louisiana state board of nursing (lsbn) jennifer alleman aprn, fnp-bc aprn compliance officer april...
TRANSCRIPT
Louisiana State Board of Nursing
(LSBN)Jennifer Alleman APRN, FNP-BC
APRN Compliance OfficerApril 3, 2013
Advanced Practice Registered Nursing
Objectives
Discuss Role & duties of LSBN Identify a brief historical review of
evolution of APRN licensure & PA in LA
Provide overview of Consensus Model
Address Significance of Nurse Practice Act/ NPA and Chapter 45
Explain Factors Effecting Scope of Practice of APRNs
Organization of LSBN
Administrative agency under the Department of Health and Hospitals (per R.S. 37:914-917)
Board members- appointed by governor & confirmed by Senate for 1-4 yr term(s) includes 9 RNs and 2 physicians
(ex officio/advisory-non voting) Organization of Board staff/agency
Departments: Education, Investigation, RNP, Hearings, Credentialing & Practice, Admin
Executive Director
Duties of the Board (R.S. 37-918)
Nursing Education Establish Minimum
Curriculum Requirements Approve Nursing Education
Programs Nursing Practice
Establish Standards of Nursing Practice
Duties of the Board (R.S. 37-918 Con’t)
Nursing LicensureExamineApproveRenewReinstate
Registered NursingR.S. 37:913 (14)
Nursing Practice Appropriate to Individual’sEducational LevelKnowledgeSkillsAbilities
RNP
Recovering Nurse Program Purpose: identify & assist impaired
nurses/students to seek treatment to remain productive members of the profession without jeopardizing public safety
70% of disciplinary actions taken by BONs are related to alcohol or substance abuse
Occupational risks: easy access, shift work, high stress
Option for confidential participation
APRN
Per LAC46: XLVII.4503 means “a licensed registered nurse who is certified by a nationally recognized certifying body…as having an advanced nursing specialty…”
The Board may establish commensurate requirements
APRN (con’t)
Advanced Practice Registered Nursing (APRN) R.S. 37:913 (3)(a) Includes (functional roles) Certified Registered Nurse
Anesthetist Certified Nurse Midwife Clinical Nurse Specialist Nurse Practitioner
APRN (Con’t)
Requires Minimum of Master’s Degree with a concentration in APRN role and population including: Didactic and Clinical Components Advanced Knowledge in
Nursing TheoryPhysical and Psychosocial Assessment
Nursing InterventionsManagement of Health Care
Practice Act
This law authorizes the Louisiana State Board of Nursing
to establish administrative
rules and regulations to implement the
Nurse Practice Act in accordance with the Administrative
Procedure Act.
The practice of the RN and APRN
is set by the Nurse Practice Act
as well as other statutory laws
including administrative,
criminal and civil
Serves as an example of statutory law
Nurse Practice Act
Nurse Practice Act (con’t)
NPA=“The Law Governing the Practice of Nursing” “what” has to be done
Rules and regulations “how” it has to be done
Purpose of Nurse Practice ActL.R.S. 37:911
Practice of nursing by qualified individuals is necessary to protect the public health, safety and welfare of the citizens of this state.
Regulation of nursing is in the public interest.
Purpose of Nurse Practice Act
L.R.S. 37:911 (Cont) The legislative intent and
purpose is to promote, preserve and protect the public health, safety, and welfare by regulating nursing education and practice and ensuring licensure of nurses.
