Joining Forces to Uphold the Legitimacy of Nationally Accredited Certification Programs: California Nurse Practitioner Case Study

In May 2021, five organizations that certify nurse practitioners (NP) were impugned by a board of nursing and the California state regulation agency to defend that their assessments represent the competencies required for NP independent practice in the state, which historically didn’t require licensed NPs to hold certifications.

These organizations — the American Academy of Nurse Practitioners Certification Board (AANPCB), American Association of Critical-Care Nurses (AACN), American Nurses Credentialing Center (ANCC), National Certification Corporation (NCC) and the Pediatric Nursing Certification Board (PNCB) — joined forces to communicate the legitimacy and respect for their longstanding and nationally accredited certification programs. This article chronicles actions taken by the certifiers to defend the validity of their programs while collaborating with the state agencies as they worked through due processes in implementing new legislation.

The process showcases the importance of professional certification programs meeting rigorous accreditation standards that assess professional competency, and how these serve as a compelling tool for validating a certification program. The process also highlighted the value of certifiers’ engagement in professional membership organizations, such as I.C.E.

California’s Certifier Challenge

The California Board of Registered Nursing (BRN) and state’s challenge occurred because of new legislation — Assembly Bill (AB) 890, signed into law in 2020 — which created two new categories of NPs that could function within a defined scope of practice without standardized procedures. The bill also defined education, training, national certification, regulatory and medical staff governance requirements for these two categories. The bill required NPs to meet additional requirements for state licensure, which included successfully passing an assessment. This assessment could be a state-approved national certification examination or one developed by the state if existing national examinations were determined to be insufficient. Most other states accept or require NPs to pass the appropriate national exam and maintain active certification.

According to California law, the Department of Consumer Affairs, Office of Professional Services (OPES) is required to determine the adequacy of each examination used for state licensure (e.g., dentists, therapists, etc.). Prior to AB 890, NP scope of practice was restricted to providing services authorized under “standardized procedures,” and national certification was not required for NP licensure in California. However, many (if not most) NPs had been obtaining certification to qualify for insurance reimbursement through the Centers for Medicare & Medicaid Services and to meet requirements of some employers.

To meet the new state requirements, the OPES contacted NP organizations individually in May 2021 and requested a list of materials for review, including most recent job task analysis study, test specifications, item development and review, security and confidentiality procedures, test construction and evaluation, standard setting, statistical performance data, pass rate data and information about the examination from recent studies conducted by test vendors. Much of the requested material was proprietary, and although assurances of non-disclosure were provided, as a governmental entity, California has open records laws. Thus, the security of exam content could be jeopardized, and full disclosure of information to the California reviewers posed an unacceptable risk for the certifying organizations.

Responding to the Challenge: A Timeline

Communication among the certifiers and with the California agencies occurred over a span of 15 months and involved the exchange of numerous emails and several conference calls. Described here is a chronological timeline of the collaboration between the certifiers, the OPES, California nursing regulators and the national accrediting bodies — the National Commission for Certifying Agencies (NCCA) and the Accreditation Board for Specialty Nursing Certification (ABSNC) — including correspondence, actions taken, outcomes of the review process and current status.

May 2021

• OPES reviewed the national certification exams. Part of this included an evaluation by subject matter experts of the content identified as critical for safe and effective practice in California. The process identified critical areas specific to California practice that are not represented on the national certification examinations.
• NP certifiers began to contact the chief of OPES regarding the certification exam information requested by her office. The chief then provided additional information on AB 890 and a sample non-disclosure and confidentiality agreement (NDA) for review. The deadline for the signing of the final NDA was June 30, 2021.

June 2021

• NP certifiers received signed NDAs from the chief of OPES. The NDA protected the NP certifiers’ confidential and proprietary information retained by OPES to evaluate their exams from disclosure by any employees, agents, representatives or expert consultants. Further, the NDAs provided a legal framework to safeguard ideas and information shared by the NP certifiers from being stolen or shared with competitors or third parties without the organization’s authorization. Breaking an NDA agreement would lead to legal ramifications.
• OPES and BRN acknowledged that none of the NP certifiers’ materials requested for review shall be used in whole or in part by OPES or the BRN in producing California’s own examinations.

