Keywords

Professional regulation is the legitimate and appropriate means – governmental, professional, private, and individual – whereby order, identity, consistency, and control are brought to the profession. The profession and its members are defined; the scope of practice is determined; standards of education, ethical, and competent practice are set; and systems of accountability are established through these means [14]. Professional regulation for advanced nursing practice (ANP) consists of the rules and policies that recognize the advanced practice nurse (APN) and officially credential APNs for practice [12]. This chapter describes the significance of having appropriate regulatory mechanisms in place for professional practice to support APNs to the full potential of their role within the context of a country’s healthcare system and settings. It begins with the ICN guidelines for establishing advanced nursing practice (ANP) professional regulation. Regulatory frameworks and models are offered in order to have examples to consult in the process of formalizing the policies and processes of regulation. Topics relevant to ANP credentialing, including accreditation, certification, licensure, registration, and endorsement are discussed. The chapter concludes with a comprehensive overview of maintaining practice competence.

Legislation and professional regulation ideally should grant a distinct title designation and protection for the APN, justify the role, and award clear authority to carry out a range of activities related to ANP. Through a formally authorized institution or agency, professional regulation has a function to legitimatize the role, protect the public, as well as to monitor individual healthcare professionals practice and behavior. This purpose also serves to hold healthcare providers accountable for their actions in an effort to protect the public and offer safe, quality healthcare service. The organization or agency regulating nursing uses current scope of practice and standards to disseminate policy and regulations. These provide direction and acknowledgement of professional educational preparation and boundaries of practice. ICN has recommended minimal standards for the professional regulation of ANP. These guidelines are as follows:

  • Develop and maintain sound credentialing mechanisms that enable the authorized nurse to practice in the advanced role within an established scope of practice

  • Establish relevant civil legislation or rules to acknowledge the authorized role, monitor APN competence and protect the public through issuance of guidance, assessment processes and when necessary, fitness to practice procedures and processes

  • Periodically revise professional regulatory language to maintain currency with nursing practice and scientific advancement

  • Establish title protection through rule making or civil legislation.

(ICN 2008, p. 21 [15])

In the process of developing a professional regulatory model or framework, clarifying the definition of ANP and the APN roles is vital when explaining the concept to external stakeholders such as legislators and healthcare planners Hamric [11]. Identifying core features of APN roles such as entry-level education, certification, licensure, and the focus of practice are key elements in delineating professional regulation and credentials specific to ANP. The next section provides guidelines and framework examples to consider when pursuing regulatory structure.

6.1 Frameworks and Models for Professional Regulation

A well-defined framework is key to achieving consistency and sustainability of the APN role and allows ANP to evolve as a distinct and legitimate part of the healthcare delivery system. Credentialing of APNs is the central function of the regulatory system arising out of this framework. Credentialing is discussed later in this chapter (see Sect. 6.1.1). Factors likely to influence development of a professional regulatory framework include:

  • Type and stability of the political system in the country

  • Legislative and regulatory traditions of the country

  • Regional and international trends that influence regulation

  • The level of detail wanted/required in the regulatory system

  • The rate of change in educational standards, practice and technology

  • Time, human expertise and financial resources needed to enact or revise regulations

Schober and Affara [29]

Dimensions of Regulation are proposed in the Healthcare Professional and Occupational Regulation Toolkit [16]. A recommendation is made that a series of questions to ask can be useful in discussing and developing a professional regulatory structure. The questions include:

  • WHY or for what purpose is a regulation created?

  • WHAT is regulated? Targets of the regulatory system could include persons providing service, educational programs preparing the professional and/or institutions.

  • WHO is the authority that licenses, registers, certifies, approves, or accredits persons, programs, or institutions?

  • WHO carries out the regulation?

  • HOW are regulation or credentialing mechanisms carried out?

  • HOW are methods and tools used in the regulatory processes to review and evaluate qualifications? How do you know standards have been met?

