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Return to table of contentsAlthough the NCSBN has advocated for the standardizedtesting of NPs through a single licensure or certificationexam, currently neither state nor nursing certificationorganizations require it. In fact, the present regulationsituation for NPs permits them to choose which of twocertification organizations will write and administertheir primary care specialty exam (adult, pediatric,gerontological or family). As discussed below, pass ratesbetween the two competing certification organizationsdiffer significantly, and raise important questions withregard to the assessment of NP competence.Adding to the confusion regarding specialty NP certification,some nursing specialties and competingcertification organizations started trademarking thenursing titles that those who passed their exams mightuse—distinctions meaningless to the public and so far,it appears, ignored by the NCBSN. This plethora oftrademarked titles does nothing more than provide anarray of potential credentials an NP may add after his orher name. While nursing specialty interests create evermore specialized certification categories and titles, statenursing boards have set their own rules about whichtitles NPs can legally use in their respective states. 175As of February 2008, the NP titles that NCSBN recognizesare as follows 176 :• Advanced nurse practitioner (ANP)• Advanced practitioner of nursing (APN), which alsoapplies to other kinds of advanced practice nurses• Advanced practice professional nurse (APPN), whichalso applies to other kinds of advanced practice nurses• Advanced practice registered nurse (APRN), whichalso applies to other kinds of advanced practice nurses• Advanced registered nursing practitioner (ARNP),which also applies to other kinds of advanced practicenurses• Certified nurse practitioner (CNP)• Nurse practitioner (NP)Many states, however, allow NPs to use (whether ontheir name badges or prescription pads) the particulartitles conferred in the following specialties for whichthere are specialty-specific certification exams:• Adult nurse practitioner (ANP)• Adult health nurse practitioner (AHNP)• Adult oncology nurse practitioner (AONP)• Family nurse practitioner (FNP)• Gerontological nurse practitioner (GNP)• Pediatric nurse practitioner (PNP)• Women’s health nurse practitioner (WHNP)Most states, including New York, require specialtycertification to ensure that NPs restrict themselvesto a certain practice area. Applicants for certificationmust prove they have met the appropriate educationalrequirements for the specialty track they selected intheir NP program. An ANP certification would imply,for example, that the nurse had completed the adult NPcurriculum at his or her school.Subspecialties for which it appears there are no specificnational certifying exams are college health, emergencydepartment, family planning, neonatal and schoolhealth. Nevertheless, New York, for example, recognizesthe NP specialties of college health, school health andneonatology, even without a national specialty certificationexamination for any of those tracks. 177Licensure examinationTo become licensed as a physician in the United States,graduates of medical and osteopathic schools mustpass either the U.S. Medical Licensing Examination(USMLE) or the Comprehensive Osteopathic MedicalLicensing Exam (COMLEX). Both standardized examsinvolve three separate occasions of one- and two-daytesting, hundreds of questions designed to sequentiallyassess the examinee’s knowledge of basic science andclinical skills, and supervised clinical interaction.Moreover, following completion of full-time medicalresidency training, physicians sit for separate exams toattain specialty board certification. This separate testingconsists of either one or two days of written examination,and may also include oral examination by experiencedphysician specialists.175. Web. NCSBN Fact Sheet, “Regulation of Advanced Practice Nursing.” According to an NCSBN staff member, there is no date on this PDF documentbecause it is continually updated. www.ncsbn.org/Regulation_of_Advanced_Practice_Nursing.pdf. Retrieved March 8, 2008.176. Id.177. Web. New York State Education Department, Office of the Professions. License Requirements: Nurse Practitioner. www.op.nysed.gov/np.htm. RetrievedApril 1, 2008.Scope of Practice Data Series: Nurse practitioners • VI. NP specialty certification36
Return to table of contentsIn contrast, the standardized licensing examination forall nurses, including NPs, is the NCLEX-RN. Nurseswith all levels of education, from associate degree RN-ADNs and diploma RN-DIPs to BSN and MSN nurses,sit for the same NCLEX-RN upon attaining their initialnursing degree, regardless of whether it is a diploma ora master’s degree. The six-hour NCLEX-RN exam consistsof 265 questions administered in a computerizedformat. Upon successfully passing the exam, the examineecan officially assume the title of “registered nurse,”or “RN.” Amazingly, as stated above (and as called forby the NCSBN), NPs are not required to take a second,separate standardized licensing exam. This is despitethe fact that their scope of practice, which may includepatient diagnosis and prescribing without physiciansupervision, is vastly different from the scope of practicefor a non–advanced practice, or staff, nurse. Most states,however, do require NPs to obtain national certificationin a nursing specialty to perform NP duties within thatspecialty.NP specialty certification and recertificationThe nursing certification process requires initial examinationand subsequent maintenance of certification.As noted earlier in this module, NPs have the convenienceof choosing between at least two initial certificationexams for each NP primary care specialty. Whilerequirements to sit for the exam and the exam formatare comparable for each of these two initial exams,exam content and pass rates differ significantly. Publicconfidence in the ability of NPs to deliver quality, safehealth care is compromised by the NP profession’s reluctanceto administer uniform, standardized licensure orcertification testing for NPs.All NP exams follow the same standard format. TheseNP specialty certification exams consist of 150–200multiple-choice questions administered over the courseof nearly three hours. Examination content, however,varies not only by specialty, but also within specialty bydesign of the nursing organization writing and administeringthe exam.No state or nursing certification organization requiresNPs to have completed postgraduate clinical training,where the knowledge and skills of the new graduateare subsequently reinforced through supervised clinicalinteraction and successive degrees of responsibility fordirect patient care. In fact, states and certification organizationsdo not require any significant clinical patientinteraction beyond the minimum 500 hours of clinicalrotations required during the NP graduate program ofstudy. Notably, this is in direct contrast to the type offull-time residency training physicians undergo aftermedical school, where they receive comprehensive andsystemic education and training on all aspects of humanphysiology, pathology and therapeutic intervention.Requirements for the maintenance of NP specialtycertification are relatively minimal. NPs can waivere-examination merely by demonstrating 1,000 hoursof professional practice over the five-year certificationperiod. With one half-day—four hours—clinic a weekover a five-year period, NPs presumably maintain theircompetency, keeping current with advanced practicenursing developments and concepts. Additional requirementsfor recertification include approximately 15 hoursof continuing education per year. For comparativeillustration, primary care physicians (internists, familyphysicians, pediatricians and geriatricians) board-certifiedin their specialty cannot waive recertification by examination(unless grandfathered in by the specialty board),and maintain their specialty certification by passinga recertification examination every seven to 10 years,depending on the specialty. In addition, physiciansmust complete additional self-study and assessmentas required by their specialty, as well as earn at least50 hours of continuing medical education annuallyto maintain state licensure.Standards for certifying bodiesStandards for certification programs for professionalswere not established until 1987, when the NationalOrganization of Competency Assurance createdthe National Commission for Certifying Agencies(NCCA). NCCA accreditation of any certificationprogram lasts for five years. 178 NCCA promulgatesstandards for certification organizations to follow.These standards relate to (1) purpose, governanceand resources, (2) responsibility to stakeholders,(3) assessment instruments, (4) recertification, and(5) maintaining accreditation. 179178. Web. National Organization for Competency Assurance. National Commission for Certifying Agencies standards. www.noca.org. Retrieved March 2008.179. Id.Scope of Practice Data Series: Nurse practitioners • VI. NP specialty certification37
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