Need for Regulation
Information Asymmetry
Bundling of Services
Secondary Harm
Forum for Complaints

Approaches to Regulation
Designation/Recognition
Registration
Certification
Licensure

Selection Criteria for Regulatory Approaches
Risk of Harm for the Consumer
Skill and Training Needed
Level of Autonomy
Scope of Practice
Consumer Expectation
Alternative to Regulation

Nursing Practice: The regulation of individual licensed nurses: Registered Nurses (RN), Licensed Practical/Vocational Nurses (LP/VN) and advanced practice nurses (APRN). A broad regulatory definition of nursing enables Boards of Nursing to adapt to the changing health care environment, to changing practice expectations and to the evolution of the profession. Nursing Practice Acts and Nursing Administrative Rules/Regulations apply to all nursing roles in all settings. However, the regulatory definition of nursing practice needs to be specific enough to distinguish nursing practice from the practice of other health care practitioners.
The practice of nursing means assisting individuals or groups to maintain or attain optimal health, implementing a strategy of care to accomplish defined goals and evaluating responses to care and treatment. This practice includes, but is not limited to, initiating and maintaining comfort measure, promoting and supporting human functions and responses, establishing an environment conducive to well-being, providing health counseling and teaching, and collaborating on certain aspects of the health regimen. This practice is based on understanding the human condition across the life span and the relationship of the individual within the environment.

License: Licensure is the process by which an agency of state government grants permission to an individual to engage in a given profession upon finding that the applicant has attained the essential degree of competency necessary to perform a unique scope of practice. Licensing requirements define what is necessary for the majority of individuals to be able to practice the profession safely and validate that the applicant has met those requirements. This regulatory method is used when regulated activities are complex, require specialized knowledge and skill and independent decision-making. The licensure process includes the predetermination of qualifications necessary to perform a legally defined scope of practice safely and an evaluation of licensure applications to determine that the qualifications are met. Licensure provides that a specified scope of practice may only be performed legally by licensed individuals. Licensure provides title protection for those roles. It also provides authority to take disciplinary action should the licensee violate provision of the law or rules in order to assure that the public health, safety and welfare will be reasonably well protected.

Certification: Certification is another type of credential that affords title protection and recognition of accomplishment, but that does not include a legal scope of practice. The federal government has used the term certification to define the credentialing process by which a non-governmental agency or association recognizes individuals who have met specified requirements. Many state Boards of Nursing use such professional certification as requirements toward granting authority for Advanced Practice Registered Nurses. Some state government entities have also used the term certification for governmental credentialing. Potential for confusion exists because regulatory agencies and professional associations in different contexts may use the term certification differently. The regulation of Advanced Practice Nurses (APRNs) varies greatly among Boards of nursing.
Boards of Nursing are state governmental agencies that are responsible for the regulation of nursing practice in each respective state. Boards of Nursing are authorized to enforce the Nurse Practice Act, develop administrative rules/regulations and other responsibilities per the Nurse Practice Act.

Boards of Nursing: Nearly 100 years ago, boards of nursing were established by state government to protect the public's health by overseeing and ensuring the safe practice of nursing. Boards of nursing achieve this mission by establishing the standards for safe nursing care and issuing licenses to practice nursing. Once a license is issued, the board's job continues by monitoring licensees' compliance to state laws and taking action against the licenses of those nurses who have exhibited unsafe nursing practice.

Individuals who serve on a board of nursing are appointed to their position. Your state law dictates the membership of the board of nursing, which usually includes a mix of registered nurses, licensed practical/vocational nurses, advanced practice registered nurses, and consumers. Together, they meet often to oversee board of nursing activities and to take disciplinary action on nurse licenses as necessary.

The boards of nursing in the 50 states, the District of Columbia, and five United States territories--Guam, Virgin Islands, Puerto Rico, American Samoa, and the Northern Mariana Islands--comprise the membership of the National Council of State Boards of Nursing. Five states have two boards of nursing, one for registered nurses and one for licensed practical/vocational nurses: California, Georgia, Louisiana, Texas and West Virginia.

Public Protection or Professional Self-preservation? Executive Summary The Purpose of Regulation: Protection of the Public

· Regulation implies the intervention of the government to accomplish an end beneficial to its citizens
· The Tenth Amendment reserves to the states all powers not delegated to the United States by the U.S. Constitution
· The power to regulate occupations is based upon the police power of the state to enact reasonable laws necessary to protect its citizens
· Regulatory authority is derived from legislative action
· State legislatures delegate many enforcement activities to state administrative agencies
· The delegation of regulatory authority allows the legislature to use the expertise of the agencies in the implementations of statutes.

