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education outcomes. The rigorously conducted systematic review by Issenberg and colleagues (2005) on the use of simulation in medical education provided crucial data for nurse regulators on how simulation might best be used in nursing education. Other nursing studies have provided similar answers (Jeffries, 2007). However, further studies on the effects of simulation on outcomes are needed. The Future of Evidence-Based Nursing Regulation Nursing regulatory bodies need to conduct more research—particularly systematic reviews. Ridenour (2009) suggests that a central clearinghouse be developed to catalog research results, including studies with negative results. Because of the challenges posed by the hierarchy of studies and the need for RCTs, Pawson (2006) and McEvoy & Richards (2003) suggest the future will bring a paradigm shift from the positivist to a realist perspective in evidence-based health care. Realists believe in the fallibility of scientific observations; they study why and how interventions work rather than “delivering summative verdicts” (Pawson, 2006, p. 93), as is currently done with systematic reviews. Pawson boldly calls for a new protocol for systematic reviews using the realist synthesis. The steps of the realist synthesis resemble those of the systematic review, but the focus differs. Realists spend much time developing questions, such as “How is the program supposed to work?” and “Is the program theory applied consistently and cumulatively?” Because the questions are more complex, the search procedures are more intricate; thus, these reviews are more likely to include “gray” literature. An example of a realist review is Pawson’s review of youth mentoring (2006). Pawson first developed from the research a theory describing mentoring. He then identified nine key studies, which included those with qualitative, quantitative, and multimethod designs as well as one highly technical meta-analysis. Mentoring involves a relationship; thus, diverse studies must be employed to analyze use of this strategy in developing policies. The conclusion of this review was offered as a model to describe why mentoring programs work and why they fail—not as a directive to develop or opt out of mentoring programs. This differs starkly from the conclusions of systematic reviews, which provide summative verdicts. While the realist view and systematic review differ philosophically, both require the scientific rigor of methodological appraisals. Pawson (2006, p. 78) also emphasizes the need in realist reviews (as in traditional systematic reviews) for “auditability” or transparency. Conclusions With the body of knowledge in nursing regulation still emerging, regulators do not have a great deal of evidence on which to base regulatory decisions. As the knowledge base broadens and the science develops, it is critical that they study the issues rigorously. While regulators face many challenges in evidence-based regulation, opportunities exist for development in this field. Comparing costs and quality of Nurse Practice Acts Guide and Govern Nursing Practice Kathleen A. Russell, JD, MN, RN The practice of nursing is a right granted by a state to protect those who need nursing care, and safe, competent nursing practice is grounded in the guidelines of the state nurse practice act (NPA) and its rules. All nurses have a duty to understand their NPA and to keep up with ongoing changes as this dynamic document evolves and the scope of practice expands. This article reviews the reasons for and the importance of state NPAs and associated rules. Continuing Education Volume 3/Issue 3 October 2012 www.journalofnursingregulation.com 37 The first nurse registration law, enacted in 1903 in North Carolina, was written to do just that—protect the title of nurse and improve the practice of nursing. Developing nursing exams and issuing licenses was entrusted to the North Carolina Board of Nursing (UNC TV, 2012). New Jersey, New York, and Virginia passed registration laws that same year. These early acts did not define the practice of nursing, but in 1938, the state of New York did define a scope of practice for nursing (NCSBN, 2010). By the 1970s, all states required licensure for registered and practical nurses. Advanced practice nurses can be traced to the Civil War, when nurses assisted during surgery with anesthesia services (Hamric, Spross, & Hanson, 2005, p. 4). Advanced practice registered nurse (APRN) roles and specialization have continued to this day as has the evolution of formal scope of practice language within legislative statutes. Nurse’s Guide to Action How could a law function as a guide to action if almost no one knows it? (Howard, 2011, p. 30). The laws of the nursing profession can only function properly if nurses know the current laws governing practice in their state. All states and territories have enacted a nurse practice act (NPA). Each state’s NPA is passed by the state’s legislature. But the NPA itself is insufficient to provide the necessary guidance for the nursing profession. Therefore, each NPA establishes a board of nursing (BON) that has the authority to develop administrative rules or regulations to clarify or make the law more specific. Rules and regulations must be consistent with the NPA and cannot go beyond it. These rules and regulations undergo a process of public review before enactment (NCSBN, 2011a;
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