Is the licensure system for nursing harming the profession? Serious consideration should be given to developing a new strategy that reflects both the differences inherent in the variety of entry-level educational programs and the expectations for practice upon graduation.

Two interrelated features of licensure practice are particularly problematic. First, one licensure examination is not appropriate for graduates of all entry-level programs. Second, nursing must reconstruct the process for developing and administering the licensure examination.

Today, graduates of all entry-level programs sit for the same examination, regardless of the type of program from which they graduate. This creates unintended negative consequences, confuses the public and potential students, and compromises the clinical development of the discipline.

Through the years, there has been much debate about this practice, with those from baccalaureate programs arguing that the examination does not adequately reflect the scope of practice of the baccalaureate graduate. The rationale for the "one exam fits all" policy is that the state boards are charged with assuring that new graduates can perform safely and effectively as newly licensed RNs.

Thus, all who use that title should demonstrate the same level of competency before licensure.

Because the present approach to testing and licensure does not acknowledge differences in either educational preparation or the scope of practice, many administrators who hire nurses do not feel there is a basis for differentiating nursing roles or salaries.

This lack of differentiation is in sharp contrast to the approach taken by other disciplines, such as physical therapy, which has physical therapy assistants, and engineering, which has technical engineers, both prepared at the associate degree level.

Most importantly, the practice roles of the physical therapist and the engineer differ from those of their technical counterparts. In these fields, the differences in licensure are consistent with the level of educational preparation.

Unfortunately for nursing, the lack of differentiation based on education and reinforced in many work settings serves to diminish the importance of education in clinical practice and is a major disincentive to associate degree- and diploma-prepared nurses to continue their education.

What can be done about the licensure situation? One path is to focus on the scope of practice of the various types of nurses and connect the educational preparation and licensure process to the scope of practice.

This would demand that those associated with AD and BSN programs and nursing service leaders come to grips with this issue and amend the examination and licensure process accordingly.

Perhaps nursing should adopt a more sequential process with some parts of the examination offered at graduation and others after graduates transition into the full scope of their new role.

It might make sense to have BSN and AD graduates take a part of the exam that is similar, but if the scope of practice is different, BSN graduates would be required to pass additional components that may address the science base and other facets of the broader scope.

Nursing is at a crossroads in a highly complex health care environment. We know that we need nursing personnel at various levels; the question is how best to structure the educational preparation, the transition into practice, the practice roles and the licensure/certification processes to achieve the best outcomes for the public.

In an effort to address the issues from the baccalaureate perspective, the American Association of Colleges of Nursing has formed a Task Force on Education and Regulation to define a more logical and coherent approach to linking education, practice roles and licensure.

The task force believes that much more attention must be paid to how we prepare and manage entry into the field of nursing.

Other groups are encouraged to engage this issue and work toward a more rational and effective approach to preparing and developing nurse clinicians.