Criteria for measuring the extent to which standards have been met include codes of professional conduct, civil service requirements, and disciplinary procedures. Validation tools, such as national examinations, school records, letters of recommendation, portfolios, interviews, institutional self- assessment, visits to facilities, and healthcare records, are other means used to gain evidence of knowledge, performance, and outcomes [16]. For further discussion of performance maintenance refer to Sect. 6.3.

6.1.1 The ICN Credentialing Framework: A Basis for ANP Professional Regulatory Structure

The degree of detail required for components of a professional regulatory model or framework for ANP is country specific. A model (see Table 6.1) based on the ICN Credentialing Framework [13] offers a point of reference to begin to change or reform a professional regulatory structure. The ICN framework proposes the following characteristics:

Table 6.1 Professional regulatory model for advanced nursing practice (Schober and Affara [29], p. 103)
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In the Law

Title protection, APN definition, nature of the agency responsible to regulate the APN along with designated functions, and powers of the agency and its authority to conduct regulatory transactions are given a level of protection provided by the law.

In the Regulations

Components more sensitive to modifications in practice, knowledge, and healthcare delivery can be addressed through regulations that include interpretation thus allowing for flexibility to respond to change in healthcare systems, healthcare settings, professional, and alterations within the public domain.

Table 6.1 demonstrates the diversity of factors requiring consideration in developing a professional regulatory model/framework for ANP. Issues that need to be discussed for inclusion in a model or framework include: titling (name and level of protection), scope of practice (level of authority and autonomy), educational requirements, types of credentialing mechanisms, and renewal of credentials and methods for validating/evaluating competence.

6.1.2 SSPP Model (Scope, Standards, Policies, and Procedures)

In the SSPP model, scopes of practice, professional standards, policies, and procedures (SSPP) are linked in a logical manner with one being the foundation stone for another [16]. Figure 6.1 illustrates how professional standards grow out of the definition of a profession’s scope of practice. The scope of practice identifies and communicates the health professional’s range of activities – roles, functions, responsibilities, activities, accountability, decision-making capacity, and authority. Competencies and standards are derived from a process of linking a situational analysis, task analysis, and scope of practice definitions.

Fig. 6.1
figure 1

SSPP model (scope, standards, policies, procedures) (Access from https://reprollneplus.org/system/files/resources/03_SSPP%20Model_tc.pdf)

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This model provides a comprehensive approach that includes introductory regulatory concepts and principles to guide key stakeholders in development of a professional regulatory framework. Defining a scope of practice for APN roles forms the foundation of the SSPP model. Scopes of practice are essential regulatory means that form the basis of APN practice. Scopes of practice inform standards and competencies, communicate role expectations, and inform curriculum content and practice standards. In addition, the defined scope of practice identifies the function of the APN, differentiates this level of nurse from other categories of nurses and healthcare professionals, and assists in the process of healthcare workforce planning.

Resting on the foundation of an established scope of practice is a defined set of competencies required of the APN for safe and capable practice. The competencies are linked to role, practice, and education. Competence in healthcare is the capacity to deliver a specified healthcare service effectively and safely. Regulators use competencies to ensure healthcare professionals function skillfully within their defined scope of practice. (Refer to Chap. 3 – Nature of Practice for further discussion on developing ANP scopes of practice).

In the SSPP model, the setting of standards includes establishing procedures and policies that provide the basis of professional accountability and autonomy. Standard setting is considered to be a central part of what professional organizations, regulatory bodies, and governmental agencies offer to a professional discipline such as ANP in the process of role development.

6.1.3 National Examples of Models and Frameworks

In order to offer a pragmatic perspective of the regulatory processes for ANP, country specific examples are presented in the following sections (Sects. 6.1.3.1, 6.1.3.2, 6.1.3.3, and 6.1.3.4) to provide descriptions of approaches taken by the selected countries with varied lengths of experience with APN roles.

