State Regulations for the Pediatric Nurse Practitioner in Acute Care

Legislation and NP practice 

The increasing growth of the NP role met with considerable resistance as the physician shortage came to an end in the 1970s. As NPs began to compete with physicians for jobs, barriers to NP practice were implemented. Each state legislative body devised regulations for NP practice that were housed in either the Board of Nursing or the Medical Board. Attempting to both restrict independent NP practice and protect the unique practice of MDs, each state legislature struggled with determining the scope of NP practice in their state. Some states initially allowed independent NP practice (without MD supervision); other states insisted on a “collaborative practice agreement” that required NPs to have a designated MD supervising their practice. As the NP scope of practice expanded and the education advanced from a 3-month postgraduate program to a 2-year master’s program, NPs realized the need to prescribe medications, order laboratory work, and admit patients to the hospital. Each state developed different regulations governing these aspects of advanced practice. Some states allowed the NP wide discretion in providing patient care, whereas others were quite restrictive in the role that an NP was allowed to play in health care. Prescriptive privileges were a particularly contentious area, and only in 2006 did all of the states finally allow prescriptive privileges for NPs (Mazacoufa, 2006).

The ability of NPs to provide care for patients at an advanced practice level was challenged in the courts. It was not uncommon in the 1980s and 1990s for an NP to be charged with “practicing medicine without a license.” Fortunately, state regulations for NPs were written to encompass NP skills within the definition of advanced practice nursing. Although their skills mirrored traditional physician practice, NPs were providing nursing care.

At the same time, research studies were undertaken to examine the cost-effectiveness and safety of NP practice. Study after study demonstrated that NPs provide safe, high-quality health care on a par with physician care (Donald and McCurdy 2002, Hopkins et al 2005, Mundinger et al 2000a, Mundinger et al 2000b). Many studies further demonstrated that patient satisfaction with NP care matched and often exceeded satisfaction with physician care (Byrne et al 2000, Mundinger et al 2000a, Robin et al 2004).

The development of the acute care NP 

In response to limits placed on hours that physician residents could practice and economic factors that increased the costs associated with the care of the acutely ill, NP practice evolved once again to provide an answer to health care shortages (American Nurses Association & American Association of Critical-Care Nurses, 1995). NP practice expanded into critical care units, emergency departments, and specialty hospital practices to meet the shortages created by these economic and professional trends.

PNPs were part of this expansion of the NP role in the late 1990s. The PNP in acute care (PNP-AC) was developed to extend the role of the primary care PNP. Changes in practice necessitated a change in the education of PNPs to accommodate the demand for PNPs with the knowledge and skills necessary for acute care practice. In support of this new role, the National Association of Pediatric Nurse Practitioners developed a “Scope of Practice” document for the PNP-AC (NAPNAP, 2004). Concurrently, the National Organization of Nurse Practitioner Faculties (NONPF, 2004) developed competencies for all NPs in acute care. These competencies provided a working outline of national, consensus-based, core competencies that graduates of acute care programs should possess.

The acute care PNP 

Acute care PNPs provide care “to meet the specialized physiologic and psychological needs of patients with complex acute, critical, and chronic health conditions including the recognition and management of emerging crises and organ dysfunction and failure” (NAPNAP, 2004). Acute care PNPs function in a variety of settings where they provide care to children with complex physiologic conditions and rapidly changing clinical conditions (Pediatric Nursing Certification Board [PNCB], 2003). There is confusion between the acute care title and the perception that all PNPs who work in a hospital setting should be educated and certified in acute care. Often the primary care PNP is viewed as a practitioner whose role encompasses only anticipatory guidance and immunizations for well children. Yet, there are many PNPs providing primary care to an acutely ill or chronically ill population that needs broadly focused primary care skills. The concept of “acuity” helps to differentiate the knowledge, skills, and abilities necessary to meet the changing nature of the role. The PNP-AC works with children who have a high level of acuity; the PNP in primary care generally works with children who have a much lower acuity level. Additionally, the skill set required for the PNP-AC role is generally more invasive than the skill set commonly practiced by the primary care PNP. For example, depending on the specialty area of practice, an acute care PNP may insert or remove chest tubes, perform lumbar punctures and bone marrow aspirations, or tap a ventricular shunt (Fabrey & Cogdill, 2003).

Certification and regulation 

Practice and education should shape certification, licensure, and regulation. In response to this new role (which requires a different set of competencies, skills, and educational requirements), a new certification examination was designed to confirm the competency of these new PNPs. The PNCB developed a new psychometrically sound and legally defensible examination. After months of consultation with expert acute care practitioners and educators, the Acute Care Nurse Practitioner Examination was tested and ready for distribution. In January 2005 the PNCB offered the first certification examination for the PNP-AC, the only certification examination currently available for PNP-ACs. The PNCB reviews programs that have met guidelines established by the AFPNP. Only PNP-AC graduates of programs that were favorably reviewed are eligible to take this examination (Pediatric Nursing Certification Board 2006a, Pediatric Nursing Certification Board 2006b). The PNCB certification examination can reliably confirm that the PNP working in acute care meets the core and specialty acute care competencies developed by NONPF that address the areas within the scope of practice as outlined by NAPNAP.

