The Journal of Continuing Education in Nursing

Guest Editorial Free

Looking Back and Leaping Forward—A Reflection on the Evolution of Nursing Continuing Professional Development Credentialing

Jennifer Graebe, MSN, RN, NEA-BC; Kathy Chappell, PhD, RN, FNAP, FAAN

Nurses engage in continuing education/professional development (CPD) for many reasons—to maintain competence, to advance professionally, and to provide the best possible care to patients and families—and sometimes just to learn. Regulatory and certifying bodies are drivers for nurses to engage in CPD, and nurses participate in learning opportunities through their workplaces, academic institutions, private providers, professional associations, and via social media platforms, as well as when collaborating as members of interprofessional health care teams. A brief review of the history of standards for nursing CPD provides context for understanding the past and a perspective on the current state. It also highlights opportunities for the future.


In 1974, the American Nurses Association's House of Delegates approved a resolution to establish an Accreditation Program for continuing nursing education (CNE) (Abruzzese & Hinthorn, 1987). The first formal accreditation review occurred the following year, and by the late 1970s a model had been instituted to accredit CNE approvers and providers at the state, regional, and national levels (DeSilets, 1998). (Please visit The Journal of Continuing Education in Nursing website to view some of the historical documents at

Early standards for CNE focused heavily on process measures, were prescriptive in nature, and emphasized compliance with rules. Educational activities were often designed to improve knowledge only, and evaluation was primarily measured by satisfaction of the learner. Credit for participating in CNE was only awarded if the knowledge gained from the educational activity was considered to be generalizable, and nurses were not given CNE credit for repeat exposure to content.

In the 2000s, a series of public reports on continuing education (CE) were published by organizations such as the Josiah Macy, Jr. Foundation and the Institute of Medicine. Stimulated by quality concerns in the U.S. health care system, these reports examined the relationship between CE and how physicians and nurses “maintain and improve their knowledge and skills in order to provide safe, effective and high-quality healthcare for their patients” (Hager, Russell, & Fletcher, 2008, p. 13). With evidence that the “quality of patient care is profoundly affected by the performance of health professionals,” the purposes of CE, as outlined in the reports, were to improve the quality of patient care by improving each individual practitioner's knowledge, skills and attitudes; ensure continued competence of clinicians; ensure the delivery of safe and effective patient care; and provide accountability to the public (Hager et al., 2008, p. 17).

These landmark reports were a call to action for multiple stakeholders including CE accrediting bodies. A new focus related to ensuring that standards for CE reflected current evidence and best practices in educational design; that providers designed CE to improve competence, practice, and/or patient outcomes; and that members of different professions had opportunities to learn from, with, and about each other in team-based models.


As the body of evidence on learning and change became more robust, the CE system evolved from its compliance roots to the flexible and active learning system of today. The terms CE and CNE have also been incorporated into a larger CPD framework. Although not intended, perceptions of CE and CNE have historically been operationalized to reflect education that is delivered in formal educational settings. In contrast, CPD is intended to convey a more active and desired process of learning over a life span versus continuing education (Cox et al., 2017). The American Nurses Credentialing Center's 2015 accreditation criteria have evolved to reflect this updated vision (

Strong evidence supports that CPD positively and significantly impacts patient outcomes by increasing or improving practitioner knowledge, skills, attitudes, or behaviors. Therefore, all health care professionals must be provided the opportunity and resources to participate (Cervero & Gaines, 2014). In addition, providers of CPD should be well-versed in theoretical frameworks and educational best practices that are the basis for high-quality education (Kirkpatrick & Kirkpatrick, 2006; Miller, 1990; Moore, Green, & Gallis, 2009; Moore, Chappell, Sherman, & Vinayaga-Pavan, 2018).

Effective CPD has common elements, and current standards for providers reflect them. CPD is based on the solid foundation of a needs assessment; and educational activities are designed to address an identified gap that is meaningful and relevant to participants. Education employs an interactive learning style and uses ongoing learner feedback to increase learner engagement. Education is longitudinal when possible, in multi-modal formats, and incorporates time for learners to grasp content. If possible and appropriate, simulation of some type is incorporated into the educational design. Learners from different professions have the opportunity to regularly engage in team-based education.


CPD in the future will continue to evolve to meet the needs of learners, organizations, and health care systems. Globally, health care systems are increasingly challenged by the pace of change and by a workforce that is not prepared to fully meet the demands of the future. As patient care delivery models shift from inpatient to community and from bedside to virtual, retooling and reskilling the health care workforce will be a major priority. CPD is critical for individuals, organizations, and systems to succeed and scale up, and accrediting bodies have a role to play in the transformation.