6.1.3.1 USA National Model. Consensus for Advanced Practice Registered Nurse Regulation: Licensure, Accreditation, Certification and Education

In the United States, until recently, there was no common ground for regulating the field of ANP that includes certified registered nurse anesthetists, certified nurse-midwives, certified nurse practitioners, and clinical nurse specialists. Core issues had been taken up by universities over the years in educating the various APNs. Leaders from professional nursing associations, certifying bodies, and regulators took the lead in 2004 to establish a process that resulted in a consensus statement on credentialing of APNs (APRN [advanced practice registered nurse] is the agreed title in the USA) and ultimately a regulatory model that established a model for education, certification, accreditation, and licensure [12]. The vision was to have one national regulatory scheme that would be beneficial to patients and allow APNs to meet patient needs [22]. The Consensus Model as of May 2016 is endorsed by 48 national nursing organizations. Even though the model is a reality and is coordinated with credentialing stakeholders, differences for credentialing APNs continue to exist across the 50 states. It is speculated that it will take time to fully implement this model [12].

The Consensus Model has wide-ranging impact on licensing boards, accreditation agencies, certification organizations, and educational programs. Some of the significant highlights of the model follow next:

  • The Consensus Model defines four APRN roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), and certified nurse practitioner (CNP). These four roles are given the title of advanced practice registered nurse (APRN).

  • Education, certification, and licensure of an individual must be congruent in terms of role and population foci.

  • The model calls for all APRNs to be educated in an accredited graduate-level education program in one of the four roles and in at least one of six population foci: family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women’s health/gender-related, or psych/mental health.

  • The emphasis for all APRNs is that a significant component of their education and practice focuses on direct clinical care of individuals.

  • All APRNs must be educated/prepared to assume responsibility for health promotion as well as assessment, diagnosis, and management of patient concerns, which includes the use and prescription of pharmacologic and nonpharmacologic interventions whether or not an APRN later chooses to gain prescriptive authority.

  • All APRNs are required to pass a national certification examination and required to maintain continued competence verified through a recertification process with a national certification agency.

  • Advanced practice registered nurses are licensed practitioners expected to practice within standards established or recognized by a licensing body.

Credentialing for APRNs is composed of: licensure, accreditation, certification, and education. The acronym LACE is used to refer to these four components. More extensive details on the Consensus Model can be found on https://www.ncsbn.org/736.htm and http://www.nonpf.org/?page=26

6.1.3.2 New Zealand: Adapting Professional Regulations

The nurse practitioner (NP) was a new scope of nursing practice launched by the Ministry of Health and the Nursing Council of New Zealand in 2001 [19]. Following extensive consultation in 2015, the Nursing Council of New Zealand made an announcement that changes will be made to the nurse practitioner scope of practice and education programs that prepare nurse practitioners to meet future health needs of New Zealanders. These changes are expected to come into effect in 2016. The scope of practice has been broadened and the requirement to restrict nurse practitioners to a specific area of practice has been removed. This model has been safely implemented in Australia and offered guidance in New Zealand. Nurse practitioners, as advanced clinicians, will be expected to self-regulate and practice within their area of competence and experience.

Nurse practitioners in New Zealand have demonstrated safe advanced practice since they were first regulated in 2001. The Nursing Council thinks that the changes will allow greater flexibility for nurse practitioners to meet future healthcare needs of the country. A revised scope of practice provided by the Council also makes the role and contribution of nurse practitioners clearer to employers and the public, and differentiates the nurse practitioner from other advanced registered nurse roles.

As previously indicated, the new scope of practice statement for the nurse practitioner will be introduced in 2016. Nurse practitioner candidates will still have an opportunity to focus on an area of practice but it will not appear on the register or on their practicing certificate. Nurse practitioner candidates will be expected to complete the same or similar papers as registered nurses preparing to prescribe for long-term and common conditions as part of their program. This will broaden their skills and knowledge and create greater consistency in their preparation. It will also prepare them to be able to mentor registered nurses who are learning to prescribe.