The next step in the formal acceptance of a new role is the development of state regulations that outline the requirements for entry into practice. Because each state has different interests in this area, a survey of states was undertaken to determine the existing requirements for the licensure of PNP-ACs.

Method 

Practice chairs, executive directors, or both, from each state and the District of Columbia (n = 51) were contacted by e-mail or phone and asked the following questions:

Each state Board of Nursing was initially contacted between January 2004 and August 2004, with ongoing communication continuing with undecided states until July 2006. Some of the state advanced practice chairs admitted to confusion about the changes in PNP practice and took the opportunity of the survey to consult with their board and develop a policy toward this new role and their decisions about regulation. Results were compiled and analyzed according to the level of certification and education required by each state for PNP-AC practice.

Results 

There is wide variation in the rules and regulations governing the recognition of PNP-ACs in each state (Table 1). Some states do not recognize the subspecialty role of the PNP-AC, and other states do not require the PNP-AC certification examination. Table 1 describes the results of the survey for each state. Thirty-one states require certification as a PNP-AC by an approved certifying body, and 11 states require formal education in a master’s or post-master’s program as a PNP-AC. Additionally, 10 states recognize certification for populations but not sites. They require education and certification as a primary care PNP, but the practice site chosen by the PNP does not involve further certification. These states have moved toward restricting the types of NPs they recognize to the basic: adult NP, family NP, pediatric NP, geriatric NP. NPs are recognized only by the population they work with (e.g., children), not their site of employment (e.g., primary, acute, emergency department). Therefore, the acute care, emergency department, or oncology NPs are not regulated by the state except as family nurse practitioners, PNPs, or adult NPs. Two states will accept either an acute care or primary care program but require that graduates take the acute care examination, and four states will accept the primary care program with either certification examination for their graduates who want to work in acute care. Two states (Nevada and Kansas) do not require any certification examination for recognition as a NP. Table 2 identifies which types of education, certifications, or both are accepted by each state, but because this is an area of practice that is quickly evolving, some of the states may have changed their requirements before this article was published.