Historically
2012 LSBN 100th anniversary- 1st NPA (organized by LSNA)
3/1981 LSBN adopted rules defining Advanced Practitioner of Nursing including Primary Nurse Associate (aka NP), CNM, CRNA, CNS Amendment adopted re: grandfathering
4/1981 civil suit filed against LSBN To invalidate rules regarding NPs Contended nurses practicing medicine
Historically
11/1989 suit dismissed after appeals exhausted
1995 Committee on prescriptive Authority developed by legislature under joint jurisdiction of LSBN & LSBME
1996 licensure & certification of APRNs required in LA
3/1996 Rules governing demonstration project “under the direction of a physician” Oversight of all Dx & Rx Co-sign charts
Historically
Physician had to be a certain geographic/time distance away
Limitations on # of APRNs per collaborator
Duplicate prescriptions required Detailed data gathered from each
APRN/site Some APRNs not participate or withdrew
from project b/c process cumbersome
Historically
~2001 rules developing for CS 2004 LSBN responsible for initial PA
apps To present- rules evolve to current
requirements Chapter 45- regulations regarding
APRNs
Chapter 45
Rules and regs pertaining to “Advanced Practice Registered Nurses” Definitions Licensure Continued competence Authorized practice (4513)
SOP, PA, CS
Chapter 45 (con’t)
Changes proposed- in process APRN Task Force (18+ people)
Met January 2010-Dec 2011 for 12 mtgs LONE-LA Organization of Ns Executives LACANE-LA Council of Administrators
of Nursing Education LSNA, LSBN (staff and Board
members), LANA, CNS, CNM, AARP
Chapter 45 (con’t)
Considered changing restrictions for APRNs utilizing controlled substances to treat chronic pain and obesity
Recommendations for guidelines for APRN delegation to unlicensed assistive personnel
Administrative functions Consistent terminology in alignment
with NCSBN Regulations for disaster/crisis
situations
NCSBN
National Council for State Boards of Nursing
Consensus Model=model for APRN regulation developed in response to expansion of APRN numbers and capabilities, lack of common definitions in APRN roles, proliferation of specialty and subspecialty roles, lack of standardization of APRN programs
NCSBN (con’t)
Position paper on NCSBN Consensus Model for APRN Regulation. LSBN adopted this model. 5 states currently comply fully (NM, MT, ND, UT, VT)
License in 1 of 4 roles with a population focus
Standardize Licensure, Accreditation, Certification, Education (LACE)
License when education and certification are congruent
https://www.ncsbn.org/2567.htm (APRN Maps)
NCSBN Goals for BONs
License in one of four roles with a population focus
Be solely responsible for licensing of APRNs Some states regulate nurses through other
agencies Only license graduates of accredited
programs Not issue a temporary license **** Only license an APRN when education
and certification are congruent
(****=LA has not reached these goals)
NCSBN (goals con’t)
License APRNs as independent practitioners with no regulatory requirements for collaboration, direction or supervision *****
Allow for mutual recognition through compact****
Have at least one APRN representative on Board and have an advisory committee including all four roles
Institute a grandfathering clause
(****=LA has not reached these goals)
NCSBN model
APRN
Role
Specialty
Competencies
Specialty Certification*
Licensure: based on EducationAnd certification**
Identified by Professional Organizations(e.g. oncology, palliative care, CV)
Measures of competencies
CNP, CRNA, CNM, CNS inPopulation context
APRN Core Courses: Patho/phys,Pharmacology, physical/health assess
Population Foci
APRN Regulatory Model
NurseAnesthetist
NurseMidwife
Clinical NurseSpecialist
Adult-Gerontology
Women’s Health/Gender Related
Family/IndividualAcross lifespan
Neonatal PediatricsPsych/Mental
Health
Lic
ensu
re a
t le
vels
of
role
an
d
p
opu
lati
on f
oci
POPULATION FOCI
APRN ROLES
APRN SpecialtiesFocus of Practice beyond role and population focus
Linked to health care needsExamples include but are not limited to: Oncology, Older Adults,
Orthopedics, Nephrology, Palliative care, Critical Care
Nurse Practitioner
Credentialing for Licensure & Practice
Must be prepared academically in the functional role
Must have demonstrated competency in the population (ie. FNP, PNP, WHNP)
Must be certified in the functional role and population
Sub-specialty certification (diabetes management, palliative care, etc) optional- cautionary note
Advanced Practice
Per NPA section 913(3)a: Assessing patients Analyzing data and synthesizing data Knowledge of and applying nursing
principles at an advanced level Working with patients & families in
meeting health care needs Collaborating with other health care
providers
Advanced Practice (con’t)
Managing patient’s physical and psychosocial health-illness status with regard to nursing practice
Using research skills Analyzing multiple sources of data Making decisions in solving patient
care problems and selecting treatment regimens in collaboration with a licensed physician or dentist
Advanced Practice (con’t)
Consulting with or referring patients to licensed physicians, dentists, and other healthcare providers in accordance with a collaborative practice agreement
May include certain acts of medical diagnosis, in accordance with R.S.37:913(8)and (9)
Medical prescriptions of therapeutic or corrective nature, prescribing assessment studies, drugs, therapeutic regimens, and distributing drugs for administration to and use by other individuals within the scope of practice
NONPF
National Organization for NP Faculties NP curriculum
Standards & criteria for programs Seamless education experience
NP competencies (for core and population focused)
NONPF (con’t)
Expectations of faculty practice Health Policy Practice Doctorate Task Force 2001
Supports/recommends clinical doctoral education for entry into NP practice
Clarification
■ NCSBN & NONPF provide models and recommendations that are widely respected, accepted, and utilized
■ However, licensing boards are the final arbiters regarding APRN practices (in non-federal settings)
Application Process for APRN Licensure
1) Must have active, unrestricted, valid RN license first
2) Application on LSBN website (with instructions)- begin 4-6 wks prior to graduation ie. initial APRN Licensure by Exam –
form AP1 3) CBC/FP
LSBN gets arrest reports M-F 4) Verification of education &
certification
Application Process for APRN Licensure (con’t)
Verification of education-directly from school Transcript and AP2 form
Verification of certification-directly from certifying body Nationally Recognized Certifying Body-
national certification organization which certifies qualified licensed nurses as advanced practice registered nurses and which requires certain eligibility criteria related to education and practice.
