Virginia Association of Clinical Nurse Specialists
The VaCNS exists to enhance and promote the unique, high-value contribution of the Clinical Nurse Specialist to the health and well-being of individuals, families, groups, and community; to promote and advance the practice of nursing; and respond to the rapidly changing health care arena and challenges facing Clinical Nurse Specialists in the Commonwealth of Virginia.
VaCNS serves as the state authority on Clinical Nurse Specialists’ practice, education, and research, and strives to increase statewide visibility and influence of clinical nurse specialists. The Association provides a forum for Clinical Nurse Specialists to advance nursing knowledge, share resources, and discuss current issues to improve healthcare outcomes in Virginia.
HB1747: CNS Licensure and Prescriptive Authority
Purpose of the Legislation
The purpose of HB1747 was to update the Code regarding CNS practice and move CNS practice in Virginia closer to the Consensus Model. The ultimate goals of the Consensus Model are uniformity of regulation of the APRN goals nationwide and allowing APRNs to practice to the full extent of their education, which includes prescriptive authority.
HB1747 also switched CNSs over from just being ‘registered’ to becoming ‘licensed, like the other APRN roles within our state. Licensure means that a governing body grants the ability to perform specific job responsibilities as defined by Code. Also, this lack of licensure has been a barrier to accurately counting the CNS workforce.
Current Bill That is Going Into Law
With the new law, all CNSs who were currently registered on July 1 became licensed as nurse practitioner in the category of clinical nurse specialist without prescriptive authority and jointly regulated by the Boards of Medicine and Nursing. CNSs who desire prescriptive authority will need to submit evidence of qualification, as required in the regulations of the Boards of Medicine and Nursing.
54.1-2957, 1.J. states “Nurse practitioners licensed by the Boards of Medicine and Nursing in the category of clinical nurse specialist shall practice in consultation with a licensed physician in accordance with a practice agreement between the nurse practitioner and the licensed physician. Such practice agreement shall address the availability of the physician for routine and urgent consultation on patient care. Evidence of a practice agreement shall be maintained by a nurse practitioner and provided to the Boards upon request. Thepractice of clinical nurse specialistsshall be consistent with the standards of care for the profession and with applicable laws and regulations.”
Our original intent was for a CNS to only need a practice agreement if applying for prescriptive authority. Unfortunately, when the law was passed, a practice agreement became mandatory for all CNSs. This need for a practice agreement for all CNSs is an error that we are working to rectify.
Why am I Called a Nurse Practitioner?
Under current Virginia law, nurse practitioner is used as an umbrella term for all advanced practice registered nurses (https://law.lis.virginia.gov/vacode/title54.1/chapter29/section54.1-2900/). CNSs became licensed as a nurse practitioner in the category of clinical nurse specialist on July 1.
The terminology used on the Board of Nursing website is licensed nurse practitioner, specialization clinical nurse specialist. This is the same terminology used for certified nurse midwives (CNM) and certified registered nurse anesthetists (CRNA). Their licenses say licensed nurse practitioner, specialization certified nurse midwife and licensed nurse practitioner, specialization certified registered nurse anesthetist.
We are all still clinical nurse specialists because that is how we were educated and how we are credentialed through our certification boards.
Why Did My License Number Change?
Plans to Correct the Language
The VaCNS collaborated with Delegate Dawn Adams, the Department of Health Professions, and the Division of Legislative Services to draft an amendment. This amendment will be introduced in the Special Session of the General Assembly, this summer, to correct this problem. Becky Bowers-Lanier, EdD, MPH, MSN, RN, the VaCNS lobbyist, has discussed possible solutions with Delegate Adams, the Board of Nursing, and the governor’s office.
Proposed Change in Language in the Amendment
The proposed language change for§ 54.1-2957, 1.J is “J. Nurse practitioners licensed by the Boards of Medicine and Nursing in the category of clinical nurse specialist shall practice in consultation with a licensed physician in accordance with a practice agreement between the nurse practitioner and the licensed physician; however, a nurse practitioner who was registered with the Board of Nursing as a clinical nurse specialist immediately prior to July 1, 2021, may practice without a practice agreement with a licensed physician if such nurse practitioner practices without prescriptive authority. Such practice agreement shall address the availability of the physician for routine and urgent consultation on patient care. Evidence of a practice agreement shall be maintained by a nurse practitioner and provided to the Boards upon request. The practice of clinical nurse specialists shall be consistent with the standards of care for the profession and with applicable laws and regulations.