TABLE 1. State survey of requirements for recognition as AC-PNPs

	State	Education required⁎	Certification required†	Additional comments	Contact for advanced practice regulations	Board of Nursing contact information
	Alabama	PCP	AC	If the NP meets the alternative criteria for the acute care PNP examination, while that is available, the acute care certification will be accepted.‡	Charlene B. Cotton, MSN, RN, Nurse Consultant for Advanced Practice Nursing Phone: (334) 242-4060 ccotton@bn.state.al.us	N. Genell Lee, MSN, JD, RN, Executive Officer P.O. Box 303900 Montgomery, AL 36130-3900 Phone: (334) 242-4060 Fax: (334) 242-4360 abn@abn.state.al.us
	Alaska	PCP	PC	Requires national certification in each specialty for ANPs.	Dorothy Fulton Phone: (907) 269-8161 dorothy_fulton@commerce.state.ak	Dorothy Fulton, MA, RN, Executive Admin. Division of Occupational Licensing 550 W. 7th Ave, Suite 1500 Anchorage, AL 99501 Phone: (907) 269-8161 Fax: (907) 269-8196 license@commerce.state.ak.us
	Arizona	ACP	AC	Educational preparation and national certification must match.	Karen Grady, MS, RN, FNP, Nurse Practice Consultant/Advanced Practice Phone: (602) 889-5150 http://www.azbn.gov	Joey Ridenour, MN, RN, Executive Director 4747 N. 7th St., Suite 200 Phoenix, AZ 85014 Phone: (602) 889-5150 Fax: (602) 889-5155 arizona@azbn.gov
	Arkansas	PCP	PC	Does not recognize AC PNP, examination, or role.	Arkansas State Board of Nursing Phone: (501) 686-2700 bcolston@arsbn.org	Faith Fields, MSN, RN, Exec Director University Tower Bldg. 1123 South University, Suite 800, Little Rock, AR 72204-1619 Phone: (501) 686-2700 Fax: (501) 686-2714 bcolston@arsbn.org
	California	PCP	PC	The educational or certification titles conferred such as “acute care” or “pediatric,” etc., indicate the NPs education and in what clinical area the NP could practice.	Alice Takahashi, RN,CNAA, BC-Retired Nursing Education Consultant Phone: (916) 322-3350 brn_licensing@dca.ca.gov	Ruth Ann Terry, MPH, RN, Executive Officer P.O. Box 44210 Sacramento, CA 94244-2100 Phone: (916) 322-3350 Fax: (916) 574-8637 brn_licensing@dca.ca.gov
	Colorado	PCP education till 2008 then will require ACP	AC	An acute care NP (ACNP) can be recognized in Colorado if certified as an ACNP by a recognized certifying body even if educated in a primary care program (PC). (In 2008 a graduate degree or higher will be required. A PCNP could successfully complete a post-master’s certificate in ACNP and be granted recognition as an ACNP.)	Linda Metzner, JD, MS, RN, Advanced Practice Nurse Consultant Board of Nursing Phone: (303) 894-2430 registrations@dora.state.co.us	Mark Merrill, Program Director 1560 Broadway, Suite 880 Denver, CO 80202 Phone: (303) 894-2430 Fax: (303) 894-2821 registrations@dora.state.co.us
	Connecticut	PCP	AC or PC	Must have passed national certification examination, but does not differentiate between acute and primary NPs.	Board of Nurse Examiners Phone: (860) 509-8389 oplc.dph@po.state.ct.us	Nancy L. Bafundo, BSN, MS, RN, Board President 410 Capitol Ave., MS #13PHO P.O. Box 34030 Hartford, CT 06134-0308 Phone: (860) 509-8389 Fax: (860) 509-7553 oplc.dph@po.state.ct.us
	Delaware	PCP	AC	Must have certification in specialty area.	Iva Boardman, RN, MSN Phone: (302) 744-4517 iva.boardman@state.de.us	Iva Boardman, MSN, RN, Executive Director Cannon Building, Suite 203 861 Silver Lake Blvd. Dover, DE 19904 Phone: (302) 744-4515 Fax: (302) 739-2711 scott.mcconnell@state.de.us debbie.heinsch@state.de.us
	District of Columbia	PCP	PC	Does not recognize a difference between acute and primary care.	Board of Nursing Phone: (877) 672-2174 Nursing@dchealth.com	Karen Scipio-Skinner MSN, RN, Executive Director 717 14th St., NW, Suite 600 Washington, DC 20005 Phone: (202) 724-4900 Fax: (202) 727-8241 http://www.dchealth.dc.gov/
	Florida	PCP	AC	If an NP has met the requirements to be able to take an accreditation examination offered by an accrediting entity approved by the National Council of State Boards of Nursing she/he could be so credentialed.	Rebecca Keaton, CNM, MSN, MPH Director of Education Phone: (850) 245-4125 Rebecca_Keaton@doh.state.fl.us	Rick García, MS, RN, CCM, Executive Director 4052 Bald Cypress Way, BIN C02 Tallahassee, FL 32399-3252 Phone: (850) 245-4125 Fax: (850) 245-4172 http://www.doh.state.fl.us/mqa
	Georgia	PCP	PC	Does not recognize subspecialty areas.	Sylvia Bond, RN MSN, MBA Phone: (478) 207-1300 www.sos.state.ga.us/plb/rn	Sylvia Bond, RN MSN, MBA, Director 237 Coliseum Drive Macon, GA 31217-3858 Phone: (478) 207-2440 Fax: (478) 207-1354 http://www.sos.state.ga.us/plb/rn
