Introduction to Nursing Licensure & Certification
Nursing licensure is a form of credentialing or regulatory method that is used when the activities being regulated are complex and require specialized knowledge coupled with the ability to make independent decisions. At the very heart of licensure are public safety and the need to ensure minimal competency in a set of nursing skills that a licensed nurse must possess in order to competently provide consistent quality nursing care for a defined level of nursing practice.
Nursing licensure is defined by the NCSBN as “the process by which BONs grant permission for an individual to engage in nursing practice after determining that the applicant has attained the competency necessary to perform a unique scope of practice”. The requirements for licensure define what is necessary for individuals to be able to practice the profession of nursing safely and ensure that each person meets those minimal requirements.
The licensure process addresses both qualification and disciplinary activities. First, licensure encompasses predetermination of the qualifications that are required to perform a defined scope of practice (e.g., LPN vs. RN) safely and an objective evaluation process to determine that the qualifications for the defined scope of practice are met.
Generally speaking, the objective evaluation is accomplished through an examination (NCLEX-RN; NCLEX-PN) that must be passed before the individual can practice. In addition, licensure provides title protection for the roles and functions that RNs perform, and it gives authority to take disciplinary action against a licensee if he or she violates the nurse practice act and governing laws, thus ensuring that the public health, safety, and welfare are protected. In the United States, nursing licensure is a regulatory function of each state.
Currently, each state’s or territory’s BON or a designated entity grants licensure to RNs within that jurisdiction. Each state has the ability through enforcement powers to designate an entity with licensing authority to ensure that each individual who claims to be a nurse can function at a minimal level of competency.
Many states’ nurse practice acts also contain language that provides protection for the title of “registered nurse” to persons who hold a valid license and prevents other persons from using the title or credentials. One example of this type of title protection can be found in Arizona’s Nurse Practice Act
The History of Nursing Licensure
Nursing licensure originally came about to protect the public from unsafe nursing practice. During the 1900s nurse practice acts consisted mainly of lists of the names of trained nurses. The state of North Carolina was the first state to enact a nurse practice act, in 1903.
By 1923, all states had enacted nurse practice acts. From the 1930s through the 1950s, nurse licensure laws were enacted to help define the practice of nursing and to prevent unlicensed individuals from practicing nursing. In 1955, the ANA issued a model definition of nursing that affirmed that not all nursing duties required physician supervision and that some duties were independent nursing functions.
However, the definition did forbid nurses from diagnosing conditions or prescribing medications. Over time, the practice of nursing has expanded, with regulatory focus on professional accountability
Historically, when an RN wanted to work in a state other than his or her home state, he/she had to apply for licensure in that other state. In the past, there was no national licensure examination. That meant there was no consistency between states’ nurse licensure exams.
The NCSBN was instrumental in developing the national licensure exam for RNs, which changed in 1982 to the National Council Licensure Examination for Registered Nurses (NCLEX-RN). Thanks to the elimination of state-specific licensure exams, nurses can be more mobile and more easily pursue career opportunities in multiple states.
Requirements for Nursing Licensure
To ensure public protection, each state or territory in the United States through its state BON or designated licensure body requires a candidate for nursing licensure to pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN) or the NCLEX for Practical Nurses (NCLEX-PN) and meet other requirements before granting a nursing license.
The passing level for the exam is set to ensure that at a minimum, a sufficient skill set is demonstrated to protect the public. The NCLEX examination measures the competencies needed to perform safely and effectively as a newly licensed, entry-level nurse. In 2011, the NCSBN Delegate Assembly adopted the Uniform Licensure Requirements (ULRs) to serve as standards for licensure for RNs and LPNs in all states and territories.
The ULR provides for additional public protection by requiring disclosure of substance use disorders and prior actions taken or initiated against a professional or occupational license, registration, or certification. States have been encouraged to adopt the ULRs to promote consistency across all U.S. jurisdictions. The requirements for nursing licensure for applicants who wish to become licensed RNs include successful graduation from high school or completion of a GED, successful graduation from an approved nursing school, application to the appropriate state agency for licensure, payment of required fees, and criminal background check in some states.
In addition, applicants must not have a criminal history such as a felony conviction that prohibits them from taking the NCLEX-RN. If an applicant successfully meets all these requirements, then a state nursing board or licensure body may grant the applicant a nursing license. Simply passing the NCLEX-RN is no guarantee that an applicant will automatically be granted a nursing license.
