As access to quality healthcare continues to be an ever-present challenge, policymakers look for opportunities to eliminate unnecessary burdens and reduce inefficiencies to promote greater access to care. This includes ways to better use Virginia’s advanced practice registered nurses (APRNs) by ensuring they have the tools they need to practice to the full extent of their education and training.
In Virginia, an APRN is a nurse with post-graduate education in nursing. While an APRN, like a registered nurse (RN), holds an RN license, the APRN must have at least a master’s degree to specialize as a nurse practitioner (NP), a certified nurse midwife (CNM), a certified registered nurse anesthetist (CRNA) or a clinical nurse specialist (CNS). In Virginia, all APRNs, except for CNS, are licensed as nurse practitioners.
With the demand for health care services already straining capacity, APRNs are well qualified to deliver care and can be a part of the solution to address the state’s health care issues and to this end, six bills related to APRN practice were introduced and passed by the 2016 Virginia General Assembly. They took effect July 1.
House Bill 580
House Bill 580, introduced by Del. Roxann Robinson, R-Midlothian, amended Virginia’s Medical Practice Act (Virginia Code § 54.1-2900) and Nurse Practice Act (§ 54.1-3000) to create a standard definition for APRN; clarify the categories of nurse practitioners defined as APRN; and eliminate the practice agreement requirement specific to nurse practitioners licensed in the specialty category of nurse anesthetist.
By defining the term APRN as “a registered nurse who has completed an advanced graduate-level education program in a specialty category of nursing and has passed a national certifying examination for that specialty,” HB 580 helps safeguard public safety by ensuring that only RNs with a graduate degree in nursing can call themselves APRNs. This definition narrows the list of APRN to nurse practitioners, certified registered nurse anesthetists (CRNA), certified nurse midwives (CNM) and clinical nurse specialists (CNS).
The legislation also took a step in eliminating an unnecessary practice barrier by removing the requirement that CRNAs jointly develop a practice agreement with a physician. Given the different practice standards for this particular category of nurse practitioner, the practice agreement requirement was an impediment to practice, and its removal promotes greater access to care.
Previously, all nurse practitioners were required to practice as part of a patient care team as evidenced by a written or electronic practice agreement. The law required that the practice agreement include guidelines for availability and ongoing communications to define consultation among the collaborating parties and the patient, as well as the periodic joint evaluation of the services delivered. The practice agreement requirements also included a provision for appropriate physician input in complex clinical cases and patient emergencies, and for referrals. Further, if a nurse practitioner had prescriptive authority, the practice agreement needed to include the controlled substances the nurse practitioner could or could not prescribe, as well as any prescribing restriction. Practice agreements had to be signed by the patient care team physician or clearly state the name of the patient care team physician who had entered into the practice agreement with the nurse practitioner.
Nurse practitioners not certified as nurse anesthetists or nurse midwives must continue to adhere to these practice agreement requirements. However, HB 480 exempted CRNAs entirely from the practice agreement requirement, and a bill introduced by Sen. Charles Carrico, R-Galax, Senate Bill 463, changed and eliminated many of these practice agreement requirements for CNMs.
Senate Bill 463
Senate Bill 463 changed the practice agreement requirements for CNMs by clarifying that they practice in consultation with a licensed physician in accordance with a practice agreement. The CNM practice agreement addresses the availability of the consulting physician for routine and urgent consultation on patient care. And while the practice agreement must include prescribing authority requirements, those requirements are limited to Schedules II through V drugs. CNMs prescribing Schedule VI drugs do not need to include this specific prescribing authority in the practice agreement.
Senate Bill 264 and House Bill 581
Senate Bill 264, introduced by Sen. Rosalyn Dance, D-Petersburg, and HB 581, a companion bill introduced by Del. Robinson, allows (in limited situations) a nurse practitioner to practice without the requirements of a practice agreement. House Bill 581 allowed that in situations where a patient care team physician dies, becomes disabled, retires, surrenders his license or has it suspended or revoked by the Board of Medicine, or relocates his practice, a nurse practitioner may continue to practice, upon notification to the Boards of Medicine and Nursing, without a practice agreement for 60 days. However, to use the 60-day exemption, the nurse practitioner must be unable to enter into a new practice agreement with another patient care team physician. If the nurse practitioner needs more time in which to secure a patient care team physician, an extension of time may be granted if the nurse practitioner provides evidence that efforts were made to secure another patient care team physician.
Further, under this law, a nurse practitioner who continues to treat patients during the 60-day period without a patient care team physician may continue to prescribe, but the prescription may only be for those drugs previously authorized by the initial practice agreement. Also, the nurse practitioner must have access to appropriate physician input in complex clinical cases and patient emergencies and for referrals.
House Bill 330
House Bill 330, introduced by Del. Brenda Pogge, R-Norge, clarified that clinical nurse specialists are defined as APRNs and removed the authority of the Board of Nursing in approving graduate nursing programs for clinical specialties. It also added a new subsection the Nurse Practice Act (§ 54.1-3018.1) which identifies the qualifications necessary to be registered as a clinical nurse specialist. While clinical nurse specialists are now identified as APRNs, they are the only category of APRN not licensed as a nurse practitioner.
Senate Bill 369
Sen. Bill Stanley, R-Moneta, introduced Senate Bill 369 which established a pilot program to expand access to care in rural and medically underserved areas through telehealth technologies. The legislation requires that the pilot program include a process for helping participating nurse practitioners identify and develop written or electronic practice agreements as well as developing and maintaining a list of physicians available to serve as patient care team physicians for nurse practitioners participating in the pilot program. The bill has an expiration date of July 1, 2018.
As Virginia continues to grapple with its health care challenges, it is not unexpected that additional changes will be made to laws governing APRNs. The legal and healthcare communities must pay particular attention to ensure each category of APRN practices in accordance with the exact legal requirements laid out for them.