	Hawaii	ACP	AC	If an RN is certified by a national certifying body the RN can be recognized as an APRN. An RN can also be recognized if the RN has an MSN degree with courses indicating specialization in acute care. However, if the RN wishes to have prescriptive authority, the RN must have both national certification in acute care and an MSN degree in the same specialty area.	Kathleen Yokouchi, MBA, BBA, BA Phone: (808) 586-3000 nursing@dcca.hawaii.gov	Kathleen Yokouchi, MBA, BBA, BA, Exec Officer King Kalakaua Building 335 Merchant St., 3rd Floor Honolulu, HI 96813 Phone: (808) 586-3000 Fax: (808) 586-2689 www.hawaii.gov/dcca/areas/pvl/boards/nursing
	Idaho	PCP	AC	Will accept national certification as an acute care NP, even though he/she completed a primary care program.	Sandy Evans, Director Phone: (208) 334-3110 http://www2.state.id.us/ibn	Sandra Evans, MAEd, RN, Director 280 N. 8th St., Suite 210 P.O. Box 83720 Boise, ID 83720 Phone: (208) 334-3110 Fax: (208) 334-3262 http://www2.state.id.us/ibn
	Illinois	ACP/PCP with additional graduate education	AC	Holds a current national certification from the appropriate national certifying body as determined by rule of the department; has successfully completed a postbasic advanced practice formal education program in the area of his or her nursing specialty.	Michele Bromberg, Nursing Act Coordinator Phone: (217) 785-0800 http://www.dpr.state.il.us	Michele Bromberg, Nursing Act Coordinator 320 W. Washington St., 3rd Floor Springfield, IL 62786 Phone: (217) 782-8556 Fax: (217) 782-7645 http://www.dpr.state.il.us
	Indiana	PCP	AC	If they have taken the acute care certification examination, they would be eligible, as long as they have an RN license in Indiana.	Kristen Kelly, Deputy Director Phone: (317) 234-2043 hpb2@hpb.IN.gov	Tonja Thompson, Director of Nursing 402 W. Washington St., W072 Indianapolis, IN 46204 Phone: (317) 234-2043 Fax: (317) 233-4236 http://www.in.gov/pla
	Iowa	PCP	AC	Could practice in the acute care setting as long as they had further knowledge and training in that specific practice arena. It would be up to the specific clinical site as to what education and experience they wanted an individual to have.	Kathy Weinberg, RN, MSN Associate Director, Practice/Education Phone: (515) 281-3255 kweinbe@bon.state.ia.us	Lorinda Inman, MSN, RN, Executive Director 400 S.W. 8th St., Suite B Des Moines, IA 50309-4685 Phone: (515) 281-3255 Fax: (515) 281-4825 www.state.ia.us/government/nursi
	Kansas	PCP	No examination required	Kansas does not require national certification for recognition as an ARNP.	Patty Brown, MS, RN Education Phone: (785) 296-4929 http://www.ksbn.org	Mary Blubaugh, MSN, RN, Executive Administrator Landon State Office Building 900 S.W. Jackson, Suite 1051 Topeka, KS 66612 Phone: (785) 296-4929 Fax: (785) 296-3929 http://www.ksbn.org
	Kentucky	ACP	AC	Certification must match education. Section 11. A nurse practicing as an advanced registered NP whose practice is inconsistent with the specialty to which he has been designated, shall be subject to the disciplinary procedures set in KRS 314.091.	Bernadette M Sutherland, Nursing Practice Consultant Phone: (502) 429-3300 BernadetteM.Sutherland@ky.gov	Charlotte F. Beason, EdD, RN, CNAA, Executive Director 312 Whittington Parkway, Suite 300 Louisville, KY 40222 Phone: (502) 429-3300 Fax: (502) 429-3311 http://www.kbn.ky.gov
	Louisiana	ACP	AC	Certification must match the program for licensure.	Peggy Griener, MPH, APRN, Credentialing Manager Phone: (504) 838-5791 grienerm@lsbn.state.la.us	Claire Glaviano, BSN, MN, RN, Executive Director 3421 N. Causeway Blvd., Suite 505 Metairie, LA 70002 Phone: (504) 838-5791 Fax: (504) 838-5279 http://www.lsbpne.com
	Maine	ACP (but will consider on a case-by-case basis)	AC	Not applicable, must have a formal program; different requirements for new grads and experienced NPs.	Virginia DeLorimer, Practice Matters; APRNs Phone: (207) 287-1133 virginia.e.delorimier@maine.gov	Myra Broadway, JD, MS, RN, Executive Director 158 State House Station Augusta, ME 04333 Phone: (207) 287-1133 Fax: (207) 287-1149 www.maine.gov/boardofnursing
	Maryland	PCP (population but not site specific)	PC	Accept national certification without additional education; does not recognize PNP-AC certification.	Quandra Horton Advanced Practice Specialist Phone: (410) 585-1926 qhorton@dhmh.state.md.us	Donna Dorsey, MS, RN, FAAN, Executive Director 4140 Patterson Ave. Baltimore, MD 21215 Phone: (410) 585-1900 Fax: (410) 358-3530 http://www.mbon.org
	Massachusetts	PCP	AC/PC	Accept national certification, will also accept supervised practice in specialty area, and continuing education.	Michael Bearse, Administrative Assistant, Supervisor Phone: (617) 973-0800 michael.e.bearse@state.ma.us	Rula Faris Harb, MS, RN, Executive Director Commonwealth of Massachusetts 239 Causeway St., 2nd Floor Boston, MA 02114 Phone: (617) 973-0800 (800) 414-0168 Fax: (617) 973-0984 http://www.mass.gov/dpl/boards/rn