Benefits to the Consumer From Each Nurse's Ten Cents a Working Day

· Articulation and enforcement of minimum requirements for safe and effective nursing practice
· Articulation and enforcement of standards for educational programs (in most jurisdictions) preparing students for nursing practice by professional and practical nursing programs within the jurisdiction
· A process for receiving, investigating and adjudicating complaints in order to discipline unsafe or unethical practitioners
· Imposition of disciplinary action as authorized
· Interpretation of the Nursing Practice Act and response to practice questions and concerns for consumers, employers and nurses
· Overall enforcement of the Nurse Practice Act
· Assurance of appropriate applicant eligibility (review of credentials)

Public Protection or Professional Self-preservation?

Opponents of regulation argue that the regulatory system was designed for simpler times, when the telephone was a startling new invention, and cross-state travel required days, not minutes or hours. They say that health care regulation is out-of-step with current needs and expectations (Pew, 1995). Some critics contend that professionals have an incentive to limit entry by setting entry requirements that are too high, and then demand grandfather clauses that specify that those already practicing a profession prior to the enactment of the regulation, regardless of their education, maintain the same authority to practice as those who are licensed after the implementation of more stringent requirements (Cox & Foster, 1990). Critics see anti competitive practices limiting consumer choice and access to services (Gross, 1984).

Why are Boards of Nursing in the business of licensing nurses? Why bother? Does it still matter in this modern world? What difference would it make if regulation of nursing practice just went away? This paper looks at the historical roots of modern regulation, explores its purposes, rationale and attempts to answer the question, why licensure?

Origins of Professional Licensure

Traditionally, medicine and law were the first regulated professions. The European foundations of licensure go back to Sicily and the Holy Roman Empire in the 13th century. This early regulatory activity was an outgrowth of the revival of learning and contact with the Arab world. By the sixteenth century, universities became more secular. King Henry VIII created the College of Physicians and Surgeons in 1511, and the College, with the archbishop of Canterbury, was given the power to license physicians and was the first to introduce practitioners as participants in the licensing process (Gross, 1984).
The first attempts to regulate occupations and professions in America were medical practice acts in colonial Virginia (1639), Massachusetts (1649), and New York (1665) (Gross, 1984). The Massachusetts law required those persons practicing the healing arts to have the advice and consent of skillful and experienced practitioners. These early laws were the forerunners of licensure and the beginning of peer-determined competence in this country (Winn, 1995). By 1800, thirteen of sixteen states had given the authority to examine and license to the state medical societies. In the second quarter of the 19th century, there was deregulation of the legal and medical professions, and at the time of the civil war, no effective state licensing system was in place. This period of deregulation has been viewed as both positive, resulting in more medical schools thus increasing the number of physicians, and negative, a time of rampant quackery and deterioration in the quality of medical care (Gross, 1984).

By the end of the 19th century, states were again beginning to pass medical practice acts which were implemented by state regulatory agencies. Beginning with Dent vs. West Virginia (1888), authority for medical licensure has been viewed as exercise of the police power of the state (Winn, 1995). One of the residual effects of physicians becoming the first health care group licensed by the state is that there is, in the 1990s, the continuation of a legislative scheme which grants physicians an exclusive and all-encompassing scope of practice for all things medical or health-related (Safriet, 1993).

The History of Nursing Licensure

The first efforts toward the regulation of nursing began in England. Although the issue of nursing regulation was raised in the late 19th century, enactment of laws to govern nursing in England there was delayed in part due to the opposition of Florence Nightingale to regulation. In 1901, New Zealand became the first country to enact a nursing licensing law. North Carolina was the first state to enact a registration law in 1903. New Jersey, New York and Virginia also passed registration laws in that same year. The early registration laws were viewed as a way to provide legal recognition of nursing and, through title protection, a mechanism for examination and the establishment of educational standards, were intended to protect the public. The laws were permissive, did not define nursing practice, and were diverse and inconsistent from state to state.
In 1938, New York became the first state to adopt a mandatory licensure law and to define a scope of nursing practice. The demands for nurses both to serve the military and the home front during World War II caused an acute nursing shortage. This resulted in a slowing of other states' movement toward mandatory licensure. In the 1950s, nursing regulation laws began to address both Registered Nurses and Licensed Practical/Vocational Nurses. By the 1970s, licensure for RNs and LPN/VNs became mandatory in all United States jurisdictions (Calico & Weisenbeck, 1991). In 1996, advanced practice nursing is also regulated by some method in 49 of the 50 states (National Council, Regulation of Advanced Practice, 1995).