The Nursing Council of New Zealand also decided to refocus education programs to prepare nurse practitioners so that they will have more specific program outcomes that include 300 h of protected clinical learning time. It is anticipated that these changes will lead to greater consistency and range in nurse practitioner preparation to hopefully improve readiness for registration upon completion of their education program. Currently the Nursing Council of New Zealand accredits clinical master’s programs as the required qualification for nurse practitioners. Over the years these programs have become increasingly diverse as they have sought to meet the needs of newly graduated nurses, nurses in diverse specialties, and nurses who wish to become educators, mangers, and researchers. The Council has decided to accredit specific nurse practitioner programs with consistent outcomes that lead to nurse practitioner registration.

In reviewing current regulations and policies for NPs, the Nursing Council of New Zealand is also investigating:

  • The possibility of requiring a year supervision for newly registered NPs

  • Developing new competencies that accurately reflect the new scope of practice

  • Whether it is necessary to submit a portfolio to demonstrate clinical competence when applying for registration

  • Ways to better ensure consistent standards for candidate assessment.

NCNZ [28]

The consultations and reexamination of NP regulations sought by the Nursing Council of New Zealand offers an example of an adaptive approach to adjusting professional regulations following 15 years of experience with the NP role. Over time and with experience, as the concept of ANP matures, professional regulations will require modification.

6.1.3.3 The Scottish Advanced Nursing Practice Framework: A Toolkit Approach

Deliberations in the UK on regulating ANP have been complex, spanning over 20 years. Debates started in the late 1980s and early 1990s as service and strategic interest in advanced nursing roles increased. Despite a great deal of strategic intent and service change, professional regulation across the UK remains unresolved and is now widely regarded as unachievable and unwarranted [2]. The Council for Healthcare Regulatory Excellence [5] in the UK outlined the complexity of professional regulatory issues and made it clear that, in its view, the code of professional conduct [24, 25] encompasses advanced practitioner practice, thus negating any need for additional formal regulation [2]. Indirectly that perspective led to the development of the Advanced Nursing Practice Toolkit [30] under the auspices of the Modernising Nursing Careers report [6]. This began to provide some national conformity and guidance to employers, practitioners, and educators. Subsequently and following the release in 2009 of the NHS Scotland Career Framework Guidance [31], the Chief Nursing Officer Directorate and Health Workforce were eager to support the consistent and sustainable implementation of ANP in Scotland. This approach was linked to the development of the Advanced Practice Toolkit [30]. The Advanced Nursing Practice Tool Kit (http://www.advancedpractice.scot.nhs.uk) supports decision-making and planning based on the needs of patients and service. Furthermore, it draws together a body of work around an advanced level of nursing practice that states this level of practice reflects a particular benchmark above “Senior” level and below “Consultant” level on the Scottish career development ladder. The Toolkit sets out a consensus position on level of practice and offers an extensive array of tools and resources to support development and implementation of ANP. In connection to The Toolkit, the Scotland Career Framework Guidance [31] recommends that when considering if the option of an APN role is the best fit to meet the needs of patients that nursing directors, healthcare planners, and key stakeholders take into consideration service needs, education needs of the entire healthcare workforce, anticipated impact of introducing APN roles along with views of sustainability, and a robust governance/accountability scheme [31].

The Chief Nursing Officer (CNO) for Scotland, the CNO’s for the other three countries of the United Kingdom (England, Northern Ireland, and Wales) and the UK Modernising Nursing Careers Coalition have all endorsed the Advanced Practice Toolkit and support clear guidance on advanced level nursing practice to be disseminated. As a result, NHS Wales (2009) accepted the principles contained within the Scottish Government Health Department’s Advanced Practice Toolkit [30] to develop a framework structured to reflect key issues from the Scottish Toolkit [23].

