nursing's concerns: credentialing proposal

Nursing’s concerns:

credentialing proposal

Anne Zimmerman, RN

Anne Zimmerman, RN, is president of the American Nurses’ Association, and executive administrator of the Il- linois Nurses’ Association. A graduate of the Sisters of Charity of Leavenworth School of Nursing, Helena, Mont, she presented this paper at “The impact of credentialing on OR nurses” educational session during the 1977 AORN Congress in Anaheim, Calif.

The federal government is concerned with monitoring the quality of practice of the health care services. Recently, the US Department of Health, Educa- tion, and Welfare (HEW) issued a Proposal for Credentialing Health Manpower.’ I want to share with you what the American Nurses’ Associ- ation (ANA) perceives to be the implications of HEWS credentialing proposal for the nursing profession. I will focus on four areas of concern:

0 the role of the federal government in credentialing health manpower

0 the health occupations affected by HEWS credentialing proposal

0 the proposed composition and functions of the certification commission

0 the role of the American Nurses’ Association in credentialing nurs- ea .

In November 1970, Congress au- thorized the HEW secretary to submit a report identifying the major problems associated with licensure, certification, and other qualifications for practice or employment of health personnel. This congressional mandate resulted in the publication of a Report on Licensure and Related Health Per- sonnel Credentialing in 19712 and a follow-up report on Developments in Health Manpower Licensure in 1973.3 Both reports were reviewed by ANA, and nursing’s concerns were shared with HEW.

HEWS Proposal for Credentialing Health Manpower, published in June 1976, is important in that it points to the need for consistency in requirements and regulations for health manpower and the need for a careful review of manpower demands and re- sources. The newly revised version of this proposal reflects some attention to the concerns voiced by the nursing community and other profession^.^

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financing programs . . . the health

Concepts supported by ANA

professional would have to be either licensed or certified by a board or organization that adhered to na-

ANA supports several basic concepts tional standards developed by (the reflected in the credentialing proposal of the certification cornmis~ion).~ US Department of Health, Education, and This federal involvement was Welfare.

The establishment of a commission responsible for recognizing certifying bodies, which in turn would certify individuals, could be a desirable alternative to state licensure for those health occuDations in which Dractitioners are not licensed or in those occupations where a variety of entry credentials are required in different states. Before enacting any legislation that would license additional categories of health manpower, states should consider the impact of a newly licensed category on the statutory and administrative authority and scopes of practice of previously licensed categories in the state. Additional studies of the best mechanisms to assure continued competence should be supported on a high-priority basis by health occupations, professional organizations, state agencies, and the federal government.

However, the proposal still contains major areas of ambiguity that cause continuing concern for the nursing profession.

Role o f federal government in credentialing health manpower. When the credentialing proposal was first intro- duced, it was recommended that the certification commission include representatives of the federal government. Furthermore, the original report recommended:

If it were determined that a service should be rendered by a properly trained and experienced health professional to qualify for reimburse- ment under federal health care

strongly opposed by nursing as well as other groups. As a result, the revised proposal recommends that the federal government not hold membership or have any vote in the decisions and policies of the commission. The proposal does suggest that limited federal assistance should be made available for activities to promote the establishment of the commission.

Equally important as the proposed role of the federal government in HEWS proposal is the explanation of the growing interest of the federal government in the credentialing of health manpower. The report em- phasizes i t is important that the federal government be represented in a liaison capacity “because of the sub- stantial interest of the federal government in the quality of health services, generally, and particularly as an employer of allied health occupations, a sponsor of allied health training, and the principal payer for services in the Medicare and Medicaid programs.”s Moreover, as pointed out in the introduction of the proposal:

The rapidly rising expenditures for health services will inevitably lead to closer examination of health manpower regulation by agencies involved with restraint of trade, an- titrust, civil rights, and other legal issues, as well as by the C o n g r e s ~ . ~ The underlining implication seems

obvious-if health professions and occupations do not assume responsibility for development and implementation of effective credentialing measures, the government will. For this reason,

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Nursing not included in allied health definition Nursing clearly is not included in the term “allied health fields.” Harris S Cohen made this announcement at the AORN Congress program “The impact of credentialing on OR nurses.” &hen is chairman of the subcommittee on health manpower credentialing of the Public Health Service, US Department of Health, Education, and Welfare (HEW), which issued the controversial A Proposal for Credentialing Health Manpower in 1976.