The Purpose of Regulation: Protection of the Public

The concept of regulation reflects the complex world that creates the context of modern life. In simpler times, when communities were small and everyone knew everyone, the majority of basic needs were met by each family or individual. And when people did turn to others, they knew the reputation of those individuals who provided services. They might not always have other options available, but they usually knew with whom they were dealing.

As the industrial revolution progressed, drawing millions to the cities from rural America, life became more complex. The direct connection between the consumer and the provider of services was replaced by a variety of individuals or groups who provided services. It became more difficult for individuals to evaluate the quality of what was done for and to them. Toward the end of the 19th century, the federal, state and local governments began to enact laws to protect the consumer, supplementing the direct accountability of provider to consumer. As knowledge and technology advanced, legislators realized that expertise in the areas being regulated was needed to develop more specific standards. The concept of administrative agencies evolved, where members of a regulated profession provided the expertise and special knowledge needed to develop detailed requirements. The professional expertise envisioned within the basic concept of administrative agencies continues to be an essential element of administrative law today.

Regulation implies the intervention of the government to accomplish an end beneficial to its citizens. The Tenth Amendment reserves to the states all powers not delegated to the United States by the U.S. Constitution. The power to regulate occupations is based upon the police power of the state to enact reasonable laws necessary to protect its citizens. States may exercise all powers inherent to government except those explicitly reserved to the federal government (e.g., interstate commerce) or pre-empted by federal law.

Laws governing individual health care providers are enacted through state legislative action. Regulatory authority is derived from legislative action. While a state constitution forms the framework for state governments, legislatures enact laws which grant specific authority to regulatory agencies, e.g., a state legislature enacts a nursing practice act to regulate nursing and delegates authority to the state boards of nursing to enforce the nursing practice act. State legislatures delegate many enforcement activities to state administrative agencies. The delegation of regulatory authority allows the legislature to use the expertise of the agencies in the implementations of statutes.

Need for Regulation

Why is there a need to protect the public in the area of health care? Other less regulated goods and services are driven by market forces, cost and demand. Factors such as reputation, guarantees and litigation work together to assure that consumers get what they pay for (and people are sometimes willing to pay less for lower quality goods). In a complex society, regulation can only control some of the factors affecting the quality of services, so why not let competitive market forces bring about the optimal combination of price, quantity and quality? Why not let the market control?

There are four critical reasons for regulation: 1) information asymmetry, 2) bundling of services 3) secondary harm, and 4) forum for complaints.

Information Asymmetry--One frequently articulated reason reflects the asymmetric access to information about the nature and quality of services between practitioner and consumer (Graddy, 1991). It is almost impossible for the average consumer to collect and evaluate information about health care because it is technically complicated and the consumer's use of the services may be infrequent. Although access to information is rapidly changing through the explosion of information available from sources like the Internet, the time it takes to search may be costly and the consumer may have difficulty evaluating the information. The fact remains that there is need for timeliness and expediency when dealing with illness and injury. Even consumers who would be willing to evaluate a number of potential resources before making critical decisions may be prevented from doing so. People dealing with crisis may be in shock, grieving, or may be unable to make this type of decision.

Bundling of Services--The access to nursing care goes beyond information asymmetry. The majority of nurses are employees of hospitals and other types of health care agencies. As such, the agency and the nurse are "bundled"--if you choose hospital A, you get nurse A, the hospital B nurse is not an option. The same is true of a variety of health care services. Regulation of health care providers provides some assurance that providers in all settings have met government set requirements before entering practice.

Secondary Harm--The third need for regulation beyond market control is the potential effect of behavior on other citizens (Cox & Foster, 1990). An incompetent health care provider who fails to identify an infectious disorder may not only affect the client at hand, but also contributes to the unknowing spread of the disease. A person who is infectious may choose to refuse treatment for himself, but does he have the right to infect others? Regulations requiring reporting of infectious diseases promote public health efforts to contain infectious agents. What are the societal implications when a consumer chooses a less costly, less effective form of health care that in the long run costs much more because of repeated health problems? In the area of engineering and architecture, the collapse of a building due to poor design could affect many individuals beyond those who developed and purchased the property. Just as building codes and standards are in place to prevent such occurrences, health care regulation attempts to provide safeguards when there can be potential risk to multiple persons affected indirectly by services provided to others.