6.1.3.4 Ireland: A Dual Credentialing Framework

In 1998, the Report from the Commission on Nursing: A Blueprint for the Future [32] recommended the establishment of the National Council for Nursing and Midwifery (NCNM) with one of its functions being the development of advanced nursing and midwifery posts and persons in Ireland. The Commission on nursing recognized that promotional opportunities for nurses and midwives wanting to remain in clinical practice should be open and recommended a three-step clinical career path in nursing and midwifery, one of which was advanced practice. In addition, in order to use the title advanced nurse practitioner (ANP) or advanced midwife practitioner (AMP), the nurse or midwife must be appointed and approved for a specific clinical post [8]. The ANP or AMP appointment follows a needs assessment, preparation of the clinical site, and accreditation of the site by the Nursing and Midwifery Board of Ireland (NMBI).

Ireland is one of the few countries currently requiring clearly defined documentation for both the development of the ANP/AMP along with the position and site where the ANP/AMP will be employed [20]. Both (post and ANP/AMP) are subject to regulatory body accreditation or oversight. The Nursing and Midwifery Board of Ireland (http://www.NMBI.ie) is the independent statutory body that regulates the nursing and midwifery professions in Ireland with its functions defined in the “Nurses and Midwives Act: 2011” [9, 10]. Over a 10-year period, 2001–2010, the NCNM (Nursing Council of Nursing and Midwifery) approved 154 Advanced Practice Posts and accredited 95 Advanced Nurse/Midwife Practitioners (ANP/AMP). In 2010, the Department of Health transferred the area of advanced practice from NCNM to An Bord Altranais, now referred to as NMBI (Nursing and Midwifery Board of Ireland). With the transfer from NCNM to NMBI, this agency now receives, reviews, and approves applications for the potential site for service delivery and for the ANP/AMP.

Documents provided to NMBI contain advanced practice role specification, job description, and site preparation details of the advanced practice posts. Site preparation includes criteria for the job title, title use, registration details, reporting relationships, location, background, and purpose of the post. In addition, documents must include a description of responsibilities for the ANP/AMP that cover clinical practice, level of autonomy, and practice expertise. The Director of Nursing of the clinical site seeking approval for the post presents information on post requirements, case load, and referral pathways to and from the ANP/AMP, scope of practice, working relationships, decision making autonomy, and competence maintenance. The Notary/Public Commission for Oaths notarizes documentation [4].

Standards and Requirements for Advanced Practice (Nursing) and Standards and Requirements Advanced Practice (Midwifery), based on the interim report WGAP 2014 [32], are due for publication later in 2016. In advance of this, NMBI has made a number of changes:

  • Established a new interim revalidation process.

  • All advanced practice forms have been reviewed and updated.

  • Guidelines for advanced practice portfolios have been updated.

  • Updated the guidelines in relation to advanced practice posts.

Expectations are that criteria for registration will change, specifically postregistration experience is being reduced. The issue of re-accreditation and portfolio development has been under review. The core concepts for advanced practice are also being extended. In the past the advanced practitioner could only work in a specific healthcare facility accredited by NMBI. This is likely to change, and a Registered Advanced Nurse practitioner will be eligible to apply to any healthcare facility they wish, i.e., approval of the post is now being separated from the person who is the ANP/AMP (K. Brennan, 21 May 2016, personal communication).

Begley et al. [3], in conducting a systematic evaluation of ANP/AMP in Ireland that also included a comprehensive literature review, emphasized that the complexity of identifying the distinctive nature of advanced practice should not be underestimated. Ireland, with nearly 20 years experience developing advanced nursing and midwifery roles, has taken the lead with a unique framework of dual credentialing and has also demonstrated the changes that take place following reassessment and evaluation of the initial regulatory process.

6.2 Credentialing

Credentialing processes and procedures refer to the mechanisms that officially regulate ANP and the individual APN. They include but are not limited to the assignment of degrees, authorization, endorsement, certification, licensure, accreditation, and registration. The methods chosen are usually connected to a country’s regulatory traditions and agency resources in addition to what level is determined to be necessary to authorize the nurse to work within a scope of practice for an APN but beyond the scope of practice for a generalist nurse. Agencies and government departments will likely develop criteria and procedures to meet the expectations and prerequisites of legislation, public health/ministry of health departments, and the public (Gardner et al. [7]). All of these factors contribute to the way ANP is defined, credentialed, and put into practice.