Anne Zimmerman, president of the American Nurses’ Association (ANA), a speaker at the same program, expressed her surprise and pleasure at the announcement. She stated, as late as February of this year at a meeting on the credentialing proposal, when a definition of allied health occupations was called for, “it was not clear whether it was the intent to include or not to include nursing in that definition.” She attributes the victory for nusing as a result of a discussion of the definition raised by her and Faye Abdellah and a letter to James M Dickson Ill, MD, acting assistant secretary of health, HEW. Abdellah is special assistant to the undersecretary of HEW and director of the office of nursing home affairs and chief nurse officer, Public Health Service.

unexpectedness of Cohen’s announcement makes it “important to be constantly in communication with Dr Cohen and with the other people who are proposing and responding to some of the suggestions and protests we and others are making.”

According to Zimmerman, the

Cohen also made known further revisions to the revised proposal. On the subject of certification, Cohen noted that the government was talking about a national certification system as opposed to a federal certification system. He said that the federal government would at best be an observer or maintain liaison status with the proposed National Certification Commission. It would not want or recommend formal membership, voting or otherwise.

Rather than embracing all of the health fields, the revised report limits coverage to “just allied health fields,” Cohen said. It was at this point he stated the definition does not include “fields such as medicine or nursing.”

The second major recommendation-the national standards recommendation-has also been further revised. The original report caused misunderstanding or confusion because it was misinterpreted to mean that the federal government would actually be writing and formulating standards for all the health fields, according to Cohen. “That was not our intent,” he said. Instead, the intent was that the federal government would act as a convener in bringing together the parties necessary to develop standards. “In the revised recommendation, even that federal rde has been deleted,” he stated.

Cohen commented that the latest revision of A Proposal for Credentialing Health Manpower is in the hands of HEW Secretary Joseph Califano, who is expected to release it as an HEW report.

ANA has given thoughtful consideration to the HEW proposal, which, in effect, would serve as a guideline for a voluntary system of credentialing health manpower. While ANA supports several basic concepts reflected in the credentialing report, a closer examination of the proposal reveals several shortcomings.

Health occupations affected by credentialing proposal. The greatest area

of ambiguity in HEWS credentialing proposal is its failure to define “the allied health occupations,” “the selected health occupations,” and “the appropriate categories of health manpower,” which are addressed in the six recommendations of the proposal. We recognize the difficulty of identifying precise occupations subject to the proposal in light of the rapid emer- gence of occupations. However, the ab-

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t is unclear I what type of standards are being proposed.

sence of some type of definition poses significant problems.

Recommendation one proposes to establish a broadly representative national certification commission responsible for performing various functions for allied health occupations. Accord- ing to the House subcommittee on health and environment, which com- piled a discursive dictionary of health care in 1976, the term “allied health personnel” has no constant or agreed- upon detailed meaning. Sometimes, the term is used to denote specially trained (and when necessary) licensed health workers other than physicians, dentists, podiatrists, and nurses. Sometimes, the term is used synony- mously with paramedical personnel. The term is also used to mean all health workers who perform tasks that otherwise must be performed by a physician. Other times, the term is used to refer to health workers who do not usually engage in independent practice.6

The implications for nursing should be obvious. Should allied health occupations, for example, be defined as “all health workers who perform tasks that otherwise must be performed by a physician,” nurses would be catego- rized as allied health personnel. It would appear as though this definition was employed by HEW in its 1971 report when observation was made:

One of the most promising ways to

expand the supply of medical care and to reduce its costs is through a greater use of allied health personnel, especially those who work as physicians’ and dentists’ assistants, nurse pediatric practitioners, and nurse midwives. Such persons are trained to perform tasks which must otherwise be performed by doctors themselve~.~ The significance of this point be-

comes more apparent when the composition and primary functions of the proposed certification commission are reviewed.

Proposed composition and functions of the certification commission. Rec- ommendation one calls for a national, nonfederal certification commission composed of representatives of (1) certifying bodies, (2) professional organizations, (3) state agencies, (4) employers, and (5) consumers. According to the HEW proposal, “By assuring participation of a variety of involved and affected interests, policy decisions would more adequately reflect the public interest.”1° The nature of these policy decisions is addressed in recommendations one and two.