Forum for Complaints--The fourth need for regulation reflects the American democratic principles of checks and balances in government to protect the rights of citizens. Regulatory boards serve as an objective third party when dealing with citizen complaints regarding services. When consumers take complaints to the employers of health care providers, employers cannot help but have a vested interest that can affect the perception of behavior and events. In the area of education programs, the faculty have a vital interest in preserving their programs. Boards of nursing provide a system of checks and balances for the public. Their members have the expertise to evaluate the technical, often complicated, professional issues and have been charged with the responsibility to protect the public. The regulatory board provides a forum to hear citizen concerns.

Critics may exclaim that the professionals, who comprise the majority of membership on boards, have professional interests in mind, and will band together to defend their own. In the past, there has been a reluctance of some boards to take action in some situations. But modern boards, well advised by legal counsel and better prepared for their important role in protecting the public, are doing more to meet this major responsibility of confronting incompetent and unsafe practice. Licensing boards are charged to maintain the balance between the rights of the professional to practice a chosen profession and the board's responsibility to protect the public health, safety and welfare.

Approaches to Regulation

Designation/Recognition--The first level of regulation, and least restrictive approach, typically corresponds to designation/recognition. This alternative does not limit the right of any individual to practice. It does provide the public with information about special credentials. This recognition of credentials does not involve state inquiry into competence.

Registration--The second level of regulation typically corresponds to registration, and requires persons to apply in order to have their names added to an official roster, maintained by administrative agencies, of individuals who provide services. Title protection may be provided to individuals who meet identified requirements. Other individuals who are not registered may still provide the service, but cannot call themselves by the registered title. Registration does not involve state inquiry into competence and the scope of practice is not generally defined.

Certification--The third level of regulation corresponds to certification and also provides title protection. Applicants for certification meet specified requirements, and those persons who have met the predetermined qualifications may use the title. Certification does not include a legally defined scope of practice. (Note: The federal government has used the term certification to define the credentialing process by which a non-governmental agency or association recognizes the professional competence of an individual who has met the predetermined qualifications specified by the agency or association. Some government entities have also used the term certification for governmental credentialing. Potential for confusion exists when this term is used by both professional organizations and regulatory boards.)

Licensure--The fourth level of regulation corresponds to licensure, a process by which an agency of state government grants permission to an individual to engage in a given profession upon a finding that the applicant has attained the minimal degree of competency necessary to perform a unique scope of practice. Licensing requirements define what is necessary for the majority of individuals to be able to practice the profession safely and validate that the applicant has met those requirements. This regulatory method is used when regulated activities are complex, require specialized knowledge and skill and independent decision-making. The licensure process includes the predetermination of qualifications necessary to perform a legally defined scope of practice safely and an evaluation of licensure applications to determine that the qualifications are met. Licensure provides that a specified scope of practice may only be performed legally by licensed individuals. It also provides authority to take disciplinary action should the licensee violate provision of the law or rules (National Council, 1993).

Selection Criteria for Regulatory Approaches

In general, the regulatory approach selected should be sufficient to assure public protection. The following criteria are relevant:

Risk of Harm for the Consumer--The evaluation of a profession to determine whether unregulated practice endangers the public should focus on recognizable harm. That harm could result from the practices inherent in the nature of the profession, the characteristics of the clients, the settings, supervisory requirements, or a combination of these factors. Licensure is applied to a profession when the incompetent or unethical practice of that profession could cause greater risk of harm to the public unless there is a high level of accountability; and at the other extreme, registration is appropriate for professions where such a high level of accountability is not needed.

Skill and Training Needed--The more highly specialized the services of the professional, the greater the need for an approach which actively inquires about the education and competence of the professional.

Level of Autonomy--Licensure is indicated when the professional uses independent judgment and practices independently with little or no supervision. Registration is appropriate for individuals who do not use independent judgment and practice with supervision.

Scope of Practice--Unless there is a distinguishable scope of practice for the profession that is distinguishable from other professions and definable in enforceable legal terms, there is neither basis nor need for licensure. This scope may overlap over professions in specific duties, functions or therapeutic modalities.