Only after all state requirements have been satisfied will a candidate be considered for licensure. Although these requirements may seem extensive, the responsibility associated with nursing licensure and safely caring for patients demands such consideration.
Certification is a form of credentialing that demonstrates attainment of increased knowledge but does not address a legal scope of practice like licensure does. Individual certification is the most common type of certification and is awarded when a nurse demonstrates a level of competency above the licensure level for a specific area of nursing practice.
The American Association of Critical Care Nurses (AACN) defines certification as “a process by which a nongovernmental agency validates, based upon predetermined standards, an individual nurse’s qualifications for practice in a defined functional or clinical area of nursing”
Numerous state BONs use professional certification as a requirement toward granting authority for APRNs. Organizations, like individuals, also can be certified. However, the certification process for organizations is very different from individual or personal certification. Organizations such as hospitals or healthcare institutions can be certified by external/reviewing entities.
Organizational certification is referred to as accreditation. The Joint Commission is one example of an external entity that accredits hospitals. Hospitals go through an accreditation process to ensure that they are achieving a defined set of performance measures. In essence, hospital accreditation provides a “gold seal of approval” for hospitals achieving those standards. This approval rating allows consumers to make choices based upon standardized measures that reflect the quality of care provided at that hospital.
Another type of organizational recognition that has particular meaning for nurses is “magnet status.” Magnet status is an award given by the American Nurses Credentialing Center, an affiliate of the ANA, to hospitals that satisfy specific criteria based on the strength and quality of nursing in that facility. A magnet hospital is an organization or facility that exhibits nursing excellence through patient outcomes, communication, and delivery of care.
Other entities provide voluntary accrediting services for community-based facilities. An example of such a voluntary accrediting agency is the Commission on Accreditation of Rehabilitation Facilities International (CARF International).
Potential for confusion exists because regulatory agencies and professional associations may use the term certification differently with individuals and organizations. As technology advances and the number of nursing specialty areas continue to grow, nurses are pursuing certification to increase their knowledge and skill beyond what they learned in their basic nursing programs.
For example, the American Nurses Credentialing Center offers certifications in over 40 areas of nursing practice. However, certification is a concept that is frequently misunderstood by employers, the public, and even other nurses. Examining the current certification process for APRNs provides a unique opportunity for understanding nursing certification in general, because it mirrors the previous development of nursing licensure. APRN certification is in an earlier phase of evolution than is RN licensure.
Therefore, APRNs today find that both the uniformity of standards and recognition of their advanced practice expertise lag behind those of their RN status (Evans, 2015). For example, APRNs’ ability to prescribe medications, professional titles, and the ability to bill third-party payers continue to vary from state to state. Therefore, APRNs continue to face many of the challenges and barriers to practicing in different states that RNs faced prior to adoption of the NLC. As states adopt the APRN Compact, barriers to advance practice across jurisdictions will potentially decrease.
However, nursing studies have demonstrated that nurses experience positive benefits if they obtain certification. Specialty certification provides positive benefits for patients, families, nurses, and employers. Certification is becoming the new standard measure for excellence in nursing care in this quickly changing healthcare system.
Certification distinguishes mastery of skills and knowledge that go beyond the scope of nursing licensure. The American Association of Critical Care Nurses Malcolm Baldrige National Quality Award, Beacon Award of Excellence, and Magnet Recognition Program recognize certification as a critical component of nursing excellence in specialized practice. Healthcare consumers and nurses are becoming increasingly aware of the benefits of certification to help ensure safe and high-quality nursing care services.
Requirements for Certification
The requirements for certification are diverse and depend upon the organization granting certification. Requirements usually address the candidate’s RN licensure status, educational preparation, and number of clinical practice hours in the chosen specialty.
Historically, large numbers of professional and specialty groups have offered certification exams. Therefore, the requirements are extremely varied. For example, the AACN has different certification requirements than the American Association of Operating Room Nurses (AAORN). To determine the exact requirements for certification, nurses should check with the specialty organization through which they wish to become certified.
Differences Between Licensure and Certification
Certification, on its face, appears to be very similar to licensure. However, licensure and certification are two different terms that carry different meanings both professionally and legally. Certification is the granting of credentials that indicate a person has achieved a level of specialization higher than the minimal level of competency indicated by licensure.
Licensure is technically a form of legal certification. Although some very specific forms of certification carry a legal status, most certifications only imply a specialized skill or knowledge set associated with specific professional status. Nursing licensure, on the other hand, implies a legal status because it establishes lawful authorization for a scope of nursing practice