It is proposed in recommendation one that the certification commission develop and evaluate criteria and policies for the purpose of recognizing and monitoring bodies certifying allied health personnel. Attention should also be drawn to the following state-

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ment included in the explanation of recommendation one, which speaks to an even broader long-range goal:

While the commission would be concerned exclusively with allied health categories, other health occupations are urged to assist in the work of the commission. Eventu- ally, other health categories may voluntarily seek recognition by the commission for appropriate certification functions. This long-range goal would provide for greater consistency in credentialing policies in

It is proposed in recommendation two that the certification commission develop and evaluate national standards pertaining to the entire range of credentialing mechanisms-including examinations, training requirements for practice, continued competence, re- licensure, and disciplinary functions. These standards are to be developed for selected health occupations. I t is unclear which health occupations could be subject to standards developed by the commission. However, it is apparent from reading the explanation of the recommendation that a number of health occupations could fall into the selected category. For example, the statement is made that:

Even in those health occupations that have made much progress in fostering the adoption of uniform standards by means of national examinations, there are still important areas of credentialing requirements that lack this uniformity.’* ANA seriously questions whether a

broadly representative body should assume responsibility for dictating specific standards for a variety of health occupations. It is stated in recommendation two that the function of developing uniform standards for a range of related occupations and levels

the health professions . . . . 11

of competence should be performed by clusters of related occupational categories and not by a single profession or organization. In addition, state licensing bodies as well as certifying agencies and consumer participation should be involved in the process. The proposal also states, “It is particularly critical that employer representatives participate fully in this process to ensure that the standards developed are practicable and responsive to the unique characteristics of certain re- gions or facilities without compromis- ing quality services.”13 Since 1973, ANA has advocated consumer involvement. However, nursing’s experi- ence with regulatory bodies dominated by medicine, hospital administrators, and other health professions makes nursing leery of this aspect of the proposal-logical though it may sound.

It is somewhat unclear what type of standards are being proposed. Are they practice and education standards? Are they standards related to disciplinary action? Are they standards related to the licensure process? It is naive to expect such a voluntary commission to set standards for licensure and to expect the state licensing bodies to take such standards into account.

It is ANA’s belief that each profession must attain certain rights and privileges that cannot be mandated by members of another occupation or profession. One such right is to define and describe its scope of practice, standards and requirements for tha t practice, and a code of ethics for its practitioners.

There is considerable difference in the degree to which the various occupations and professions have attained and exercised these rights. This does not negate the fact that the rights exist, nor does i t follow that those occupations or professions that are in-

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he nursing profession needs T a common approach to certification.

creasingly exercising these rights should be restrained because they lack interprofessional uniformity. Unifor- mity could well restrict the ability of a profession to respond to new knowledge in the health field, new roles as they evolve in response to new knowledge, or the entrance of a new occupation or profession better able to im- plement new knowledge.

It is also ANA’s belief that the professions that have delineated their scope of practice, established standards of practice and education, and developed a code of ethics must be responsible for defining and documenting the proficiency of its practitioners through appropriate mechanisms.

Lastly, it is the belief of the Ameri- can Nurses’ Association that the role of the federal government should be to provide support and consultation that will (1) assist occupations and professions to identify and exercise these rights and (2) assist the professions to study and describe new educational and practice standards so the health and illness needs of people may be served. As one of the first health professions to be responsive to the 1973 HEW suggestion regarding mandatory continuing education, nursing is most interested in federal policy regarding the facilitation of research on the rele- vance of continuing education activities for continued competence as well as other measures of competence.

What are the implications of recommendations one and two for nursing? In August 1976, during an invitational meeting regarding the development of a national commission for health credentialing agencies, representatives of ANA, the Association of Operating Room Nurses, and the National League for Nursing voiced support of the concept of unlicensed occupations seeking an overall structure to approve certifying bodies. However, at that time, the opinion was expressed that nursing did not see it- self participating in a structure primarily concerned with certification for entry into an occupation. This response was based on the fact that nursing has already achieved a common standard for credentialing entry into nursing practice.

HEWS proposal for a broadly representative national commission responsible for setting standards for various health personnel poses a dilemma for the nursing profession. On the one hand, if nursing becomes a part of the commission, decisions regarding nursing standards could be made by a group representing related occupations, certifying bodies, state agencies, employers, and consumers-with nursing having no greater voice than any other representative. On the other hand, if nursing does not become part of the national commission, standards for occupational groups that impinge

1366 AORN Journal, June 1977, Val 25, No 7

on nursing or are part of nursing personnel will be developed without nursing’s input. In either instance, the result could be a lowering of nursing standards. Arriving at a consensus as to what are appropriate standards across health occupations is apt to in- volve compromise that could lead to lower standards than now prevail in some health occupations.

