Practice Issues JANA CONOVER, BA AANA State Legislative Affairs Analyst MITCHELL H. TOBIN, JD AANA Director of State Government Affairs State master's degree requirements for nurse anesthetists Key words: Master's degree, state legislation, state regulations. In recent years, a trend toward requiring master's degrees for Certified Registered Nurse Anesthetists (CRNAs) and other advanced practice registered nurses (APRNs) has emerged in state laws and regulations. To date, 16 states have enacted laws or adopted regulations that require master's degrees either currently or at a future date. State requirements vary widely regarding when master's requirements will be implemented, required degree concentration, and the potential effect on CRNAs who wish to practice in states having master's degree requirements. This article will explore the implications of state master's degree requirements for all nurse anesthetists, including those who have master's degrees and those who do not. Background The Council on Accreditation of Nurse Anesthesia Educational Programs required that, as of 1998, all programs be at the graduate level-that is, awarding at least a master's degree. This requirement has been met-all 84 nurse anesthesia educational programs are at the graduate level. Consequently, all nurse anesthetists entering nurse anesthesia educational programs in or after 1998 will graduate with a minimum of a master's degree. All programs, however, do not grant master's degrees in the same concentration. Currently, 40 nurse anesthesia educational programs grant master's degrees in nursing. The remaining 44 programs grant master's degrees in a variety of concentrations; most commonly, these programs grant master's degrees in nurse anesthesia (or nurse anesthesiology), anesthesia, or biology. Information regarding specific nurse anesthesia educational programs is available on the AANA website at www.aana.com. This information is also available at no charge in brochure form by contacting the AANA Resource Center at (847) 692-7050, extension 3009. In the 1990s, a number of nursing organizations developed models or standards for APRNs that included recommended educational requirements. For example, the National Council of State Boards of Nursing (NCSBN) developed a model nursing practice act and model nursing administrative rules for advanced nursing practice, while the American Nurses Association (ANA) developed a document concerning the scope and standards of practice for APRNs. (The NCSBN is the not-for-profit membership organization for state boards of nursing.) Both the NCSBN models and the ANA scope and standards contain provisions that reflect the belief of both organizations that APRNs should be educated at the graduate level. The NCSBN model nursing practice act states in its definition of "advanced practice registered nurse" that such nursing is based on "a graduate degree with a major in nursing or a graduate degree with a concentration in the advanced nursing practice category.... " The ANA scope and standards document states that "[a]dvanced practice registered nursing education is at the graduate August 1998/ Vol. 66/No. 4 351
level and prepares registered nurses with additional knowledge and skills." The NCSBN and ANA recommendations, although not legally binding on the states, may influence state legislatures and boards of nursing who are considering revising nursing laws or regulations. 2 State requirements The trend of states requiring master's degrees for CRNAs and other APRNs has emerged in the past decade. State master's degree requirements sometimes vary depending on the type of APRN (e.g., CRNA, nurse practitioner, nurse midwife, or clinical nurse specialist) involved. This article discusses requirements for CRNAs only, and does not address the requirements for other APRNs. As of July 1, 1998, seven states (Connecticut, Louisiana, Missouri, Montana, North Dakota, Washington, and Wisconsin) require certain CRNAs to have master's degrees. Nine other states (Colorado, Florida, Georgia, Maine, Mississippi, Nevada, New Mexico, Ohio, and Texas) have either enacted laws or adopted rules that will require certain CRNAs to have master's degrees at some future date. The specifics of which CRNAs are affected by these requirements, and in what manner, are detailed later in this article. In addition, four states (Delaware, Hawaii, Iowa, and Wyoming) require possession of either a master's degree or another credential to practice. Delaware requires that a nurse anesthetist possess either a master's degree or a postbasic program certificate in a clinical nursing specialty. Hawaii requires either a master's degree in clinical nursing or nursing science or evidence of current certification by a national certifying body. Iowa requires either a master's degree in a nursing clinical specialty area or completion of a formal advanced practice educational program. Wyoming requires either completion of a nationally accredited education program and national certification or a master's degree in nursing. In West Virginia, after December 31, 1998, a master's degree in nursing will be required to "announce advanced practice." The nursing board in West Virginia, however, has reportedly indicated that "announcing" advanced practice will not be required to practice as a CRNA. Table I lists state master's degree requirements for CRNAs, and was compiled from information obtained from state nursing laws and board of nursing rules. State laws and regulations, as well as interpretations of them, sometimes change, however. Consequently, if you are considering relocating to a state, you should contact that state's board of nursing before doing so to obtain the most cur- rent information regarding the requirements to practice in that particular state. State master's degree requirements vary considerably. In evaluating these requirements, we have considered four primary elements: 1. Effective dates of master's degree requirements. 