	Michigan	PCP	PC or AC	Complete a formal advanced nursing program devoted to supervised clinical practice in the specialty area. And pass a national certification examination.	Customer Service Michigan Bureau Of Health Professions Phone: (517) 335-0918 bhphelp@michigan.gov	Diane Lewis, MBA, BA, Policy Manager for Licensing Division Ottawa Towers North 611 W. Ottawa, 1st Floor Lansing, MI 48933 Phone: (517) 335-0918 Fax: (517) 373-2179 http://www.michigan.gov/mdch/0,1607,7-132-27417_27529_27542-59003--,00.html
	Minnesota	PCP	AC	APNs must practice in the specialty for which they are certified by a national nurse certifying body acceptable to the Board.	Shirley A. Brekken, Executive Director Phone: (612) 617-2270 www.nursingboard.state.mn.us	Shirley Brekken, MS, RN, Executive Director 2829 University Ave. SE Minneapolis, MN 55414 Phone: (612) 617-2270 Fax: (612) 617-2190 www.nursingboard.state.mn.us
	Mississippi	PCP	PC	Must graduate and certify in specialty but (no specific recognition of subspecialties) also must work with an MD whose practice area is compatible, and scope of practice can never exceed the MD’s.	Delia Owens, Executive Director Phone: (601) 987-4188 http://www.msbn.state.ms.us	Delia Owens, RN, JD, Executive Director 1935 Lakeland Dr., Suite B Jackson, MS 39216-5014 Phone: (601) 987-4188 Fax: (601) 364-2352 http://www.msbn.state.ms.us
	Missouri	PCP	AC	Does not recognize acute care PNPs but is under consideration; accepts certification board’s assessment of knowledge in subspecialty area.	Janet Wolken Phone: (573) 751-0681 janet.wolken@pr.mo.gov	Lori Scheidt, BS, Executive Director 3605 Missouri Blvd., P.O. Box 656 Jefferson City, MO 65102-0656 Phone: (573) 751-0681 Fax: (573) 751-0075 http://pr.mo.gov/nursing.asp
	Montana	PCP	AC	A general NP program at the MS APRN level is recognized as appropriate educational preparation for a variety of subspecialty certification/credentialing examinations, one of which includes acute care.	Sandra M. Dickenson, MS, BAN, RN-C Phone: (406) 841-2340 http://www.discoveringmontana.com/dli/bsd/license/bsd_boards/nur_board/board_page.asp	Sandra M. Dickenson, MS, BAN, RN-C 301 South Park, P.O. Box 200513 Helena, MT 59620-0513 Phone: (406) 841-2340 Fax: (406) 841-2305 http://www.discoveringmontana.com/dli/bsd/license/bsd_boards/nur_board/board_page.asp
	Nebraska	PCP	AC/PC	Does not recognize AC PNP role; may use generic education and certification.	Karen Bowen, Nursing Practice Consultant Phone: (402) 471-4376 karen.bowen@hhss.ne.gov	Charlene Kelly, PhD, RN, Executive Director 301 Centennial Mall South Lincoln, NE 68509-4986 Phone: (402) 471-4376 Fax: (402) 471-1066 www.hhs.state.ne.us/crl/nursing/nursingindex
	Nevada	PCP	Does not have to be certified	Has a physician collaboration agreement, needs to prove competency in the area of practice.	Donna Cowling, MSN, RN, Education Consultant Phone: (702) 486-5800, 1 (888) 590-6726 (toll free) nursingboard@nsbn.state.nv.us	Debra Scott, MS, RN, Executive Director 5011 Meadowood Mall Way, Suite 201 Reno, NV 89502-6547 Phone: (702) 486-5800 1 (888) 590-6726 (toll free) http://www.nursingboard.state.nv.us
	New Hampshire	ACP	AC	To be recognized as an ARNP in acute care has to complete an acute care advanced education program and hold an acute care certification.	Judith A. Evans, EdD, RN Assistant Director Phone: (603) 271-2323 boardquestions@nursing.state.nh.us	Margaret Walker, MBA, BSN, RN, Executive Director 21 South Fruit St., Suite 16 Concord, NH 03301-2341 Phone: (603) 271-2323 Fax: (603) 271-6605 http://www.state.nh.us/nursing
	New Jersey	PCP	AC	Proof that the applicant has been certified as a NP/clinical nurse specialist in one or more of the specialization areas listed in N.J.A.C. 13:37-7.11 by a national accrediting agency approved by the Board, and evidence that advanced practice nurse program included pharmacology in its required curriculum.	Naomi Monroe Phone: (973) 273-8040 Naomi.Monroe@lps.state.nj.us	George Hebert, Executive Director 124 Halsey St., P.O. Box 45010 Newark NJ 07101 Phone: (973) 504-6430 Fax: (973) 648-3481 www.state.nj.us/lps/ca/medical/nursing.htm
	New Mexico	ACP	AC	Must graduate from an acute care program to be recognized as an acute care NP. If the practitioner does not have that education then he or she must complete a post master’s in that area to be recognized.	Joanna D. Giglio, MSN, RN, Assistant Director Nursing Education/Advanced Practice/Licensure Phone: (505) 841-9083 jgiglio@state.nm.us	Allison Kozeliski, RN, Executive Director 6301 Indian School Rd., NE, Suite 710 Albuquerque, NM 87110 Phone: (505) 841-8340 Fax: (505) 841-8347 http://www.state.nm.us/clients/nursing