It is the belief of the American Nurses’ Association that the nursing profession, working through the professional association, must retain responsibility for developing and im- plementing necessary standards. Soci- ologist Robert Merton has pointed out, “Only the informed professionals can know the potentialities and not merely the current realities of professional practice.”14

Standard setting in nursing was launched with the formation of the American Nurses’ Association in 1896. The development of standards-ethical standards, educational standards, practice standards, service standards-has been a long, complex process, which has stretched over the span of some 80 years.

The loss of autonomy for nursing that can be seen in the long-range effects of the credentialing proposal is alarming. Nursing has always been hampered by various groups who felt ready and able to identify what nursing should be. To agree to joint deci- sion making on nursing standards at this point in nursing’s history would be a significant step backward.

In light of HEWS credentialing proposal, it is essential that the nursing profession collectively determines to what extent it wants to be involved in the credentialing of other health occupations. Moreover, i t is crucial that nursing organizations explore the potential consequences should indi-

vidual groups within nursing decide to participate in the proposed certification commission. There is a need for the nursing profession to have a common approach to certification, including a common definition and criteria, to the degree this is possible. Any difference in approach to certification should be based on the nature of the knowledge and theory development in the specialty areas.

Licensure and competency measures. HEW’S proposal for credentialing health manpower also explores the effectiveness of existing licensure boards and competency measures.

The HEW proposal recommends that states should entertain proposals to license additional categories of health personnel with “caution and delibera- tion.” In doing so, such questions as, How will the newly licensed category impact upon the statutory and administrative authority and scopes of practice of previously licensed categories? should be investigated. This recommendation deserves consideration by states to avoid further proliferation of licensed professions and occupations in the health field. However, the composition and source of funding for the independent review mechanism sug- gested in the recommendation should be studied carefully and clarified.

ANA is cognizant of trends in soci- ety that challenge the traditional purpose of licensure and imply that the current licensure system is inadequate to deal with the complex issue of continued competence in practice. How- ever, it should be pointed out that the licensure problems of one health occupation are not necessarily the same for other groups. Nursing, for instance, permits licensure by endorsement, reciprocity, and examination in all states, thus eliminating the geograph- ic mobility problem. In addition, the

1368 AORN Journal, June 1977, Vol25, No 7

fact that all states have used the State Board Test Pool since 1946 has resulted in a reasonable degree of uniformity in the preparation of nurses throughout the country.

The HEW credentialing proposal ig- nores, or fails to understand, that a profession has a responsibility to police its practitioners and to work for high-quality performance. The burden does not rest with the licensing authority alone. Joint effort is required.

It is the contention of ANA that individual licensure coupled with the initiation of such measures as peer review and certification of excellence and the encouragement of participation in continuing education activities will collectively provide a valid tool by which to monitor nursing competency.

Role of ANA in credentialing nurses. I have already alluded to the role of ANA in the credentialing of nurses. Throughout its 80-year history, ANA has fostered and supported the basic principle of accountability of all health care practitioners to provide care that is of a high standard and available and accessible to all Americans at a reasonable cost. Effecting improvement in quantity and quality of nursing care has been a constant challenge facing nursing and ANA. The activities of the association represent an intensified effort to define nursing’s responsibilities in the delivery of health care and to provide mechanisms by which to evaluate nursing performance and im- prove nursing practice.

The next biennium will be critical for the nursing profession to achieve its rightful place as an active partici- pant in health policy development at all levels of government. The evolution of a coherent credentialing system is an essential aspect of accountability of nurses for the quality and quantity of nursing care being provided to the

public. Consequently, in January of this year, ANA announced the award of a $410,835 contract to the School of Nursing a t the University of Wis- consin in Milwaukee to conduct a comprehensive 22-month study of credentialing in nursing. Inez Hinsvark has been named the project director.

The initiative for the study grew out of action by ANAs House of Delegates in 1974. The study was launched in September 1976 after two years of pre- liminary planning and in response to recommendations from three invitational conferences sponsored by ANA. Participants to these conferences were selected from the nursing profession, governmental agencies, other disci- plines, and public members with ex- pertise in the area of credentialing. Based on recommendations made at these conferences, the credentialing study will (1) assess current credentialing mechanisms in nursing, including accreditation, certification, and licensure, and where indicated suggest ways for increasing the effectiveness of credentialing, and (2) recommend fu- ture directions for credentialing in nursing.