2. Required concentration of the master's degrees (e.g., nursing, biology). 3. Effect of a state's master's degree requirement on a CRNA who has been practicing in the state but does not have a master's degree 4. Effect of a state's master's degree requirement on a CRNA from another state who does not have a master's degree, is currently practicing, and would like to relocate to the state. * Effective date. The effective date of a state master's degree requirement is critically important. All nurse anesthesia educational programs are now required to be at the graduate level. Some students who entered programs that were still at the certificate level in 1997, however, may not graduate until the year 2000 because some programs are more than two, but less than three years long. Consequently, these students would be unable to meet a master's degree requirement in the year 2000. Optimally, therefore, states should not require master's degrees for new graduates of nurse anesthesia educational programs until the year 2001. As of 2001, all new graduates would be able to meet a master's degree requirement. Although a master's degree effective date of 2001 or later is optimum, nine (Connecticut, Georgia, Louisiana, Mississippi, Missouri, Montana, North Dakota, Washington, and Wisconsin) of the 16 states that have adopted master's degree requirements have effective dates prior to the year 2001. (The effective dates are indicated in Table I.) A CRNA who does not have a master's degree but has already been practicing in a state prior to the date a state's master's requirement went into effect, will continue to be able to do so. The small number of CRNAs who will graduate in the next few years without a master's degree, however, will not be able to practice in these nine states. CRNAs who graduated without a master's degree after the effective date in one of these nine states would also be unable to practice. States are not uniform regarding the level of detail they include concerning master's degree requirement effective dates. For example, some state requirements appear to apply generally to all "applicants" on or after a certain date. Other states, though, link the effective date with other specific requirements, such as certification or graduation date. Connecticut, for example, requires a master's 352 Journal of the American Association of Nurse Anesthetists
Table I Current state requirements State Effective for Degree required Colorado Applicants on and after July 1, Graduate degree in the appropriate specialty 2008 Connecticut Applicants certified after Decem- Master's degree in nursing or a related field ber 31, 1994 Delaware Optional Master's degree or a postbasic program certificate in a clinical nursing specialty Florida Applicants for "initial [state] cer- Master's degree in a nursing clinical specialty area tification" graduating on or after October 1, 2001 Georgia Applicants for "initial authority to Master's or higher degree in nursing or a graduate degree with a practice" beginning January 1, concentration in anesthesia 1999 Hawaii Optional Master's degree in clinical nursing or nursing science or evidence of current certification by a national certifying body Iowa Optional Master's degree in a nursing clinical specialty area or completion of a formal advanced practice educational program Louisiana Applicants who enrolled in an Master's degree with a concentration in the respective advanced educational program afterjanu- practice nursing specialty ary 1, 1996 Maine Applicants for "initial approval" Master's degree with preparation in the specialty area for which as of January 1, 2006 application is made Mississippi Applicants graduating from an Graduate program with a concentration in the applicant's respeceducational program after De- tive advanced practice nursing specialty cember 31, 1998 Missouri Applicants from and after July 1, Graduate degree with a concentration in an advanced practice 1998 nursing clinical specialty area Montana Applicants for "original recogni- Master's degree from an accredited nursing education program tion" who graduate and are certified after June 30, 1995 Nevada Applicants for "initial approval" Master's degree in nursing or anesthetic care after June 1, 2005 New Mexico Applicants "initially licensed" af- Master's level or higher nurse anesthesia education program ter January 1, 2001 North Dakota Applicants after August 1, 1995 Graduate degree with a nursing focus Ohio Applicants after December 31, Master's degree with a major in a nursing specialty or in a related 