Consumer Expectation--Consumers expect that those professions, which have a potentially high impact on the consumer, on their physical, mental or economic well-being, are subject to regulatory oversight. The costs of operating regulatory agencies and the restriction of practitioners who do not meet the minimum requirements are justified in order to protect the public from harm.

Alternative to Regulation--There are no alternatives to the selected regulatory approach which would adequately protect the public. It should also be the case that when it is determined that regulation of the profession is required, then the least restrictive level of regulation consistent with public protection will be implemented.

Costs and Benefits of Regulation

The cost-benefit analysis of the method of regulation must consider the value of the service and the value of the protection, as well as potential risks in not regulating complex professional activity. Individual licensees bear the cost of compliance with regulation, but costs are ultimately passed on to the consumer. Much is said about the costs of regulation. According to the Profiles of Member Boards (National Council, 1994), the following licensure costs are incurred by individual licensed nurses:

This means that, using the median costs, an RN who practices 40 years will spend $988 (assuming renewal every two years) over the course of a career for licensure (or $24.70 a year). An LPN/VN who practices 40 years (also assuming renewal every two years) will spend $991 ($24.48) a year for licensure. Additional costs are incurred by the nurse in those jurisdictions requiring continued competency activities as a part of renewal. This is part of the cost of doing business for the nurse, and averages out to just about a dime a working day for a nurse employed full time.

For the jurisdiction, costs may include agency operation, providing examinations, reviewing licensure applications, auditing continued competency requirements, communications, discipline, education program approval processes, coordinating with other boards (in and out of state) and advising nurses and employers regarding the law.
Boards of Nursing support their activities with licensing fees. Although in some jurisdictions, the fees go into the general fund and operating expenses are allotted to agencies annually, the bottom line is that fees collected cover the expenses of regulation in most jurisdictions. And what is received by the consumer for each nurse's ten cents a working day?

· Articulation and enforcement of minimum requirements for safe and effective nursing practice
· Articulation and enforcement of standards for educational programs (in most jurisdictions) that prepare students for nursing practice within the jurisdiction
· A process for receiving, investigating and adjudicating complaints in order to discipline unsafe or unethical practitioners
· Imposition of disciplinary action as authorized
· Interpretation of the Nursing Practice Act and response to practice questions and concerns for consumers, employers and nurses
· Overall enforcement of the Nurse Practice Act
· Assurance of appropriate applicant eligibility (review of credentials)

Current Challenges to Regulation

The Pew Health Care Workforce Regulation Task Force, in its report, Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century, focused attention on the fundamental transformation of the health care delivery and financing structures, and its impact upon regulation of the health care workforce. Other advocates for health care reform see regulation as a barrier to health care access.

The truth is that regulation does pose barriers--necessary barriers to provide assurance that complex professional activities are reserved to those individuals who have demonstrated minimum competence to practice a profession. Whenever mandatory requirements for education and meeting other conditions prior to entering a profession are implemented, some people are denied the privilege to practice the profession. There are always outliers in any system devised by man, and most people can cite anecdotal accounts of individuals who did not meet minimum requirements to provide a service, yet had provided that service (albeit illegally) to many without mishap. The fact that there needs to be a disciplinary process at all indicates that entry requirements in and of themselves cannot screen every unsafe professional. But the requirements are geared to how the majority of individuals demonstrate entry-level competence, just as licensure examinations are geared to what is actually done in practice by the majority of licensees.

It is very true that outcomes research is needed to validate the usefulness of regulatory activities. It is true that all regulatory bodies are challenged to explore new ways of promoting flexibility for new educational and practice endeavors, and to assure permeability of state boundaries so that safe and competent practitioners can be mobile and accessible to consumers. It is true that some of these functions can be improved. But if all these functions were removed, it would leave a gaping hole in the information and assurances available about nurses for employers and consumers.

It is not the why of regulation, or even the regulatory approach that seem to trigger concerns of critics. It is when, in the effort to be precise, thorough and anticipatory, regulation can become overwhelming and burdensome. Phillip K. Howard (1995) makes painful observations and poses difficult questions in The Death of Common Sense. He asks, "How can law function as a guide to action if almost no one knows it?" (p. 30) He notes that compulsive devotion to uniformity in law can generally be achieved only by infidelity to fairness in life, and quotes Justice Cardozo, "uniformity of method will carry us upon the rocks the curse of this fluidity, of an ever shifting approximation, is the one that law must bear " (p. 39). Howard worries about making diversity illegal.

