By Barbara Stevens Barnum, RN, PhD, FAAN

Article originally published August 13, 1997

Introduction

Licensure

Let's begin with licensure. A registered nurse (RN) or licensed practical nurse (LPN) sometimes called a licensed vocational nurse) — is individually licensed in a particular by testing that validates she/he has acquired the basic knowledge required for safe practice. Licensure does not purport to do more than that. The philosophy is one of protecting the client, public, from harm. This testing aims to eliminate those not qualified for minimal safe performance; it does not recognize exceptional performance (although the test is scored).

A nurse must be licensed in a state in order to work as an RN or LPN (barring special circumstances not to be elaborated here). The exams for these two levels are separate and distinct, as are the qualifications that must be completed before a candidate sit for the test. Licensure in general is a granted to the states, not the federal government. Of course, nursing has conveniently gotten around this fact by, among other things, creating the Council of State Boards of Nursing. This body has allowed for national uniformity in testing and related criteria (between and among states) while technically skirting the fact that each state is legally free to write its own licensure rules and examinations. This coordination has meant that a nurse could move from New Hampshire to Tennessee without the trauma faced, for example, by a lawyer making the same move. As a nurse who is old enough to remember the early insanities of each state having different requirements, I appreciate these efforts. I remember, for example, classmates who moved (even in my earlier days nurses were peripatetic), yet couldn't sit for licensure in the new state because their school program had offered 1,040 hours of psychiatric nursing instead of the 1,250 hours required in the new state. (Don't hold me to the hours, but the type of problem was typical.) The solution to such problems wasn't easy: the nurse would have to find some school willing to take him or her as a part-time student for more experience in the area judged inadequate. It was a numbers game of ultimate frustration that our present system avoids.

Historically, there have been few "hot" issues concerning licensure, at least since licensure became a fact. There always have been, of course, various arguments concerning what crimes and misdemeanors can cost one a license, as well as issues of who should or should not serve on the administrative boards. On the national scene, however, there have been few historical proposals to change who gets licensed for what.

RN licensure was well established in each state when I graduated and started working (circa 1958), but I can remember when there were still "waivered" LPNs, that is, people who worked as practical nurses but had not had the requisite education. As always happens in a situation of upgrading (in this case to licensure), there has to be some accommodation for those who get caught in the middle of such an historical change. So the waivered LPNs were given their licenses by the grandfathering mechanism. Employers, of course, knew who had earned the license and who was waivered, and sometimes waivered LPNs were paid less, and not all institutions hired them.

The Lysaught report (1981) by the National Commission for the Study of Nursing and Nursing Education, sponsored by the Kellogg Foundation, was another (almost) challenge to licensure. Lysaught and the Commission recommended two separate licenses, one in acute, one in distributive care. The Commission thought that nursing had grown too big for a single license (by this they meant that the total content of nursing had expanded beyond what could be contained in a single curriculum). The nursing profession decided to pass on that one, although the report looks more interesting now that we're in an era when much nursing delivery is moving out of acute, episodic care into what Lysaught called distributive care.

The next big fluff concerning licensure was — and still is twenty years later — the proposal to make two RN licenses, one for 2-year nurses and one for 4-year degree-holding nurses, with the latter credential bearing the label, "professional." This licensure change never came about for many reasons, one of which was the rigidity of the proposers who did not want to waiver in as "professionals," nurses who didn't then hold the 4-year credential. Ironically, if there had been a little more accommodation, by now most of those waivered RNs would be retired and the issue would be finished. Instead, we are still arguing the same issue in our professional organizations. No profession in the history of this nation, incidentally, has managed to bootstrap its credentials without using the waivering mechanism. I don't know why the advocates of "no waivering" thought nursing could be different. Anyone who can count could tell that the 2-license plan would not happen without waivering, as long as nurses without the 4-year degree outnumbered those with it.

Another perennial issue is that of institutional licensure. This proposal recommends that an institution be allowed to create its own job descriptions and license employees for them. The proposition has always been fought tooth and nail by nurses. (Not surprisingly, the proposal never suggests that institutional licensure apply to physicians, only to nurses and "lower level" personnel.) Fortunately, we live in an era when people no longer trust the beneficence of institutions, so perhaps institutional licensure as an issue is dead for a while.

The newest issue is that of licensure for the nurse practitioner, an issue which is steadily being settled, one state at a time, with a few states still being controlled by medical interests that hope to stop or restrain the inevitable nurse practitioner tide. (On this issue, don't move to California.) But, once again, because licensure is a state's right, the licensure requirements differ from state to state. Will we ever have a Council of State Boards of Nurse Practitioners? Who knows.

On the whole, because of our contrived uniformity from state to state, basic licensure (for RNS and LPNs) is relatively simple. This will be true until some state decides to lead a change, probably that of dividing RN licensure into two or more separate licenses (e.g., acute versus episodic,baccalaureate versus other, or some new proposal on the scene). As to issues, the practitioner license is evolving, at different speeds and with different rules, from state to state; but essentially, the movement has been toward giving practitioners more extensive authority and more power to work independently of physicians. Some states, such as New Jersey, extend relatively comprehensive powers to all advanced practice nurses (clinical nurse specialists and nurse practitioners).