2000 field Texas Applicants beginning January 1, Master's degree in the advanced practice role and specialty 2007 Washington Applicants after January 1, 1995 Graduate degree with a concentration in advanced nursing practice West Virginia Optional/on or after December Master's degree in nursing is required to "announce advanced 31,1998 practice." However, West Virginia Board of Examiners for Registered Professional Nurses has reportedly indicated that "announcing" advanced practice will not be required to practice as a CRNA. Wisconsin Applicants certified after July 1, Master's degree in nursing or a related health field 1998 Wyoming Optional Completion of a nationally accredited education program and national certification, or a master's degree in nursing j August 1998/ Vol. 66/No. 4 353
degree of applicants who were certified after December 31, 1994. Florida's effective date, however, applies to applicants who graduate on or after October 1, 2001. * Required degree concentration. The second element of state master's degree requirements that must be evaluated is the required concentration of the degree (e.g., "in a nursing clinical specialty area"). Fortunately, the language of most, if not all, state master's degree requirements is sufficiently broad to encompass the variety of degrees that nurse anesthesia educational programs award. Degree concentrations required by the states are listed in Table I. Again, however, individual state boards of nursing are the authoritative source concerning how particular language in a state will be interpreted. * Grandfather clauses (in-state CRNAs). Another important element of a master's degree requirement is a grandfather clause for CRNAs currently practicing in the state. Generally, in the context of recognition or licensure of healthcare providers, a grandfather clause is a provision in a law or regulation that exempts a provider from having to comply with a new requirement that would otherwise affect prior rights or privileges. In other words, a grandfather clause allows practitioners to continue to practice, even if additional restrictions imposed by a law or regulation would otherwise prohibit their practice. In the case of a master's degree requirement, a grandfather clause would allow CRNAs without master's degrees who are currently recognized by a state to continue to practice with their existing educational credentials. All of the states that have adopted master's degree requirements to date have "grandfathered" current in-state CRNAs. The "grandfathering" of current practitioners is achieved in several ways. Some states have an explicit grandfather clause that states the educational requirements that are required for practitioners who were recognized by the state before the master's degree requirement was implemented. North Dakota, for example, requires that a CRNA "either has a graduate degree with a nursing focus or has completed the educational requirements in effect when the person was initially licensed."[emphasis added] Other states indicate that the master's degree requirement applies specifically to CRNAs who apply for initial state recognition after a certain date, thereby indicating that the new requirement does not apply to practitioners already recognized by that state. Georgia, for example, requires that "[b]eginning January 1, 1999, for initial authority to practice as a certified registered nurse anesthetist, an applicant must submit an official transcript which verifies completion/graduation with a master's or higher degree in nursing or a graduate degree with a concentration in anesthesia..." [emphasis added] The effect of this type of provision is unclear concerning a CRNA whose recognition to practice lapses for some reason. It is uncertain whether, in this case, a board of nursing would consider this an instance of an "initial recognition" rather than a "recognition renewal," and require a CRNA whose recognition had lapsed to meet the same requirements as a new applicant. The safest course for a CRNA without a master's degree who practices in a state with a master's degree requirement is to continuously maintain recognition in the state for as long as the CRNA wishes to practice there. * Grandfather clauses (out-of-state CRNAs). The fourth element that states may include in their master's degree requirements is a grandfather clause for CRNAs from other states. Eight of the states (Louisiana, Maine, Missouri, Nevada, New Mexico, North Dakota, Ohio, and Washington) that have adopted master's degree requirements have explicit language concerning whether CRNAs initially licensed in another state must possess a master's degree in order to relocate. All eight of these states require out-of-state applicants to meet the educational requirements that were in effect in the state at the time that the applicant was initially recognized as a CRNA in another state. In addition, Missouri and Ohio also require out-of-state applicants to have "maintained" certification with a national certifying body. Missouri, for example, requires that "active, up-to-date recertification status" must have been "continuously maintained." It is particularly advisable, therefore, that CRNAs who may consider moving to another state be diligent and not allow their