APRN Temporary Permit
Temporary permit is optional- no added fee
Maximum 120 days - why Nullified once certification results
received by LSBN (regardless of results) or can be recalled
Roles: APRN student APRN applicant licensed APRN
APRN Temporary Permit (con’t)
“What can I do as an APRN applicant?” must practice “under the guidance of a
licensed APRN, physician, dentist, or approved preceptor within the practice specialty and functional role of the applicant” as per LAC 46:XLVII.4507B(1).
must use the title “advanced practice nurse applicant” or “APRN applicant” while working under the temporary permit
Cannot legally work in APRN role without permit or license once APRN program completed
APRN Temporary Permit (con’t)
Temporary Permits for APRNs may no longer be an available option after June 2013 Therefore, if students completing a
program in May 2013 wish to be employed as an APRN shortly after completion of the APRN program, then they should consider applying for certification as soon as they are eligible
Check with certifying body for eligibility Apply for licensure promptly
Prescriptive Authority (PA)
Can be applied for and granted after being fully licensed as an APRN
The APRN who engages in medical diagnosis and management must have a collaborative practice agreement (LAC 46:XLVII.4513B) which is submitted to & approved by LSBN.
Definition adopted by LSBN of “prescribe-to direct, order, or designate…”
Prescriptive Authority (con’t)
Prescriptive authority (PA)- gives authority to medically manage clients; authorizes APRN to prescribe assessment studies, medications, therapeutic regimens, medical devices, receive & distribute prepackaged medications and samples
Must apply for PA and receive written approval by the board before engaging in medical diagnosis and management
Prescriptive Authority (con’t)
34 states have requirements for documentation of physician involvement with NP prescribing
16 states + DC have no requirement for physician involvement with NP prescribing
CRNAs in LA- work “under the direction and supervision of a physician” Supervision effects billing with MCare Some exceptions to needing PA
Prescriptive Authority (con’t)
Authorized Prescriber - a licensed physician, dentist, or other health care provider authorized by law to prescribe drugs, medications, medical devices or appliances, and health care regimens.
Collaborative practice - the joint management of the health care of a patient by an advanced practice registered nurse and one or more consulting physicians or dentists
Prescriptive Authority (con’t)
Be aware of Ch 45 regs regarding prescribing
Format of prescription dictated by LA Board of Pharmacy (LBP)- ver batim in LSBN regs
Guidelines for prescribing in regulations: Perform and document H&P Make diagnosis Formulate therapeutic plan Provide for follow-up
CPA
Collaborative practice agreement (CPA) is defined in LAC 46:XLVII.4505 as a formal written statement addressing the parameters of the collaborative practice which are mutually agreed upon by the advanced practice registered nurse and one or more licensed physicians or dentists, referred to as collaborating physicians.
An agreement between APRN & collaborating physician(s)-must be approved by LSBN
CPA (con’t)
Collaborating physician is defined as a physician actively engaged in clinical practice and the provision of patient care with whom the APRN has developed and signed a collaborative practice agreement for prescriptive and distributing authority and who holds a current, unencumbered, unrestricted and valid medical license issued or recognized by the Louisiana State Board of Medical Examiners.
CPA (con’t) Can use template on LSBN website or
customize one Must meet certain criteria and contain
specific information such as: 1) Availability of the collaborating physician, 2) Methods of management, 3) Coverage of health care needs of patient
during any absence of APRN and/or physician, 4) other
Clinical practice guidelines Assist in defining parameters of practice &
methods of joint management that are agreed upon
CPA (con’t)
May elect to keep a copy of CPA for yourself LSBN does not require APRN or
employers to keep copy of CPA ( but is prudent practice)
Employment relationship vs collaborative relationship Collaborating physician & employer
may or may not be the same (unless required by facility, billing agency, CMS, etc.) – ie. “incident to” billing
Collaborating physician must have privileges at same facilities where APRN provides services
CPA/PA
Consulting with physicians other than the collaborator is obviously not prohibited
Approval letter sent to APRN when he/she applies for PA or makes any changes
How can someone validate if an APRN has PA? Licensure verification on LSBN website PA=prescriptive authority CS=controlled substances
Controlled Substances (CS)
Will continue to be an additional privilege- not required
Next steps after being granted CS authority by LSBN: Apply to LBP for LCDS number; then Apply to DEA for number (costs
>$700/3 yrs) APRN is fully authorized to
prescribe CS after LSBN has LCDS+DEA on file & APRN receives letter
Controlled Substances (con’t)
“an APRN granted authority to prescribe or distribute controlled substances shall not utilize such substances in connection with the treatment of:
(a). chronic or intractable pain, as defined in
LAC 46:XLV.6515-6923;(b). obesity, as defined in LAC 46:XLV.6901-
6913; or(c). oneself, a spouse, child or any other
familymember;”
Controlled Substances (con’t)
Do not use someone else’s DEA! Suggestion- Sign up for PMP when
you have CS authority Be familiar with schedules (ie.