NP certifiers sent a letter to the chief of OPES requesting that the BRN and OPES accept accreditation by the NCCA or the ABSNC as evidence in lieu of the original request to each certification board. Each of the NP certifiers’ national certification programs is accredited by one or more national accrediting bodies — either the NCCA or ABSNC. In their communication to OPES, the NP certifiers stated that the rigor of these accreditation standards should be accepted as the established standard for OPES’ review and for consideration of the BRN’s certification examinations.

The certifiers delineated several problems if the state proceeded with developing its own certification exam, such as the potential to disenfranchise tens of thousands of NPs currently licensed and practicing in California who already hold a nationally accredited NP certification. Further, this introduces the risk of reducing health care services nurses can provide to their patients and communities. A state specific certification is counter to national practice standards and guidelines, costly and burdensome for the state and its NPs. A state examination also burdens NPs who are licensed to practice in multiple states.

In their letter to OPES, the NP certifiers also requested that the occupational analysis (OA) of NP practice in California under development as well as the results of the evaluations be made available to them upon completion.

In reviewing the proposed regulation in full, described as the “Proposed Regulatory Action Concerning Requirements for a Nurse Practitioner Certification,” other concerns were included in the letter to OPES:

1. The state of California was using the term “certification” as opposed to “licensure” to designate an individual’s right to practice. NP certifiers felt this would create confusion as the term “certification” is traditionally used by certification organizations to mean an individual has satisfied and completed the requirements to be competent in an activity or occupation. The word “certification” is generally not used by state boards of nursing or other governmental regulatory agencies. NP certifiers asked for clear, accurate BRN terminology that delineates actions to be taken in applying for new categories of practice at the state level and those actions to be taken when applying for national board certification.
2. The BRN stated current law does not authorize a fee to be charged for certification and that no fees were included in the proposal. There was concern that nurse practitioners may think this no certification fee policy applies to the specialty certification examinations.
3. There was language in the proposed regulation that could suggest passing a national NP certification exam assures certification. The examination is but one component of obtaining certification. There must also be verification of eligibility, licensure and maintenance of certification requirements.

June 2021 – August 2022

The OPES, on behalf of the California BRN, conducted an evaluation of NP certification examinations. The evaluation was part of an effort by the BRN to determine whether national nurse practitioner certification exams would meet the terms of the DCA Licensure Examination Validation Policy OPES 18-02, mandated by Business & Professions Code § 139, which establishes the standards for review of licensure examinations in the state of California. In the review process, OPES:

1. Conducted an OA of California NP practice in eight specialty categories: family care, adult-gerontology care (primary and acute), neonatal care, pediatric care (primary and acute), women’s health care and psychiatric mental health care.
2. Performed a psychometric and security review of the 11 NP certification examinations offered by the five NP certifiers.
3. Performed an analysis comparing NP practice in California as outlined by the California OA to the content of the 11 NP certification examinations (11 linkage studies).
4. Evaluated the results of the 11 linkage studies and made recommendations.

July 2021

• NP certifiers uploaded the information about their certification exams that was requested in May to OPES’ website, along with additional background on the organizations and their role in advancing care in their respective specialties.

September/October 2021

• The chief of OPES requested ongoing information from NP certifiers; for example, insight on the process used to reclassify item (exam) banks, explanation of the pre-equating process used to create exam forms and how final determination of passing scores are achieved.

November 2021

• The chief of OPES and NP certifiers exchanged correspondence regarding the status of the OPES and BRN linkage study workshops conducted by test specialists. Licensed nurse practitioners served as subject matter experts to evaluate the content of NP certification examinations against a description of California nurse practitioner practice. Results of the linkage study workshops would be included in OPES’ national review reports. NP certifiers were then informed that, as test specialists conduct psychometric reviews and finalize reports, NP certifiers may be contacted for clarification of the information provided.

January 2022

• A virtual meeting led by the chief of OPES was held with representatives of the NP certifiers, national accreditation bodies and BRN to address the status of the linkage study evaluation and future steps. Attendees discussed whether OPES would accept accreditation by the NCCA and ABSNC in lieu of evaluating the proprietary examination development documents the NP certifiers submitted to OPES.
• NP certifiers asked OPES if a copy of the California NP practice analysis document would become available to them. OPES provided the document and NP certifiers reviewed it.

August 2022

• NP certifiers received evaluation findings from OPES in alignment with the “Standards for Educational and Psychological Testing” (2014 Standards, Standard 8.1) and DCA’s “Departmental Procedures Memorandum on Examination Security” (DPM OPES 22-01).