- That an emergency exists and this act is in force from its passage.”
Steps That Will Occur and Expected Timeline
- 6/3/21 The VaCNS contacted the Board of Nursing to request that CNSs not be audited during the time we are working to get the amendment passed. We received email confirmation from Jay Douglas, Executive Director, that the Board does not have any plans to audit this group of licensees in 2021.
- 6/16/21 The VaCNS Board and the VaCNS Legislative Committee reviewed and approved the proposed amendment.
- 6/17/21 Adams submitted a request to Governor Ralph Northam, Speaker Eileen Filler-Corn, and President Pro Tempore Louise Lucas for emergency legislation.
- 6/17/21 Becky Bowers-Lanier notified Speaker Eileen Filler-Corn about the situation and the proposed correction.
- 7/30/21 Budget Bill HB7001 released. Full text of the bill can be read here. The amendments related to clinical nurse specialists are I1 and I2,
"I.1. Nurse practitioners licensed by the Boards of Medicine and Nursing in the category of clinical nurse specialist shall practice in consultation with a licensed physician in accordance with a practice agreement between the nurse practitioner and the licensed physician.
2. Notwithstanding the provisions of paragraph I.1. of this item, a nurse practitioner who was registered with the Board of Nursing as a clinical nurse specialist immediately prior to July 1, 2021, may practice without a practice agreement with a licensed physician if such nurse practitioner practices without prescriptive authority. This provision shall expire after June 30, 2022."
- 8/2/21 Special Session of the General Assembly to convene.
How This Impacts CNS’s Current Practice
- The law that went into effect on July 1 requires a practice agreement until the amendment is approved.
- Malpractice coverage most likely could be impacted if one practices without a practice agreement. Also, your insurer will need to be informed of this agreement. You may incur a fee for this change in your policy.
- Coverage for 3rd party reimbursement, especially Medicare & Medicaid, could be impacted.
- Your billing software and electronic medical record services may also be affected. You will need to change your registration number to your new license number.
Information About Practice Agreements
- "Patient care team physician" means a physician who is actively licensed to practice medicine in the Commonwealth, who regularly practices medicine in the Commonwealth, and who provides management and leadership in the care of patients as part of a patient care team (https://law.lis.virginia.gov/vacode/title54.1/chapter29/section54.1-2900/).
- "Practice agreement" means a written or electronic statement, jointly developed by the collaborating patient care team physician(s) physician and the licensed nurse practitioner(s) that describes the procedures to be followed and the acts appropriate to the specialty practice area to be performed by the licensed nurse practitioner(s) practitioner in the care and management of patients. The practice agreement also describes the prescriptive authority of the nurse practitioner, if applicable (https://www.dhp.virginia.gov/media/dhpweb/docs/nursing/leg/NursePractitioners.pdf).
- The practice agreement is kept by the CNS and is only provided to the Board if requested.
- You will not operate under the physician’s license.
- The practice agreement addresses the availability of the physician for routine and urgent consultations on patient care.
- Physicians who have participated in practice agreements with other APRNs may be familiar with the statutes governing their role.
- Click here for a sample template of a practice agreement. This document can be personalized according to your specialty (Mental Health, Emergency Medicine, Oncology, Heart Failure, Diabetes, etc.).
Information About Consulting/Collaborating Physicians
- May have a practice agreement with 6 APRNs at any given time.
- How do I find a consulting/collaborating physician? You should ask a physician you work with, already consult with, or refer patients to. Neither the VaCNS nor the Board of Nursing is responsible for helping you find a physician.
- Any physician in any specialty could be a consulting/collaborating physician. The law does not give any specific requirements.
- CNSs who work in a hospital could ask a physician on their care team or physician who signed their privileging agreement. If in private practice, perhaps ask a physician to whom you refer patients.
- The HB1747 SBAR may be used to explain the situation to physicians when requesting a practice agreement.