Ambien, Lyrica, testosterone, Soma, PSE)
Be familiar with DEA and LBP regulations ie. Tramadol
Standards of Practice
The core standards for advanced practice: Must meet Registered Nurse Standards Shall assess patients at an advanced
level, identify abnormal conditions, analyze and synthesize data to establish a diagnosis, develop treatment plans ,and evaluate patient outcomes.
Use critical thinking skills and independent decision making
Scope of Practice
Must practice in the area that APRN is prepared
Must meet entry level competency for licensure
Competency in nursing practice appropriate to an individual involves: Knowledge Skills Abilities Educational Level
Scope of Practice (con’t)
Multiple factors considered/influence SOP:- Laws
Nurse Practice Act (NPA) Federal & state statutes
- Rules & regulations of the NPA- Professional Competencies- Certifying Bodies - Other professional regulatory agencies
(ie LBP, LSBME)
Scope of Practice (con’t)
- Declaratory Statements from LSBN- Practice opinions issued by LSBN - Institutional/Facility policies- cannot
exceed legal limits nor requirements of regulatory agencies
- Professional organizations
Scope of Practice (con’t)
Understand that for an activity to be within your SOP, an APRN must have BOTH the ability as well as the authority to perform the function.
Algorithm on LSBN website to assist with determining whether activity is within SOP “Are you prepared to accept the
consequences of your action?” Can submit practice petition to
LSBN
Scope of Practice (con’t)
Specific prohibitions (in LA): PICC placement- “…placement must be
determined by a physician prior to initiation of therapy.” (recently revised to include certain APRNs)
Pronouncement of death per LA R.S. 9:111 – out of SOP of APRN. Must be physician. (consideration to coroner’s investigators, EMTs on scene)
PEC-Out of SOP of APRN except PMHNP
DEA- has specific guidelines about methadone/suboxone/ calling in CS
Scope of Practice (con’t) Drug Addiction Treatment Act (DATA) -
prescription use of Suboxone in the treatment of opioid dependence is limited to physicians (who meet certain qualifying requirements & are certified)
Prescription of Methadone for opioid dependence- must be in approved setting
Prescribing suboxone/methadone for chronic pain by APRN-prohibited in Louisiana (including refills)
Scope of Practice (con’t)
Specific prohibitions (in LA per LSBN regs): Cannot delegate your PA Cannot compound Cannot receive CS samples Cannot delegate complex tasks to non-
licensed personnel including medication administration
Scope of Practice (con’t)
Specific prohibitions con’t Some federal laws have physician only
language. Per federal regulations: Nursing Home rounds- cannot be performed
by APRN IF APRN is employee of the facility Initial examination for NH- must be by
physician-debated Physician must order home health Every hospitalized patient under Medicare
will be under the care of a physician Only a physician can be medical director of
hospice/home health
Scope of Practice (con’t)
Maintain advanced practice recertification
In accordance with nationally certifying organization’s criteria CE requirements Active clinical practice
Co-signatures
LSBN does not have a specific regulation requiring that an APRN’s prescriptions or documentation must have a co-signature.
Employer, facility, institution, or other federal or state statute may require a co-signature.
What does the co-signature mean?
Co-signatures (con’t)
***a co-signature does not expand an APRN’s (or RN’s) scope of practice to that of the person co-signing. If an APRN or RN is not authorized to provide a certain procedure or service, then a co-signature or order written as a verbal order does not provide immunity from liability and responsibility for an act or service provided by the APRN.
TIPS
Remember you are an RN first #1 Know your SOP Provide recertification
documentation to LSBN Know your SOP & avoid role
confusion LSBN can help support your practice
Tips
Keep informed about issues effecting your practice (regarding LSBN)-access your resources Read “The Examiner” Keep your address and email up to date Read emails sent to you from LSBN
Make sure these are not in your spam/junk mail folders
Monitor Board meeting agenda items Check out the website
TIPS
Understand and comply with NPA, rules & regs
Familiarize yourself with clinical practice guidelines/evidenced-based practices
Seek preceptors who have achieved the title/credentials, experience, and licensure you are pursuing
Questions
“Will I need a DNP to practice as an APRN in the future?”
“What if I want to work in another state?”
“Do I need PA as a CRNA?” “Should I join a professional
organization?” “What if I do not pass certification
on my first attempt?”