	New York	PCP	AC	Will accept 60 contact hours of continuing education. It may be obtained through the completion of any combination of the following: 1. Academic courses or continuing education programs approved up to 12 contact hours of independent study in an academic course or CE program may be accepted. 2. Evidence of preparation for the specialty by service as a presenter or lecturer in an academic or continuing education program, or by the publication in a professional journal of clinical information related to the specialty. Credit for such services or publication may not exceed 30 contact hours.And 1000 hours of clinical practice after April 1, 1986, in the specialty for which additional certification is sought.	Barbara Zittel, PhD, RN, Executive Secretary Phone: (518) 474-3817, ext. 280 http://www.nysed.gov/prof/nurse.htm	Barbara Zittel, PhD, RN, Executive Secretary 89 Washington Ave. 2nd Floor West Wing Albany, NY 12234 Phone: (518) 474-3817, ext. 280 Fax: (518) 474-3706 www.nysed.gov/prof/nurse.htm
	North Carolina	PCP	PC	Generic education and certification. Subspecialties are not recognized.	North Carolina Board of Nursing Phone: (919) 782-3211 email@ncbon.com	Polly Johnson, MSN, RN, FAAN, Executive Director P.O. Box 2129 Raleigh, NC 27602-2129 Phone: (919) 782-3211 Fax: (919) 781-9461 http://www.ncbon.com
	North Dakota	ACP	AC	Evidence of completion of an advanced practice track; submit evidence of current certification by a national nursing certifying body in the specialty appropriate to educational preparation	Constance B. Kalanek, PhD, RN, Executive Director Phone: (701) 328-9777 http://www.ndbon.org	Constance Kalanek, PhD, RN, Executive Director 919 S. 7th St. Bismarck, ND 58504 Phone: (701) 328-9777 Fax: (701) 328-9785 http://www.ndbon.org
	Ohio	PCP	AC	Acute care certification is required, but there are no requirements for specific education beyond the primary care PNP.	Susan Milne, RN, MSN, JD Advanced Practice Consultant Phone: (614) 466-6180 apn@nursing.ohio.gov	Betsy J. Houchen, RN, MS, JD, Executive Director 17 S. High St., Suite 400 Columbus, OH 43215-3413 Phone: (614) 466-3947 Fax: (614) 466-0388 http://www.nursing.ohio.gov
	Oklahoma	PCP	PC	An examination in the area of certification shall be open only to RNs who have successfully completed the appropriate formal program of study as defined in these Rules and Regulations. Based on this rule of the Board, the PNP would need to complete an acute care program. At this time, the acute care pediatric NP is not approved for recognition by the Oklahoma BNE.	L. Louise Drake, MHR, RN, Associate Director, Nursing Practice Phone: (405) 962-1800 ldrake@nursing.state.ok.us	Kimberly Glazier, MEd., RN, Executive Director 2915 N. Classen Blvd., Suite 524 Oklahoma City, OK 73106 Phone: (405) 962-1800 Fax: (405) 962-1821 www.youroklahoma.com/nursing
	Oregon	PCP	PC	PNP would need to demonstrate clinical and didactic preparation at this acuity level. Currently, the State of Oregon does not recognize the acute care PNP examination or role. PNPs who wish to have this focus are advised to take the appropriate coursework in their programs.	Tracy Klein, WHCNP, FNP, Advanced Practice Consultant Phone: (971) 673-0686 tracy.klein@state.or.us	Joan Bouchard, MN, RN, Executive Director 800 NE Oregon St., Box 25 Portland, OR 97232 Phone: (971) 673-0685 Fax: (971) 673-0684 http://www.osbn.state.or.us
	Pennsylvania	PCP	AC	Requires specific certification, but education is not necessarily specific; the PA Board of Nursing would need to evaluate the curriculum of the program at the time of application.	Colleen M. Rosborough, RN, MSN, CRNP, Nursing Practice Advisor Phone: (717) 783-7142 crosboroug@state.pa.us	Laurette D. Keiser, RN, MSN, Section Chief P.O. Box 2649 Harrisburg, PA 17105-2649 Phone: (717) 783-7142 Fax: (717) 783-0822 www.dos.state.pa.us/bpoa/cwp
	Rhode Island	PCP	AC	May work in acute care setting as long as it is within the scope of practice for PNPs and have obtained qualifying certification.	Gina Rocha, MPH, RN, Director, Nurse Registration and Nurse Education Phone: (401) 222-5700 http://www.health.ri.gov	Pamela McCue, MS, RN,, Executive Officer 105 Cannon Building Three Capitol Hill Providence, RI 02908 Phone: (401) 222-5700 Fax: (401) 222-3352 http://www.health.ri.gov
	South Carolina	PCP	AC	A master’s degree in nursing and national certification in specialty area.	Maggie Johnson, Program Nurse Consultant Phone: (803) 896-4522 johnsonm@llr.sc.gov	Joan K. Bainer, RN, MN, CNA BC, Admin. P.O. Box 12367 Columbia, SC 29211-4522 Phone: (803) 896-4550 Fax: (803) 896-4525 www.llr.state.sc.us/pol/nursing