recertification to lapse. Eight (Colorado, Connecticut, Florida, Georgia, Mississippi, Montana, Texas, and Wisconsin) of the 16 states that have adopted master's degree requirements do not have explicit statutory or regulatory provisions regarding out-of-state applicants. In five (Connecticut, Florida, Mississippi, Montana, and Wisconsin) of these eight states, however, the master's degree requirement appears, on its face, to apply to both in-state and out-of-state applicants. Connecticut and Wisconsin require CRNAs certified after a certain date to have a master's degree. Consequently, it is implied that both in-state and out-of-state CRNAs without master's degrees who are certified prior to the effective dates would be eligible to practice in these states. Florida and Mississippi require CRNAs who graduate after a certain date to have a master's degree. It appears, therefore, that both in-state and 354 Journal of the American Association of Nurse Anesthetists
out-of-state CRNAs without master's degrees who graduate prior to the effective date in these two states would be eligible to practice. Similarly, Montana requires CRNAs who graduate and are certified after June 30, 1995 to have a master's degree; this requirement would also seem to apply to both in-state and out-of-state CRNAs. The requirements in Colorado and Georgia are more problematic for out-of-state CRNAs. Colorado law requires a graduate degree "on and after July 1, 2008" for inclusion in the state's advanced practice registry. The law includes a grandfather clause, which states that "individuals who are included in the registry as of June 30, 2008, but have not successfully completed such degree, may thereafter continue to be included in the registry and to use the appropriate title and designation." Because this grandfather clause only exempts CRNAs included in the state's registry as of the effective date, it appears that the state would not grandfather outof-state CRNAs after that date. Although it is possible that the state board of nursing would interpret this provision liberally, the law, on its face, appears to exclude out-of-state applicants without master's degrees after June 30, 2008. In Georgia, the rules of the board of nursing provide that, "[b]eginning January 1, 1999, for initial authority to practice as a certified registered nurse anesthetist, an applicant must submit an official transcript which verifies completion/graduation with a master's or higher degree in nursing or a graduate degree with a concentration in anesthesia..." The Georgia Board of Nursing reportedly intends to interpret this language as requiring any applicant for initial authority to practice, whether in-state or out-of-state, to have a master's degree. Regarding Texas, the rules of the Texas Board of Nurse Examiners state that "[b]eginning January 1, 2007, a master's degree in the advanced practice role and specialty will be required for recognition as an Advanced Practice Nurse." Reportedly, the Texas Board of Nurse Examiners has indicated that it will interpret this language as grandfathering CRNAs without master's degrees, who were practicing prior to January 1, 2007, regardless of whether they are from Texas or another state. To illustrate the operation of an out-of-state grandfathering provision, consider the following example: Assume that a CRNA named Ms. Smith lives in state X and does not have a master's degree. Ms. Smith graduated from an accredited nurse anesthesia educational program in 1988 and obtained initial authorization to practice in state X in 1988 as well. Ms. Smith wants to relocate to state Y. State Y currently requires initial applicants for recognition to practice as a CRNA to possess a master's degree; in 1988, however, state Y merely required graduation from an accredited nurse anesthesia educational program. State Y has an explicit provision exempting an out-of-state applicant from having to possess a master's degree if the applicant met the educational requirements that were in effect in state Y at the time the applicant was initially recognized to practice in the other state. Ms. Smith graduated from an accredited program in 1988 and therefore held that credential when she was initially recognized to practice in State X in 1988; since in 1988 state Y required graduation from an accredited program and did not yet require a master's degree, Ms. Smith would be eligible to practice in state Y. Would it be legal for a state to "grandfather" CRNAs currently practicing in the state without master's degrees but not to "grandfather" out-ofstate CRNAs without master's degrees who apply for recognition? This is a very complex legal question without an easy answer. There are substantial arguments that such action by a state would violate the U.S. Constitution. There are few appellate court decisions that illuminate this subject, however, and it is difficult to determine with any certainty how a court might rule. Considerations for state nurse anesthetist associations The trend toward requiring master's degrees for CRNAs is likely to continue in the states, albeit at the modest pace that has developed during the past decade. As a result, state nurse anesthetist associations must monitor proposed legislation and board of nursing regulations carefully regarding master's degree requirements. State associations should develop and maintain a good relationship with the state board of nursing and the state nurses association, as well as other APRN groups in the state. The better a state nurse anesthetist association's relationship is with these groups, the more likely it will receive advance notice that proposed legislation or regulations are being drafted. State nurse anesthetist associations should focus on the four primary elements discussed previously when drafting or reviewing proposals regarding master's degrees: 1. Effective date of the master's degree requirement. 