Taking the confusion out of the regulation of health care professions

AORN Journal,  Jan, 2000  by Christopher Habgood

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There has been much confusion regarding the different ways that health care professions are regulated. The terminology and jargon used to describe regulation can intimidate even the seasoned regulatory professional. As a result, one might wonder what an RN exactly is. An RN is a licensed professional and not a registered professional--and this is how the confusion begins. Registered nurse is a historical term, as opposed to a regulatory term, for how RNs are regulated. Using historical terms has confounded the issues surrounding regulating professionals. For example, the historically used term certified public accountant actually indicates that the practitioner is licensed rather than certified by state regulation.

In many states, a professional may be licensed. In others states, the same profession may be only registered. Furthermore, many nongovernment agencies (eg, professional societies and associations) grant "certification" to those who meet predetermined qualifications, including passing examinations. This type of certification is called a national voluntary certification, rather than a state regulated certification. National voluntary certification can be used in cooperation with state regulatory certification.

One of the most important concepts to understand is that all health care professional regulation is performed at the state level--first enacted by the state legislature and then administered by the state regulatory agency. It is important, therefore, to understand that health care professional regulation is a state issue only. The US Congress is not involved in health care professional regulation. The confusion surrounding professional terms may never be resolved because of the use of historical terminology. Nevertheless, states use the basic principal to regulate professions that only the minimal level of regulation should be used to protect the: public.

MODES OF OCCUPATION REGULATION

There are several different methods that states use to regulate health care professionals.

Practice standards. Without the use of special enforcement, practice standards can establish restrictions--through the adoption of state statutes and rules--on the practice of an occupation with civil or criminal penalties enforceable through the courts. This type of regulation requires no inspections, registration, or special enforcement staff members. Instead, it relies on action by the harmed parties or by a consumer affairs office.

Practice standards also can establish restrictions through statutes, rules, or both, on the practice of an occupation with the use of special enforcement. In this way, practice standards can establish inspections, enforcement mechanisms, and penalties. This method, however, does not require registration, certification, or any assessment of the practitioner's credentials or competency. An example of this practice standard is a section of Arkansas' Rules and Regulations for Hospitals and Related Institutions that states that an RN shall be present in the OR for the duration of the surgical procedure, additional auxiliary personnel shall be available as necessary, and only qualified RNs may perform circulating duties in the OR.

Practice standards like these become hospital rules and regulations that a hospital must follow to be in compliance with hospital licensure. These standards do not define a professional scope of practice, but rather designate standards for the hospital to follow.

Registration. Registration can be accomplished with or without standards. With standards, it is possible to have a registration requirement in combination with minimum practice standards that are set by a designated agency. Although registration would not be exclusionary, it would subject registrants to minimum standards and thereby provide some protection to the public. Registration with standards can include certain minimum practice standards of what a practitioner can do. It is not intended to provide a scope of practice for the profession--it simply provides limits as to what practitioners can do.

Through regulation without standards, a state agency can require people in an occupation to register and supply certain information without requiring any standards, testing, or enforcement.

Registration is the most appropriate form of regulation when the threat to life, health, and safety is relatively small and other forms of legal redress are available to the public. Registration in most states requires an individual to file his or her name and address with a designated agency. Usually, there is no preentry screening by a regulatory agency. Registration in its simplest form does little more than provide a roster of practitioners.

Statutory certification. Statutory certification can be implemented through two methods. One way is without state standards and state enforcement in which occupation members are required to meet certain standards, and only those who meet the predetermined qualifications may legally use the designated title of the occupation. This mode entails standards, testing, codes of practice, possible inspections, and enforcement.