	South Dakota	PCP	AC	An applicant must have completed an advanced practice program in nursing that awards a graduate degree and must specifically prepare the nurse to function in the advanced practice role of NP and have passed a national certification examination.	Linda Young, RN, MS Nursing Program Specialist, Project Director Phone: (605) 362-2772 Linda.Young@state.sd.us	Gloria Damgaard, RN, MS, Executive Secretary 4305 S. Louise Ave., Suite 201 Sioux Falls, SD 57106-3115 Phone: (605) 362-2760 Fax: (605) 362-2768 http://www.state.sd.us/doh/nursing
	Tennessee	PCP	AC	Additional evidence on the transcript of graduate education in acute care nursing short of a post-master’s certificate would suffice, post-MSN, or MSN in acute care is not necessary.…	Elizabeth Lund Phone: (615) 532-9839 Elizabeth.Lund@state.tn.us	Cheryl Stegbauer, RN, Chairman, BNE 277 French Landing, Suite 300 Nashville, TN 37243 Phone: (800) 778-4123 Fax: Not listed http://www2.state.tn.us/health/contact.htm
	Texas	ACP	AC	Holds current education and certification in the advanced nursing role and specialty recognized by the board. Such certification must be granted by a national certifying body recognized by the board. (c) Advanced practice nurse applicants who wish to be authorized by the board for more than one designation shall complete additional education in the desired area(s) of approval in compliance with §221.3 of this chapter and obtain national certification in the advanced role and specialty from a national certifying body recognized by the board.	Board of Nursing Education Phone: (512) 305-6843 Fax: (512) 305-7401 apn@bne.state.tx.us	Katherine Thomas, MN, RN, Executive Director 333 Guadalupe, Suite 3-460 Austin, TX 78701 Phone: (512) 305-7400 Fax: (512) 305-7401 http://www.bne.state.tx.us
	Utah	PCP or ACP	AC	Documented competence in the area of acute care by education or examination. It is the responsibility of the licensee to confine his or her practice to that which he or she is competent.	Laura Poe, RN, MS, Executive Administrator Phone: (801) 530-6628 http://www.dopl.utah.gov	Laura Poe, RN, MS, Executive Administrator 160 E. 300 South Salt Lake City, UT Phone: (801) 530-6628 Fax: (801) 530-6511 www.dopl.utah.gov/licensing/nurse.html
	Vermont	PCP	AC	Will accept PNP certification examination in acute care.	Nancy Morin, Nurse Practitioners Phone: (802) 828-2363 nmorin@sec.state.vt.us	Susan Farrell, RN, Chairman Redstone Building, 26 Terrace St.—Drawer 09 Montpelier, VT 05609-1101 Phone: (802) 828-2363 Fax: (802) 828-2496 http://vtprofessionals.org
	Virginia	ACP	AC	Evidence of professional certification consistent with the specialty area of the applicant’s educational preparation.	Charlotte M. Creed, Nurse Practitioner licensure and prescription authority Phone: (804) 662-9946 nursebd@dhp.virginia.gov	Jay Douglas, RN, MSM, CSAC, Executive Director 6603 W. Broad St., 5th Floor Richmond, VA 23230-1712 Phone: (804) 662-9909 Fax: (804) 662-9512 http://www.dhp.virginia.gov/nursing
	Washington	PCP	PC	Continuing education must reflect specialty area of practice.	Chuck Cumiskey, RN, Practice Manager Phone: (360) 236-4700 hpqa.csc@doh.wa.gov	Paula Meyer, MSN, RN, Executive Director Health Professions Quality Assurance P.O. Box 47865 Olympia, WA 98504-7865 Phone: (360) 236-4700 Fax: (360) 236-4738 http://www.fortress.wa.gov/doh/hpqa1/hps6/Nursing
	West Virginia	ACP or PCP	AC or PC	National certification in an area approved by the Board and a master’s in nursing are required; can work according to their knowledge, skills, and competencies.	Laura Rhodes, Executive Director Phone: (304) 558-3596 rnboard@state.wv.us	Laura Rhodes, MSN, RN, Executive Director 101 Dee Dr. Charleston, WV 25311 Phone: (304) 558-3596 Fax: (304) 558-3666 http://www.wvrnboard.com
	Wisconsin	PCP	AC	If he or she is certified as an acute care NP on the basis of passing the examination, that is sufficient for her to work as such in Wisconsin.	Cathy Pond, Division Administrator of Credential Phone: (608) 266-0145 Cathy.Pond@drl.state.wi.us	Kimberly Nania, PhD, MA, BS, Director 1400 E. Washington Ave., Rm. 173 Madison, WI 53708 Phone: (608) 266-0145 Fax: (608) 261-7083 http://www.drl.state.wi.us
	Wyoming	ACP	AC	Completion of an advanced program of study in a specialty area and has taken and passed a national certification examination in the same area.	Dr. Mary Calkins, Practice Consultant/Assistant Executive Director Phone: (307) 777-7601 mcalki@state.wy.us	Cheryl Lynn Koski, MN, RN, CS, Executive Director 1810 Pioneer Ave. Cheyenne, WY 82001 Phone: (307) 777-7601 Fax: (307) 777-3519 http://nursing.state.wy.us

