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Which Credentials Should Nursing Adopt as Standard?
Christy Price Rabetoy, Department Editor
NP Should Be the Only Credential Used in Clinical Practice
Mary Knudtson, NP
Professor, and Director of the FNP Program
Department of Family Medicine
University of California Irvine
Irvine, CA
One of the main barriers we continue to face as nurse
practitioners (NPs) is lack of recognition by the public, legislators
and the media. Nurse practitioners need to clearly identify themselves
to those we care for and those around us in our practice if we are to
overcome this lack of professional identification. One of the main
barriers to recognition is the jumble of initials we put behind our
names in the clinical arena.
In order for others to recognize nurse practitioners we need to use a
simple uniform set of initials to identify ourselves to others as an
NP. Using only the initials “NP” after our name, and not our specialty
area or educational degree, would help to clarify to others that we are
a nurse practitioner. Nurse Practitioners are the only group of health
care providers who use our specialty certification in our initials,
FNP, PNP, ANP, GNP, WHNP, etc All allopathic physicians use the
initials MD regardless of specialty. For example, dermatologists do not
use DMD. Doctors of Osteopathy use DO regardless of specialty. Even
registered nurses use RN regardless of specialty area or academic
degree. Adding our educational preparation (such as BSN,
MSN, DNSc, PhD etc.) only further confuses the jumble of initials
behind our name. These credentials should be used in publications but
not in the patient care arena.
APN is not a preferable or equivalent term because it can mean
clinical nurse specialist, certified nurse midwife or certified
registered nurse anesthetist as well as nurse practitioner. CNMs,
CRNAs, CNSs and NPs are all advanced practice registered nurses, but
our scope of practice and skill sets are very different. Patients need
to be able to clearly recognize the type of provider they are seeing in
a clinical arena. Using the term APN does not allow patients to
recognize which type of health care provider they are seeing. Many NPs
are erroneously called “Doctor” by their patients, office staff, and
consultants to whom they refer their patients. It is important to take
the time and effort to educate those individuals that we are nurse
practitioners and NOT physicians.
The initials NP are the simplest and most common abbreviation for
nurse practitioners. All nurse practitioners should use the
initials “NP” to help identify us to patients, legislators, and the
media more easily. Your lab coat, name tag, examination room signs and
business cards should clearly identify you as a nurse practitioner with
the initial NP after your name. Your specialty area of practice can be
written out below your name and initials for further clarification if
desired.
Preserve the CNS as it Was Meant to be Recognized
Barbara J. Hasbargen, CNS, CNN
Nephrology Clinical Nurse Specialist
Clinical Assistant Professor of Nursing, Purdue University North Central
Westville, IN
Member, ANNA’s Dunelands Chapter
Clinical Nurse Specialists (CNSs) are “clinical experts in the
diagnosis and treatment of illness, and the delivery of evidence-based
nursing interventions” (ANA, 2004). Contrary to the position of the
American Nephrology Nurses’ Association (ANNA) (1997), which endorsed
the title of Advanced Practice Nurse (APN) to designate both CNSs and
Nurse Practitioners (NPs), the American Nurses’ Association (ANA)
stipulates that the term ‘Advanced Practice Nurse’ is an umbrella term
that covers four distinctly different roles.
Therefore, the ANA affirms that the definition and title of CNS
needs to be retained for those APNs who are licensed registered
professional nurses with graduate preparation (master’s and doctorate)
from a program that prepares CNSs (National Association of Clinical
Nurses Specialists [NACNS], 2004). CNSs are one of four categories of
Advanced Practice Nurses. Each category (CNS, NP, Nurse Midwife, Nurse
Anesthetist) has a unique expanded knowledge base to support its
distinctive contribution and specializes in diverse ways to meet the
needs of patients, families, groups, and communities (NACNS, 2004).
To take the title issue one step further, it is imperative that
legislative regulation of CNS practice include both title protection
specified by law and evidence of specialty practice as defined in
regulation. Lack of title protection by a State Nurse Practice Act can
result in the misuse of the CNS title by individuals who do not meet
the graduate preparation requirements of a CNS. Evidence of
advanced specialty CNS practice should be professional validation from
the nursing specialty organization, such as ANNA. Examples of
potential evidence for this purpose include but are not limited to the
following: psychometric examination or the use of a portfolio
that is equivalent to psychometric examination and is legally
defensible (NACNS, 2004).
Although the argument persists that the APN title should continue to
represent both nephrology CNSs and NPs, it is becoming increasingly
clear that the two titles should remain separate entities. If an APN is
dually educated as a CNS and NP, then that nurse may practice in a
‘blended role.’ Because both CNSs and NPs are also RNs, their practices
will have commonalities related to the RN practice. However, the
advanced practice of CNSs and NPs have distinctly different
components, and it is those distinctions that are recognized by
education and title.
The other predominant argument is centered around the confusion
concerning the differences and/or similarities of the two roles. To
make policy decisions that affect Advanced Practice Nurses in
nephrology based upon confusion about differences is a faulty argument.
Rather, Advanced Practice Nurses in nephrology should embrace the
differences that CNSs and NPs bring to the care of the patients they
serve, and work to more clearly articulate those differences.
Professional documents, such as the ANA Scope and Standards of Practice
(2004), the NACNS Statement on Clinical Nurse Specialist Practice and
Education (2004), and the Nurse Practitioner Primary Care Competencies
in Specialty Areas (2002) as well as articles published in journals
provide a framework for ANNA to use the label advanced practice nurse
as an umbrella term and retain the title of CNS and NP to endorse the
specialty practice of each.