While Howard notes that regulatory goals enjoy wide support; he observes that it is the often formalistic implementation by government, with a web of requirements such that total compliance is impossible, that has fostered a culture of resistance' that destroys cooperation. "Before American law became the world's thickest instruction manual, it worked on general principles that reflected the law's goals Rules dictate results, come what may,' the legal philosopher Ronald Dworkin noted. Principles do not work that way; they incline a decision one way, though not conclusively,' and permit a judgment that fits the situation" (p. 175-176). Howard suggests that the concept of having discretion implies constraint, that "Relaxing a little and letting regulators use their judgment is the only way to liberate our judgment The majority of people will do right if they are given goals and left to get the job done" (p. 180). Principles, discretion and common sense may be what is needed to survive in a complex and ever-changing world.

The challenges to regulation are enormous, but challenges also present opportunity:
· Opportunity to articulate and promote public attention on the goals of regulation
· Opportunity to inform, to educate, and to make sure that the rules which guide are accessible, clear, concise and understandable
· Opportunity to promulgate flexible rules that encourage innovation
· Opportunity to assure the continuing competence of nurses
· Opportunity to improve identification of incompetent and unsafe licensees, and tighten the safety net for public protection
· Opportunity to foster cooperation, collaboration and communication among consumers and professionals
· Opportunity to enhance Board member participation, to facilitate decision-making and support the wise use of regulatory discretion
There are also enormous pressures on the health care industry to reduce costs, and legislative mandates to increase access to health care. The regulatory system, of which licensing boards provide focus for the individual practitioner, serves the important role of advocate for the public welfare in terms of the quality of care in the midst of these competing forces. A revised 21st century licensure model for the health care professions must be flexible with respect to process, but firm with respect to quality of care outcomes. Boards of Nursing are currently exploring whether value-added services and the economies of scale could be achieved through centralizing some licensure activities while still maintaining the protections of state authority for practice.

Why Licensure?

So then, why licensure of nurses? Because nursing is a profession that requires specialized knowledge, skill and independent decision-making. Nursing involves behavior, attitude and judgment, and physical and sensory capabilities in the application of knowledge, skills and abilities for the benefit of the client. Nursing careers take widely divergent paths--practice focus varies by setting, by types of clients, by different disease, therapeutic approach or level of rehabilitation. Nurses work at all points of service in the health care system.
Why licensure of nurses? Because nursing is unique in its provision of caring, health promotion, implementation of therapeutic regimens, and coordination of health care. The scope of nursing practice clearly overlaps with other professions in specific duties, functions or therapeutic modalities. But the breadth of nursing, the particular combination of its caring, is unique. To authorize such practice and to delineate the legal boundaries within which nurses practice appropriate to their education and experience reflect the critical nature of the services provided. The public has a right to information about those individuals who meet those predetermined requirements.
Why licensure of nurses? Because harm could result from the practices inherent in the intimate nature of nursing care. Harm could result because of the vulnerability of clients. Harm could result from the variability of settings and available resources. Harm could result because of the independent nature of the work. It is appropriate to limit who can perform such life and death functions to those individuals who have met predetermined requirements. It is appropriate that there is an objective regulatory body, to which nurses are professionally accountable, in addition to being accountable to their clients and employers.
Why licensure of nurses? Because nurses are mobile and sophisticated and work within a society that is changing, and asymmetrical for consumers. It is not an attack on all nurses to recognize that there is potential of harm by the few who are unsafe. It is not an assumption that the majority of licensure applicants have shady pasts to ask background questions on applications and validate the answers. Rather, the assumption is that the large majority of applicants are sound practitioners. But background information should be evaluated by licensing agencies for the benefit of the public. Crimes which have potential impact on the ability to practice a profession safely, or predict how the applicant might treat vulnerable clients subject to their care, should be considered as part of a credentialing decision. They are indicative of that aspect of competence comprised of affective or behavioral elements.
Why licensure of nurses? Because, with all its imperfections, with all the need to improve and be flexible and future-oriented, licensure has worked to protect the public for almost 100 years. Consideration is needed of the political diversity, historical roots and legal precedents of licensure prior to going forward with systematic revision of the regulatory system. The past should not be allowed to hold back the evolution of regulation, but it needs to be recognized. The challenge is to negotiate the tumultuous waters of change, to move our current system so that it better meets the public protection needs of our citizens in an evolving health care system. Perhaps the biggest challenge is to continue protecting during change and transition.
Why licensure of nurses? Because it matters.

See the Nursing Kit