All current aspects of credentialing in nursing will be addressed, including accreditation of basic, graduate, and continuing education; accreditation of organized nursing services; certification; and laws that regulate the practice of nursing. ANA is the sole sponsor of the study. A significant role has been identified for other nursing organizations, designated as cooperat- ing agencies, and for state nurses as- sociations in the implementation of the study.

Conclusion. Although the American Nurses’ Association supports several basic concepts in the Proposal for Cre- dentialing Health Manpower issued by the US Department of Health, Educa-

1370 AORN Journal, June 1977, Vvl25 , N o 7

tion, and Welfare, it believes some areas need further study. ANA believes each profession must attain cer- ta in r ights and privileges tha t cannot be mandated by members of another occupation or profession, eg, the right to define and describe i t s scope of practice, standards and requirements for that practice, and a code of ethics for i t s practitioners. Further, those professions that have delineated these r ights must be responsible for defining and documenting the proficiency of i t s practitioners through appropriate

Notes 1. Subcommittee on Health Manpower Cre-

dentialing, Public Health Sewice, A Proposal for Credentialing Health Manpower (Washington, DC: US Department of Health, Education, and Welfare, 1 976).

2. US Department of Health, Education, and Welfare, Report on Licensure and Related Health Personnel Credentialing (Washington, DC: US Government Printing Office, 1971).

3. US Department of Health, Education, and Welfare, Developments in Health Manpower ticensure (Washington, DC: US Government Print- ing Office, 1973).

4. Subcommittee on Health Manpower Cre- dentialing, Public Health Service, Credentialing Health Manpower (Washington, DC: US Depart- ment of Health, Education, and Welfare, 1977), revised proposal.

5. Subcommittee on Health Manpower Cre- dentialing, A Proposal for Credentialing Health Manpower, 5.

6. Subcommittee on Health Manpower Cre- dentialing, Credentialing Healtb Manpower, 10.

7. lbid. 5-6. 8. Subcommittee on Health and Environment,

Committee on Interstate and Foreign Commerce, US House of Representatives, A Discursive Dic- tionary of Health Care (Washington, DC: US Gov- ernment Printing Office, 1976) 6.

9. US Department of Health, Education, and Welfare, Report on ticensure, 49-50.

10. Subcommittee on Health Manpower Cre- dentialing, Credentialing Healtb Manpower, 9.

11. /bid, 11. 12. /bid, 14.

14. Robert K Merton, “The functions of the professional association,” American Journal of Nurs- ing 58 (January 1958) reprint, 3.

mechanisms. 0

13. lbid, 15-16.

Accident mortality in childhood “Fatal accidents met by children must not be accepted as inevitable, and effective preventive measures can lead to improvement,” is one conclusion of a study on Accident Mortality in Childhood in Selected Countries of Different Continents. The study is published by the World Health Organization (WHO).

Children studied were divided into boys and girls in age groups, ages 1 to 4, 5 to 9, and 10 to 14. Types of accidents were classified as motor vehicle and other transport accidents; accidental poisonings; accidental falls; accidental drowning and submersion; accidents caused by firearms, machinery, and hot substances; and “all other accidents.”

Accident mortality rates vary considerably from country to country. The study suggests that the proportion of the accidental mortality rate to the total mortality rate of a country could be an indicator of its socioeconomic and industrial development. In many countries, motor vehicle accidents are responsible for high accident mortality rates. Their proportion is particularly high in the industrial countries.

drownings rank second among causes of accidental deaths. Fatal accidents resulting from fires also rank relatively high-7% for boys and 10% for girls in the 1 to 4 age group. However, differences are observed between the high averages in the Americas and considerably lower averages in Europe, Asia, and Oceania.

Accident mortality rates decline with age, especially for girls. However, during the period of investigation (1 950 to 1971), the death rate for children 1 to 4 years of age dropped by 15% for boys and 19% for girls. In Europe, there was an average increase for both sexes in the age group 5 to 14 years, with the increase higher for girls than for boys. In Europe, accident mortality rates, mainly due to motor vehicle accidents, rose sharply for both boys and girls in the age group 10 to 14 years.

In almost all countries, accidental

1372 AORN Journal, June 1977, Vol25, No 7

nursing's concerns: credentialing proposal

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