The final choices for regulating or credentialing APNs depend on the regulatory environment of the region, country, or setting developing the credentialing processes. The following issues should be considered:

  • Perceived potential and level of risk or harm to the consumer

  • Potential benefit to the consumer

  • Depth of specialized and advanced knowledge required

  • Skills and abilities needed for practice

  • Degree of autonomy expected of the role

  • Extensiveness of the defined scope of practice

(Based on NCSBN [21])

Section 6.2.1 defines credentialing terminology and describes methods to consider when establishing a credentialing process for the APN.

6.2.1 Accreditation, Certification, Licensure, Registration, Endorsement

Various approaches are considered relevant for APN regulation and credentialing processes. In addition, credentialing may involve several steps (e.g., certification + licensure + registration) before a nurse can be declared to have full authority to practice as an APN. Some of the commonly used mechanisms are described below [12, 14]:

  • Licensure: The use of licensure originates from the practice of creating standards for protection of the public [12]. Based on criteria of attaining a designated level of education and competency to practice within a defined scope, licensure is the most restrictive type of credentialing. Licensure grants the authority to practice. The validation processes to obtain the license ensures that the APN has met predetermined standards and is qualified to practice within a specified scope. It is generally used within a regulatory system that prohibits practice without a license.

  • Certification: A time-limited formal process (examination, portfolio, or panel review of the applicant by clinical experts) used to validate an individual’s knowledge, skills, and abilities. It can be voluntary or used as a requirement in the process to obtain an APN license. A nongovernmental agency or professional body usually conducts the process.

  • Registration: Registration is a system whereby an individual’s name is entered into an official register for persons who have specific qualifications. A register is maintained and monitored by a regulatory agency or official governmental department. If a country stipulates title protection for the APN, the person assigned the country designated title is registered as a method of identifying the APN. Registration is not a validation of competence and is usually the aspect of credentialing that requires renewal periodically for the APN to continue to practice.

  • Accreditation: A process of review and approval by a qualified agency whereby a program, institution, or particular service is granted time-limited recognition having met predetermined criteria and standards.

  • Endorsement: The use of endorsement as a requirement for entry into advanced practice stipulates criteria that must be met to be eligible for endorsement [1]. Criteria can include an unrestricted general nurse license, clinical leadership in a specified area, demonstrated competence, and completion of required qualifications as determined by an official regulatory agency within the country. Completion of the endorsement process authorizes the APN to function in an advanced clinical role (Australian Health Practitioner Regulation Agency/Nursing Midwifery Board Australia https://www.ahpra.gov.au/).

Regulatory terminology can mean different things in different countries leading to misunderstanding and misconception of the intent of the expressions. When assessing any one country’s credentialing system, it is necessary to confirm what is involved in becoming credentialed, including the rights and protections that it includes. One issue that arises in reviewing credentialing processes is whether professional associations, governmental agencies, or other regulatory entities should establish the professional regulatory mechanisms. In Thailand the Nursing Council is the certifying agent and the credentialing authority [29]. A joint approach has been adopted by South Korea. The Ministry of Health and Welfare is the credentialing authority and has appointed the Korea Accreditation Board of Education to conduct the certification examinations for the APN [17, 18].

Credentialing can be considered mandatory or voluntary based on the established standards and requirements for the APN in the country and/or region. An education program for APNs may design a competency based and outcome focused curriculum that includes methods that ensure that the APN graduate has passed an assessment of professional knowledge including concrete clinical skills and complex decision making relevant to their practice focus. Initial appraisal of competency can be assessed through methods such as written examinations, OSCE (objective structured clinical examination), portfolio, and self-assessment.

Continued competency can be assessed through recertification and other compulsory processes. Under these circumstances the requirements are considered mandatory. When competence maintenance is viewed as voluntary, credentialing is viewed as simply a professional responsibility. Section 6.3 discusses issues to bear in mind when defining competence maintenance for APNs.

