including ACNM, the American Midwifery Certification Board (AMCB), and the Accreditation Commission for Midwifery Education (ACME). The purposes of the document are to:
- Promote common definitions related to APRN roles
- Establish a set of standards that protect the public and improve access to safe, quality APRN care
- Improve mobility for APRNs state to state
- Strive for harmony and common understanding in the APRN regulatory community
The Consensus Model and Midwifery: Midwifery in the United States and the Consensus Model for APRN Regulation is a white paper developed by ACNM, ACME, and AMCBthat describes the impact of certain recommendations of the Consensus Model on the profession of midwifery. The paper also provides a brief overview of the evolution of midwifery in the United States and a chart listing the key similarities and differences among professional midwives in the United States.
For additional resources about Midwifery and the Consensus Model, please see resource list below.
Nurse-midwives are educated in two professions, nursing and midwifery. Nurse-midwives practice midwifery under regulations by Boards of Nursing in 44 jurisdictions, including 5 in which they are jointly regulated by Boards of Nursing and Boards of Medicine. In the remaining states, they are regulated by Boards of Midwifery, Boards of Health, or Boards of Medicine.In 36 jurisdictions (35 states plus the District of Columbia), CNMs are licensed as Advanced Practice Nurses. The Consensus Model does not address Certified Midwives.
Implementation: Organizations are making changes in their educational standards, criteria for certification, and criteria for accreditation in order to better align with the recommendations in the Consensus Model. In addition, many state boards of nursing (BONs) are changing the regulations that govern the licensing of APRNs in order to comply with the recommendations in the model.
The midwifery certification process, governed by AMCB, is consistent with the recommendations in the Model, as is our accreditation process, governed by ACME. Most nurse-midwifery education programs are already in alignment with the Model; however, a few programs are in the process of assuring that their graduates will have three separate graduate level courses in advanced health assessment, physiology/pathophysiology and advanced pharmacology as recommended in the Model.
Opportunities: The Model consistently insists that APRNs be licensed as "independent practitioners", and further affirms that they have "no regulatory requirements for collaboration, direction or supervision" (p. 13). This language will be very helpful in making changes in regulations in states where CNMs are still required to have collaborative arrangements with physicians. In 44 states, CNMs may be considered licensed independent practitioners (LIPs) under the Joint Commission definition.
The Model recommends that all BONs have APRN advisory committees that include one CNM, one CRNA, one CNP, and one CNS. It further recommends that there be at least one APRN on every BON. This opens the door for CNMs to have more representation and input to the majority of the boards that regulate them.
The Model states that Boards of Nursing will be "solely responsible for licensing APRNs" in an effort to separate APRNs from Boards of Medicine. A footnote that was added to this statement about midwifery clarifies "except in states where state boards of nurse-midwifery or midwifery regulate nurse-midwives or nurse-midwives and midwives jointly." This footnote provides an opportunity for midwives to establish boards of midwifery, thus increasing the recognition of midwifery as a distinct profession. ACNM's position statement, Principles for Licensing and Regulating Midwives, precedes and is consistent with these recommendations.
Concerns: Because the majority* of APRNs are Nurse Practitioners, many state BONs may loosely interpret the recommendations in the Model and insert new language in their regulations that are valid for NPs but are incorrect for CNMs. For example, NPs must have documented 500 hours of clinical experience during their educational program in order to sit for their national certification exams, and this language is now appearing in some states' licensing regulations as a requirement for all APRN licenses, including CNMs—even though the Consensus Model does not support or recommend this change. This confusion may have been further exacerbated by imprecise statements included in an article on the Consensus Model that was published in the American Journal of Nurse Practitioners, which ACNM and the American Association of Nurse Anesthetists have called to the attention of AJNP editors.
Another incorrect interpretation that has arisen is that some BONs have asserted that all APRNs must hold a Master of Science in Nursing. The Consensus Model requires a graduate degree and does not specify the MSN. The document states: "APRN education must be formal education with a graduate degree or post-graduate certificate (either post-master's or post-doctoral) that is awarded by an academic institution and accredited by a nursing or nursing-related accrediting organization recognized by the U.S. Department of Education and/or the Council for Higher Education Accreditation." (p. 10) Click here to access a sample letter to regulatory boards that provides clarity as to what the Consensus document recommends on this issue.
Recommendations: In short, while the LACE Consensus Model includes a number of very positive recommendations and ACNM believes that the Model will generally provide benefits to CNMs and all APRNs, it has created a highly dynamic environment in which there are opportunities for improvements as well as setbacks if misinterpreted.
ACNM recommends that ACNM state leaders and midwifery advocates:
- Become familiar with the Consensus Model by reading the complete document and by monitoring this web page and ACNM's LACE Consensus Model FAQs.
- Monitor steps being taken by your state regulatory boards. Be vigilant for opportunities for improved regulations for midwifery as well as for interpretations that are incorrect or could be adverse for CNMs.
- Volunteer for your state regulatory board when a position becomes open. CNMs should be represented on BONs in the 44 jurisdictions in which CNMs are regulated or jointly regulated by BONs.
*approximate numbers of APRNs:
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