CPD of the future is the foundation of a learning health system that is part of a larger learning ecosystem. A learning health system is defined as “one in which science and informatics, patient-clinician partnerships, incentives, and culture are aligned to promote and enable continuous and real-time improvement in both the effectiveness and efficiency of care” (Institute of Medicine, 2013, p. 17). In a learning health system, leadership is committed to teamwork, collaboration, and adaptability, and the system continuously refines itself through team training and skill building, analysis, and feedback loops for improvement (Institute of Medicine, 2013, p. 18). The system is dynamic, flexible, and increasingly global. Learning health systems are not confined by organizational boundaries. Learners of the future will build and continue to grow their own personal learning networks without barriers of geography and time.

CPD of the future is outcome-based and competency driven. Learners of the future will build professional portfolios based on their own practice gaps, tailor their CPD to address those gaps, and be supported within a learning health ecosystem that enables learners to access CPD whenever needed and wherever they are. CPD of the future is focused on utilizing outcome-based continuing education (OB-CE©), compared with the current model that is primarily based on time. As health care becomes increasingly outcome driven, the OB-CE is a conceptual framework that specifically addresses the level of learner engagement and expectations for assessment and evaluation (competency) that can demonstrate the potential impact on performance beyond self-report (American Nurses Credentialing Center, 2019; Graebe, 2019). Organizations that invest in implementing OB-CE accreditation standards will be in a unique position to leverage CPD as a strategic organizational priority for nurses (and the health care workforce) throughout their professional careers. Accreditation standards will continue to evolve to support the future of CPD.

CPD of the future will be solution-oriented. Organizations will take advantage of CPD to address performance, patient outcomes, and organizational goals. CPD of the future will no longer be prescribed to adverse events and annual mandatory compliance requirements. CPD will be recognized as an ongoing, fluid, proactive opportunity to promote a growth mindset, support lifelong learning, and address strategic outcomes. CPD will be readily recognized as an opportunity to promote innovation and entrepreneurship, to advance professional practice, and to address key organizational and community-based needs such as adaptive learning, artificial intelligence, and virtual learning.

Building on the rich past of continuing nursing education has transformed what we do and has carried us to the future vision of what the development of a professional means. The movement from counting hours to being outcome based has the potential to celebrate the next 50 years for The Journal.


Nurses have no better time than now to lead the charge in paving a future of CPD that is outcome-based and competency driven, is interprofessional, and supports the lifelong learning of nurses and other members of the health care workforce. Nurses, representing the largest profession in health care, are in a unique position to begin to conceptualize how they will operationalize the envisioned future of CPD to maximize achieving individual, team, patient, and system outcomes. The future is ours to shape!


  • Abruzzese, R.S. & Hinthorn, P.C. (1987). Credentialing. In Puetz, B.E. (Ed.), Contemporary strategies for continuing education in nursing (pp. 277–303). Rockville, MD: Aspen.
  • American Nurses Credentialing Center. (2015). ANCC primary accreditation provider application manual. Silver Spring, MD: Author.
  • American Nurses Credentialing Center. (2019). Awarding credit for outcome-based professional development: Outcome-based CE© model manual. Silver Spring, MD: Author.
  • Cervero, R. & Gaines, J. (2014). Effectiveness of continuing medical education: Updated synthesis of systematic reviews. Chicago, IL: Accreditation Council for Continuing Medical Education.
  • Cox, M., Blouin, A.S., Cuff, , Paniagua, M., Phillips, S. & Vlasses, P.H. (2017). The role of accreditation in achieving the quadruple aim. NAM Perspectives. doi:10.31478/201710a [CrossRef]
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  • Institute of Medicine. (2013). Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press.
  • Kirkpatrick, D.L. & Kirkpatrick, J.D. (2006). Evaluating training programs (3rd ed.). San Francisco, CA: Berrett-Koehler.
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  • Moore, D.E., Chappell, K.B., Sherman, L. & Vinayaga-Pavan, M. (2018). A conceptual framework for planning and assessing learning in continuing education activities designed for clinicians in one profession and/or clinical teams. Medical Teacher, 40, 904–913. Retrieved from doi:10.1080/0142159X.2018.1483578 [CrossRef]30058424
  • Moore, D.E., Green, J.S. & Gallis, H.A. (2009). Achieving desired results and improved outcomes: Integrating planning and assessment throughout learning activities. Journal of Continuing Education in the Health Professions, 29, 1–15. doi:10.1002/chp.20001 [CrossRef]19288562

Ms. Graebe is Director, Accreditation in Nursing Continuing Professional Development and Joint Accreditation, and Dr. Chappell is Senior Vice President, Accreditation, Certification, Measurement, and the Institute for Credentialing Research and Quality Management, American Nurses Credentialing Center, Silver Spring, Maryland.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Jennifer Graebe, MSN, RN, NEA-BC, Director, Accreditation in Nursing Continuing Professional Development and Joint Accreditation, American Nurses Credentialing Center, 8515 Georgia Avenue, Suite 400, Silver Spring, MD 20910; e-mail:


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