6.3 Maintaining Competence

Maintenance of professional competency or competence maintenance is a lifelong process of documenting professional accomplishments and activities. Mandatory competency maintenance is often a requirement for relicensure and ongoing credentialing for healthcare professionals including APNs. However, it is not clear that systems or methods intended to validate continued professional competence are successful in their intent to equip healthcare professional to maintain competence and keep up with advances in practice [16].

A number of factors have been identified as contributing to an inadequate demonstration that competence maintenance ensures quality professional practices [16]. The limitations include:

  • Excessive reliance on lecture format and designated hours of learning rather than acquired knowledge or competence

  • Limited attention placed on individuals meeting learning needs through self-assessment and self-directed learning

  • Promotion of interprofessional collaboration or efforts to improve systems is weak

  • Inadequate assistance for practitioners who want to assess and improve practice

Traditionally, under the continuing education model, value is measured by time spent attending a course such as a standard classroom lecture, workshop, or online offering. Competence maintenance in a continuing competence model calls for valuing activities based on a variety of factors beyond time. This perspective can include traditional options but broadens the choices that could be considered for maintaining competence. The range of choices could include: participation in or conduct of research, writing for publication, mentoring of APN students, clinical instructor, in-service teaching, structured interactive activities (e.g., group study), simulation, and participation in leadership functions (e.g., Board and Committee work). A move to interdisciplinary offerings at conferences, courses, workshops, and online learning has increased the variety of choices available. Competence maintenance also includes verification that the APN is clinically current and competent through regular practice in an identified clinical setting that includes identified hours in that clinical practice [12].

Criteria for maintaining competence are commonly linked to the APN scope of practice and/or focus area, identified competencies, and certification/licensure requirements. The timing cycle (commonly 5–8 years), documentation of accomplishments, and audit is typically determined by the credentialing bodies/authorities. If a written examination, generally called a certification exam, is utilized for the initial competency assessment, there is usually an option to retake the written examination to maintain certification. Standardization of competency assessment and reassessment processes is believed to be fundamental to ensuring the credibility of ANP [22].

In 2004, the Nursing Council of New Zealand established a Continuing Competence Framework (CCF) [26] with the intent to provide a mechanism to ensure nurses are competent to practice their profession. The Council has the authority to decline to issue an annual practice certificate (APC) if the applicant has failed to meet the required standard. The standards of competence expect a healthcare practitioner to practice within their scope of practice. In New Zealand, the four legislated scopes of practice for nurses (including nurse practitioner) each have their own set of competencies and standards and are expected to:

  • Provide evidence of ongoing professional practice

  • Provide evidence of ongoing professional development

  • Provide evidence of meeting the Council’s stipulated competencies for nursing scope of practice [27]

After reviewing the issue of continuing competence, the Nursing Council of New Zealand (2010) concluded that standards for entry level nursing competencies are clear while those for continued competence are not. Based on this report, one recommendation is for the NCNZ to provide a clear and more comprehensive definition of competence maintenance and the status of self-declaration assessment and the evidence needed to validate accomplishments.

Conclusion

This chapter describes the significance of professional regulation and credentialing in establishing as well as supporting the legitimacy of advanced practice nurses within healthcare systems and the healthcare workforce. Examples of professional regulatory frameworks and models are provided to offer guiding principles to inform and facilitate development of standards relevant to advanced nursing practice. Healthcare reform and changes within nursing communities and the nursing culture are leading the way for an era of progressive change that promotes a maturing of the discipline. Notable progress continues to be made internationally in the development of professional regulation supportive of the emerging diversity in advanced nursing practice. In addition, countries with longer histories of experience with advanced nursing roles demonstrate that sustainability of advanced nursing practice is linked to professional regulation and standard setting. All of these events suggest a bright future for the discipline and for nurses working at an advanced level in providing healthcare services.