Barnum describes the "hot issue" around licensure as the proposed variety of new licensures suggested, but never approved, especially around entry to practice. This difference has been hampered, she says, by the rigidity associated with waivering or grandfathering of present RNs. I'm convinced, as Barnum, that this change will not be reached by consensus without grandfathering as long as associate degree and diploma nurses outnumber the baccalaureates for entry positions, as they will surely continue to do through several decades.

With the massive reforms in health care delivery and market forces in search of efficient and productive quality outcomes, employers care more for needed competencies than the breed, hybrid, degree or credential. Lindeman recently asserted the entry to practice as the single most divisive "wedge" issue for the profession.

My sense is that the "entry" issue will soon be replaced with the next "hot issue": models of workforce patterns and differential practice abilities across and within disciplines. The professional entry has changed over time, with added complexity and knowledge, and will likely continue to do so. More importantly will be the issue of how each discipline's preparation, including differential levels within the nursing profession, contribute uniquely and efficiently to the productive workforce team. What do you think?

Changes in health reform, driven by financial pressures for efficient practice with respectable outcomes, will drive the profession to new levels of differential practice, preparation and competence. Licensure, accreditation and credentialing processes should be collaboratively transformed and linked to accommodate this differentiation.

Most agree that the marketplace is forcing us to think differently about tomorrow's practice and to re-engineer how we prepare nurses for these new and emerging ways of practice. Along with these changes will come the cessation of our stale obsession with counting content and process based on disease models of caretaking for institutionalized sick individuals. Outcome measures of competency for different levels of practice with different populations will be the new day ... for licensure, accreditation and credentialing.