References
American Nephrology Nurses’ Association. (ANNA). (1997). Position
statement: Advanced practice in nephrology nursing. Pitman, NJ: Author
American Nurses Association (ANA). (2004). Nursing: Scope and standards of practice. Washington, DC: Author.
National Association of Clinical Nurses Specialists (NACNS). (2004).
Statement on clinical nurse specialists’ practice and education.
Harrisburg, PA: Author.
U.S. Department of Health and Human Services, Health Resources and
Services Administration. (2002). Nurse practitioner primary care
competencies in specialty areas: Adult, family, gerontology, pediatric,
and women’s health. Rockville, MD: Author.
APN and APRN Are the Appropriate Credentials
Andrea Easom, ASN, BA, MA, MNSc, APN, FNP, BC, CNN
Instructor
College of Medicine, Division of Nephrology
University of Arkansas for Medical Sciences
Member, ANNA’s Arkansas Chapter
I knew I was in trouble when I asked, in my
last semester of graduate school, “How do we sign our name when we
graduate?” Three nursing professors, all doctorally or masters
prepared, huddled together in the front of the room to discuss the
question prior to giving an answer. Little did I know that this was
just the beginning of the stirring of the alphabet soup pot.
An Advanced Practice Nurse (APN) is a Registered Nurse (RN) who has
completed an advanced nursing educational program and has achieved
national certification from an approved certifying body. So the APN
generally has a master’s degree in nursing and is certified in the
clinical category and specialty for that degree. The APN can use the
initials signifying the degree or degrees held and the initials of the
nursing specialty such as Family Nurse Practitioner (FNP), Neonatal
Nurse Practitioner (NNP), Pediatric Clinical Specialist (PCS), and
Gerontological Nurse Practitioner (GNP). Even though these initials
have no legal standing, they enrich, but also, increase confusion in
the alphabet soup.
APNs and APRNs (Advanced Practice Registered Nurse) are generally the
legally recognized terms used by State Boards of Nursing. The American
Nurses’ Association (ANA) recognizes four categories of nurses that can
be licensed as APNs in most states. They are Advanced Nurse
Practitioner (ANP), Certified Nurse Midwife (CNM), Clinical Nurse
Specialist (CNS) and Certified Registered Nurse Anesthetist (CRNA). In
Arkansas, when writing prescriptions, the initials APN must follow the
nurse’s signature. There is no law stating how other paperwork must be
signed. Please note that when I received my first license, I questioned
the initials ANP on it. I thought it meant Adult Nurse Practitioner and
that I was an FNP.
Why not just NP for Nurse Practitioner? In the past there were a number
of Registered Nurse Practitioners (RNPs). In Arkansas, these RNs are
not required to hold board- approved national certification and they
practice under defined protocols with no prescriptive authority. Most
were not master’s prepared. Many states have found ways to grandfather
RNPs into APN categories. Arkansas is the only state that still
licenses RNPs, and these are renewal licenses only. As the number of
RNPs decreases, this will be a nonissue. But the term NP also excludes
other advanced nurse clinicians, specifically CNSs, who practice in
nephrology.
APN and APRN are umbrella titles. They include rather than exclude.
They encourage collaboration and support between all levels of advanced
nurse clinicians. They are also the terms used for licensure in most
states. Though not as old or widely recognized as NP, their acceptance
is growing.
The American Nephrology Nurses’ Association (ANNA) has spent a fair
amount of time educating nephrology nurses and our physician colleagues
about who APNs and APRNs are and what they can do. There are joint
position papers on their credentials and practice by ANNA, the American
Society of Nephrology (ASN), and the Renal Physicians’ Association
(RPA). Through ANNA, nephrology APNs and APRNs have developed a Scope
of Practice and Standards of Care and Professional Practice. ANNA was
careful to be inclusive, considering both the roles of the varied NPs
and CNSs practicing in nephrology in developing these documents.
As the soup continues to thicken, much will depend on what State Boards
of Nursing decide across the country. Since APN and APRN seem to be the
most used legal terms for advanced practice nursing clinicians,
hopefully there can be consensus on one of these terms, and mutual
nurse licensure compacts can be formed. According to the National
Council of State Boards of Nursing, Utah was the first state to pass
APRN compact legislation on March 15, 2004. A cornerstone has been set.
Regardless of what happens, I like soup. I refuse to apologize for any
of the initials I can place behind my name. I earned each and every one
of them! I remain, respectfully yours, Andrea Kay Morrison Easom, ASN,
BA, MA, MNSc, APN, FNP, BC, CNN.
The Controversies in Nephrology Nursing
department focuses on exploring ethical and clinical issues within the
nephrology clinic practice in a point/counterpoint format. Address
correspondence to: Christy Price Rabetoy, Department Editor, through
the ANNA National Office; East Holly Avenue/Box 56; Pitman, NJ
08071-0056; (856) 256-2320; or by emailing her at
christycpr@comcast.net. You may also log onto this column at
www.nephrologynursingjournal.net (clink on Department link) and email
your comments to the Editor (see Discussion Area). The opinions and
assertions contained herein are the private views of the contributors
and do not necessarily reflect the views of the American Nephrology
Nurses' Association.
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Copyright 2005, American Nephrology Nurses' Association. Anthony J. Jannetti, Inc., publisher. An iNurse Web site.
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