⁎ ACP = acute care program, PCP = primary care program. † AC = acute care examination, PC = primary care examination. ‡ The PNCB will be accepting PNPs who are currently primary care educated and certified by the PNCB or American Nurses Credentialing Center (ANCC) but want to take the AC examination. All applications must be completed and received by the PNCB by March 31, 2007 (PNCB, 2006a).

TABLE 2. State requirements

	Current requirements for recognition as an acute care PNP	States (by abbreviation)
	Primary care program/primary care examination	AK, AR, CA, DC, GA, MD, MS, NC, OR, WA
	Primary care program/acute care examination	AL, CO, DE, FL, ID, IN, IA, MN, MO, MT, NJ, NY, OH, PA, RI, SC, SD, TN, VT, WI
	Primary care program/either examination	CN, MA, MI, NE
	Acute care program/acute care examination	AZ, HI, KY, LA, ME, NH, NM, ND, TX, VA, WY
	Either program/acute care examination	IL, UT
	Either program/either examination	WV

Implications for regulation 

The National Council of State Boards of Nursing (NCSBN, 2002) stated that the focus of advanced practice education must correspond to the certification examination and NP clinical practice of the NP. Some states require adherence to regulatory standards that support the determination of the NCSBN. They require that advanced practice nurse licensure be determined by graduate level education, reflecting both didactic knowledge and clinical competency skills unique to an advanced practice role (NCSBN, 2003) and certification related to that role. Only 11 states currently adhere to this recommendation. To address this problem, universities are developing PNP-AC programs. Additionally, continuing education programs and postgraduate preceptorships have been developed to prepare the PNP for the PNP-AC role. There is currently a high need for PNP-ACs and few PNP-AC graduate programs (Table 3) The information for Table 3 was retrieved from the PNCB’s Web site (PNCB, 2006b).

TABLE 3. PNP-AC programs in the United States

	States	Program
	AL	The University of Alabama, Birmingham—Acute Care and Continuing Care Pediatrics
	CA	California State University–Los Angeles—Pediatric Acute Care
	GA	Emory University Nell Hodgson Woodruff School of Nursing—PNP Acute Care
	IL	Rush University School of Nursing—Acute/Chronic PNP
	MD	University of Maryland—Acute Care PNP
	NC	Duke University School of Nursing—Pediatric Acute/Chronic Care NP
	NJ	Seton Hall University College of Nursing—Acute Care PNP Program
	PA	University of Pennsylvania School of Nursing—Pediatric Critical Care NP
	PA	University of Pennsylvania School of Nursing—Pediatric Acute/Chronic NP
	PA	University of Pennsylvania School of Nursing—Pediatric Oncology NP
	TN	Vanderbilt University School of Nursing—PNP Program—Acute Care
	TX	The University of Texas at Arlington—School of Nursing—Acute Care

Data from PNCB, 2006.

Other states have determined that advanced practice nursing licensure should be granted through a general graduate level education focused on the population of concern (e.g., pediatrics) and not the site (e.g., primary or acute care). They accept the population-focused certification examination (e.g., primary care PNP examination) regardless of the NP’s employment environment and have decided that additional regulation is unnecessary at this time.

Limitations 

Because regulation is focused on protection of the public and is shaped by practice, a limitation of this study is the rapidly changing landscape of NP practice. Each state reviews its rules and regulations on a regular basis but may not always change its regulations until there is evidence that changes in practice are permanent and that regulation is necessary. This study reports the current state of regulations in response to the newly emerging PNP-AC role. It is expected that state regulations will continue to change as PNP practice evolves.

Conclusion 

Regulatory bodies focus on ensuring that professionals providing care are educated and trained so that safe care is provided. However, there is much overlap and no clear delineation between pediatric primary and acute care. Consequently there is much variation in the type of education and certification required of PNPs who practice in acute care settings. NPs working in these settings need to be very aware of their state requirements and changes that occur in their state.