2. Required concentration of the master's degree. 3. Effect of the requirement on CRNAs currently recognized in the state who do not have master's degrees. 4. Effect of the requirement on CRNAs who August 1998/ Vol. 66/No. 4 355
are currently recognized in other states but who do not have master's degrees. Although all nurse anesthesia educational programs are currently at the master's degree level, state associations must still consider the effective date of any new master's degree requirements. Optimally, new graduates should not be required to have a master's degree until the year 2001. Because the concentration of the degrees granted by nurse anesthesia educational programs varies, it is important that the degree concentration required by a state law or regulation is not too narrow or restrictive. Broader requirements, such as a "master's degree in nursing or a related field," or a "master's degree with preparation in the specialty area," are preferable to the more restrictive "master's degree in nursing." Restrictive language could prevent graduates of some nurse anesthesia programs from practicing in your state. For example, requiring a "master's degree in nursing" might exclude graduates of many of the current nurse anesthesia programs. Although this language could be interpreted liberally, it is possible that a board of nursing could adopt a strict position and interpret the language to include only those who have a degree in "nursing." It is always preferable to have statutory or regulatory language be as clear as possible on its face, so that few questions of interpretation can arise in the future. State associations facing a legislative or regulatory proposal to require a master's degree should include a grandfather clause for CRNAs currently practicing in the state. State associations should also seek a grandfather clause for CRNAs who wish to relocate from other states. Considerations for individual CRNAs Does the trend toward states adopting master's degree requirements mean you should obtain a master's degree if you are currently practicing without one? This is invariably a personal decision that can only be reached after assessing your unique career situation. Possible factors to consider include: 1. The stage of your career, e.g., how near you are to retirement. 2. The likelihood that you will want or need to relocate to another state. 3. The possible effects of further education on your chosen career path, e.g., whether additional education would provide more opportunities. If you intend to stay in your state, keep in mind that each state that has a master's degree requirement has "grandfathered" CRNAs currently recognized by the state. This is unlikely to change; in other words, it is improbable that a state would require CRNAs who have been practicing without a master's degree to obtain one. If it is possible that you will want or need to relocate, and you have many years of practice ahead of you, you should evaluate whether a master's degree would be beneficial to you. It is likely that the trend toward master's degree requirements at the state level will continue; how quickly states will move in this direction is, of course, unknown. We cannot guarantee that states that adopt master's degree requirements in the future will grandfather out-of-state CRNAs as well as those in-state. (Although, as stated previously, we would strongly urge state nurse anesthetist associations to seek an explicit grandfathering provision for out-of-state applicants as master's degree requirement proposals arise in the future.) It is extremely important that you contact a state's board of nursing well in advance of any move you are considering. While we have prepared this article with the most current information available, this information could change at any time. In addition, boards of nursing may have internal policies or processes regarding educational requirements that we are unaware of; consequently, it is imperative that you check with the state board of nursing before you relocate. One option for CRNAs who want to obtain a master's degree is a master's degree "completion" program. A list of master's degree completion programs is available on the AANA website at www. aana.com. This information is also available, at no charge, in brochure form by contacting the AANA Resource Center at (847) 692-7050, extension 3009. The AANA website and the brochure contain basic information regarding these programs including prerequisites and degree granted. Many of these programs may be completed on a part-time basis. In addition, some programs are structured for "distance learning." Such programs require infrequent presence on campus, making it possible for CRNAs who do not live near an educational program to complete a degree. Please contact the individual educational programs or the AANA Department of Education at (847) 692-7050, extension 3065 for more information regarding distance learning opportunities. The potential effect of interstate compacts for nursing One concept on the horizon that could affect the educational requirements for APRNs, including CRNAs, is the "interstate compact" model for nurse licensure and regulation, developed by the National Council of State Boards of Nursing (NCSBN). An interstate compact is a "voluntary agreement between two or more states which is de- 356 Journal of the American Association of Nurse Anesthetists
