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Credentialing and psychiatric clinical nurse specialist practice: current issues.

Credentialing requirements for psychiatric advanced practice registered nurse (APRN) practice, and in particular as a psychiatric clinical nurse specialist (CNS), is not uniform across the country. Some states do not recognize CNSs in the advanced practice role, and some of the states that do may require certification. Further complicating the issue for psychiatric-mental health CNSs is a trend of some psychiatric APRN educational programs toward a Bblended CNS/nurse practitioner (NP) role[ and subsequent role confusion as to which examination the candidate is truly adequately prepared to sit for. This matter is currently being examined by a task force convened by the American Psychiatric Nurses Association (APNA). This writer, who is a member of the Legislative and Regulatory Committee of the National Association of Clinical Nurse Specialist (NACNS) and a resident of Ohio, is appointed to this task force. By describing the current dilemma of psychiatric APRN credentialing, this column will address CNS credentialing issues overall. One of the central issues is the National Council of State Boards of Nursing’s support of certification as a requirement for CNSs to obtain licensure. Although not a regulatory body, its recommendations are often referenced by state boards of nursing in developing rules. Many states, Ohio among them, now require certification for any APRN to obtain a certificate of authority, the credential offering title protection to practice as an APRN. In these states, CNSs enjoy all of the privileges afforded to other APRNs who focus on direct care (title protection/recognition, opportunity for prescriptive license if desired, ability to bill for services, etc), but this has created a dilemma for those CNSs whose practice, by choice, focuses more on indirect roles. In addition to requiring certification to hold an APRN title, all practicing APRNs in Ohio must be in a collaborative relationship with a physician, regardless of their practice foci and setting. This makes no sense at all for a hospital-based CNS whose primary foci are in the indirect spheres of influence, whichmight include activities to promote healthy function at multilevel systems, and conducting research to support nursing practice and improve outcomes. Lastly, the issue of mandating credentialing as a way of ensuring competence is being questioned by some psychiatric APRNs in Ohio because of incidents of APRNs who are not psychiatrically prepared reportedly functioning in roles that do not match their credentials. Examples of this controversy are community mental health centers that replace departing psychiatric CNSs and psychiatric NPs with women’s health NPs or adultNPs. The question professionals inOhio are asking iswhat ultimate good does it do to mandate credentialing in obtaining APRN status if competent scope of practice is not ensured? Regulation of psychiatric CNS practice tends to be done in comparison to NP practice and unfortunately has tended to focus on the similarities thus homogenizing the roles, adding to the confusion of credentialing between CNS and NP. Further compounding confusion over the role credentialing plays in CNS practice is the impact of combined/blended psychiatric CNS-NP programs. Trends in psychiatric CNS certification numbers have been declining steadily since 2005 according to the American Nurses Credentialing Center (ANCC). More graduates from master’s psychiatric programs are opting to sit for the psychiatric NP examination rather than the psychiatric CNS examination. Since 2005, there has been a steady decline (46%) in applicants for the psychiatric CNS examination. This may be due to the combined programs’ emphasis on direct care NP roles, the current situation of some states not recognizing CNSs as advanced practice nurses and only credentialing NPs, or a combination of both trends. The current dilemma of preparation and credentialing of psychiatric APRNs is not new and has been a volatile topic for over a decade. The limits of this column prevent a full review of events leading to this juncture. Key elements driving this change have been discussed by others. Puskar proposed that the current psychiatric CNS-NP dilemma was driven by economics and agreed with the American Association of Colleges of Nursing’s position that much of the crisis in today’s healthcare system results from high costs, limited access, and concerns about quality. The psychiatric Pamela A. Minarik, MS, APRN, BC, FAAN