The two findings identified by OPES for the NP certifiers pertained to charging candidates for practice examinations (2014 Standards, Standard 8.1) and the use of remote proctoring (DPM OPES 22-01). OPES advised NP certifiers of the following recommendations:

1. Practice examinations should be offered to all candidates at no cost to increase transparency and fairness.
2. Remote proctoring should be reconsidered for high-stakes examinations due to an increased risk of item harvesting and examination subversion.
3. Item performance data should be closely monitored to detect potentially compromised examination items.

September 2022

• The chief of OPES informed NP certifiers that OPES completed its review of the examinations and would soon release each of the reports to the BRN. NP certifiers were asked to review and confirm that the reports do not contain confidential information violating the provisions of the NDA.

October 2022

• OPES completed and submitted to the BRN a comprehensive study that evaluated the suitability of using the existing NP board certification examinations as part of the regulatory transition to independent practice.

Overall, OPES supported the use of the existing 11 NP certification examinations offered by the five NP certifiers to adequately assess the critical competencies required for NP independent practice in California. However, OPES provided recommendations for improving the NP certification examinations.

• As a result of their findings, OPES confirmed the BRN’s use of the NP certifiers’ 11 examinations as part of the licensure/credentialing process for an NP who meets the requirements of B&P Code § 2837.103 to practice independently as an NP in California.

OPES shared that if the BRN and OPES identify additional competencies necessary to perform the functions specified in B&P Code § 2837.103 that are not adequately assessed by the national board certification examinations, then the BRN would be required to develop a supplemental California examination that assessed the identified competencies. While OPES did not recommend the use of a supplemental examination, it was in favor of additional clinical experience and mentorships as part of the transition to practice.

• During the open comment period, NP certifiers submitted their comments to the BRN on “Proposed Regulatory Action Concerning Requirements for a Nurse Practitioner Certification.” Among the comments, the certifiers reiterated concerns outlined earlier in this article and definitions for “certification” and “licensure” from I.C.E.’s December 2020 “Basic Guide to Credentialing Terminology, 2nd Edition,” to guide the BRN with industry terminology.

November 2022

• OPES summarized their conclusions and recommendations at their Nurse Practitioner Advisory Committee (NPAC) meeting. The BRN asked the NP certifiers for their approval to post the proposed regulation on the BRN website for access by the BRN board, NPAC members and the public.
• OPES’ nurse practitioner-specific evaluation reports were posted to the California Board of Nursing website following approval from the NP certifiers.

Current Status of the Exams

Today, thanks to the work of the five NP certifiers, the 11 national NP examinations offered are identified on the California nursing website as approved for NPs obtaining recognition and licensure as they transition to independent practice. NP practice acts vary across states, but California is one of the last states to require national certification. The certifiers continue to collaborate and seek resolution for those NPs who hold national certification for programs that are no longer accredited because the examination has been retired. These “legacy certifications” are not included in the California transition to independent practice.

OPES determined that for each of the examinations, the procedures used to establish and support the validity and defensibility of the essential components generally meet professional guidelines and technical standards, and no supplemental examination is warranted. The report stipulates that the California BRN is mandated to ensure that all examinations used for state credentialing/licensure undergo periodic review. Thus, future reviews of NP certification programs are expected.

7 Lessons Certifiers Can Learn From This Case Study

1. Accreditation provides the respectability, rigor and processes to defend against state challenges. As a result of successfully completing NCCA and/or ABSNC accreditation, the certifiers were able to provide OPES with the necessary materials to complete their charge within the predetermined time limits, and moreover were found to be sufficient and consistent with the state’s requirements.
2. Relationships with other certification boards enable swift communication, powerful strategic group think and a strong unified front when threats arise.
3. Stay agile to pivot your team’s time and energy to emerging threats. Identify fiscal year projects early each cycle that can be delayed if a challenge arises that needs prompt action.
4. Communicate the issue openly and clearly with all your staff in case front-line customer service team members receive certificant concerns. Create a communication plan early so team members know how to manage incoming inquiries.
5. Understand the pros and cons of complying with a regulated process. Use this case study to talk with your leadership team as a real-world exercise. Would your organization be ready to handle a similar challenge? Are you prepared to set a collaborative but firm tone with regulators to find a path forward that meets their needs while protecting your programs.
6. Seek to understand the situation from multiple perspectives and work to achieve a common goal that is acceptable and benefits all entities.
7. Keep communication open, collegial and positive.