signed to meet common problems of the parties concerned." 3 (An example of an interstate compact is the driver's license model that permits the holder of a driver's license in one state to legally drive in other states without possessing multiple licenses.) A model interstate compact for registered nurses and licensed practical/vocational nurses was adopted by the NCSBN in December 1997. The model has no legal import until enacted into law in individual states. The NCSBN interstate compact for registered nurses (RNs) and licensed practical nurses (LPNs), if widely adopted in the states, would significantly change the administrative process for nurses who currently hold RN or LPN licenses in multiple states. For example, if an RN were to work in more than one state, and those states participated in the compact, the nurse would only have to hold an RN license in the state in which the nurse had a primary residence. The current requirements for scope of practice, disciplinary procedures, and advanced practice authorization, however, would largely remain unchanged. To date, only Utah has adopted the RN/LPN interstate compact, although compact language is expected to be introduced in a number of state legislatures in upcoming legislative sessions. The Utah law is effective January 1, 2000, which is the effective date suggested in the NCSBN's model. It is unlikely that any state enacting the compact into law would adopt an earlier effective date. The RN/LPN interstate compact does not appear to have implications for educational requirements for APRNs, such as CRNAs. The NCSBN is in the process, however, of developing a model interstate compact for APRNs. The AANA has participated with a variety of other national nursing organizations in meetings with the NCSBN to discuss the APRN compact concept. If the NCSBN adopts such a compact model, it will likely contain provisions regarding educational qualifications. The model may well include an educational requirement of completion of an accredited, graduate-level education program for new graduates, with a grandfather clause for current practitioners. If this requirement were included in a model APRN interstate compact and then enacted in a number of states, it would provide a uniform educational standard for APRNs, including CRNAs, practicing in those states. This would facilitate interstate mobility of APRNs and help eliminate any current confusion concerning the various state educational requirements that APRNs must meet in order to practice. For complete uniformity, of course, the compact would have to be adopted in all 50 states. It is unlikely that an APRN compact will be adopted by the NCSBN, and subsequently enacted in the states, in the near future. As a result, the compact is unlikely to provide a quick solution to any problems caused by state master's degree requirements. Conclusion It seems likely that an increasing number of states will adopt master's degree requirements for CRNAs, as well as other APRNs. State nurse anesthetist associations must remain vigilant in monitoring state legislation and regulations to prevent inappropriate provisions that could be harmful to in-state or out-of-state CRNAs or to new graduates. While the adoption of an interstate APRN compact may prove to be a promising approach to resolve confusion at the state level regarding master's degree requirements, adoption of such a compact is not imminent. As changes occur in the states, individual CRNAs need to determine the educational level that best serves their personal circumstances. Further, CRNAs considering moving to another state should first contact the board of nursing in that state to ascertain its practice requirements and to request appropriate application forms. REFERENCES (1) Model Nursing Practice Act and Model Nursing Administrative Rules for Advanced Nursing Practice. Chicago: National Council of State Boards of Nursing, Inc. 1993. (2) Scope and Standards of Advanced Practice Registered Nursing. Washington, DC: American Nurses Association. 1996. (3) Nolan JR, Nolan-Haley JM. Black's Law Dictionary. 6th ed. St. Paul, Minnesota: West Publishing Co. 1990:820. ACKNOWLEDGMENTS The authors would like to thank AANA General Counsel Gene Blumenreich, JD, and Kajal Chattopadhyay, JD, for their legal research and insights concerning the potential legal arguments regarding out-of-state grandfathering provisions. August 1998/ Vol. 66/No. 4 357
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