The broadly written laws and rules allow nurses to practice to their full scope of practice in any setting. It is impossible for the Nursing Care Quality Assurance Commission (NCQAC) to provide a comprehensive listing of the duties that licensed nurses are permitted to perform since nursing practice is reflective of the dynamic changes occurring in healthcare and society. The Revised Code of Washington (RCW) 18.79 and Washington Administrative Code (WAC) 246-840 provide the statutory and legal basis of nursing practice. The nursing commission provides advisory opinions and interpretive statements about specific areas of nursing practice.
These commonly asked questions and answers offer information and general guidance regarding the practice of professional nursing in the State of Washington and do not constitute legal advice. You should contact your legal advisor to obtain advice with respect to any particular issue or problem.
Advanced Registered Nurse Practitioner (ARNP) Practice Information
The nursing commission recognizes and licenses 4 ARNP designations in accordance with WAC 246-840-302 which include:
- Nurse practitioner (NP)
- Certified nurse-midwife (CNM)
- Certified registered nurse anesthetist (CRNA)
- Clinical nurse specialist (CNS)
Advanced Practice Subcommittee Information
The Advanced Practice subcommittee meets every 3rd Wednesday of the month from 7:00 - 8:00 PM (PST).
Resources and Links
- Clinical Nurse Specialist
- Why did the Nursing Care Quality Assurance Commission (NCQAC) add a new designation of clinical nurse specialist (CNS) to advanced registered nurse practitioner licensure?
The National Council of State Boards of Nursing (NCSBN) Advanced Practice Registered Nurse (APRN) Consensus Model describes a model of regulation with four roles:
- certified registered nurse anesthetist (CRNA),
- certified nurse-midwife (CNM),
- certified nurse practitioner (CNP), and
- clinical nurse specialist (CNS).
The NCQAC is a member board of the NCSBN and supports alignment with the APRN Consensus Model, viewing it as an important step to promote uniformity in nursing regulation.
- When did the new rules go into effect?
The NCQAC approved the rules on January 8, 2016. The new rules became effective April 30, 2016. See WAC 246-840-300 through 455 for more information.
- How do I apply for licensure as an ARNP CNS?
You must be licensed, or obtain a current/active Washington RN license, and submit the:
- appropriate ARNP license application (initial application or endorsement),
- required fees, and
- employment verification of advanced practice hours (when applicable).
Your university and certifying body must send official transcripts and proof of national certification directly to the NCQAC. See the advanced registered nurse practitioner webpage for information, instructions, and application forms.
- What requirements do I need to meet to get my initial licensure as an ARNP CNS?
The requirements for initial ARNP CNS licensure include:
- An active Washington State registered nurse (RN) license without sanctions or restrictions
- A graduate degree from an advanced nursing education program accredited by a national nursing, accreditation body recognized by the U.S. Department of Education
- National certification as a CNS from a NCQAC approved certification body
- If requesting prescriptive authority:
- If you graduated within the past two years when applying, your official transcripts must show a completed pharmacology course
- If you are endorsing, you must show proof of 30 continuing education hours of pharmacology completed within the past two years
- If you graduated within one year of applying, no employment verification is needed
- If you graduated more than one year ago, you must show proof of 250 hours of ARNP CNS practice hours within the last two years.
- If you do not have the completed hours, you must complete supervised hours (125 hours for every year out of practice [maximum 1,000 hours])
- I received my advanced practice education and license outside of the United States. What requirements do I need to meet in order to get an ARNP CNS license?
The requirements for ARNP CNS licensure for an applicant who received an education and license as an advanced practice nurse outside of the United States include:
- Holding an active RN license without sanctions or restrictions issued by a regulatory entity outside the United States and proof of practicing as an ARNP CNS,
- Applying for and being granted a Washington State RN license,
- Submitting a course-by-course evaluation of education from a NCQAC approved credential evaluating service,
- Holding a national certification as a CNS from a NCQAC approved entity, and
- Completing at least 250 hours of advanced clinical practice hours within two years before the date of application.
- Do I need national certification to be licensed as an ARNP CNS?
Yes. ARNP CNS licensure requires national certification by a NCQAC-approved entity:
- I have a Washington State RN license and meet CNS requirements. I have not been practicing in an advanced role. I plan to apply for the ARNP CNS license. Will I need to meet the practice hour requirement in advanced practice?
If you do not apply within one year of earning your graduate degree from an advanced nursing education program, you will need to meet the 125 hours advanced clinical practice hours for each year following graduation (not to exceed 1,000 hours). The nursing rules define advanced clinical practice as practicing at an advanced level of nursing in a clinical setting performing direct patient care. Advanced nursing practice means the delivery of nursing care at an advanced level of independent nursing practice that maximizes the use of graduate educational preparation, and in-depth nursing knowledge and expertise in such roles as autonomous clinical practitioner, professional and clinical leader, expert practitioner, and researcher.
- I have a license and practice as a CNS advanced practice nurse in a state that does not require national certification. Is there a way to get my ARNP license without the national certification through NCQAC?
Applicants for ARNP licensure in the CNS designation must meet the national certification requirements. Qualifications and requirements are determined by the certifying body:
- I do not meet the advanced clinical practice hours required for ARNP CNS licensure but meet the other requirements. How can I get advanced practice hours?
An ARNP, a physician, or an osteopathic physician licensed in Washington State (or equivalent licensure from another state or United States jurisdiction) may provide supervised practice hours. You may also take a course at a university to obtain the needed practice hours. The supervisor must meet the following requirements:
- Be in the same practice specialty of the applicant,
- Have an active advanced practice or physician license, without sanction or restrictions,
- Not be a relative of the applicant,
- Not have a personal or financial relationship with the applicant,
- Not have a current disciplinary action on the license, and
- Submit a written evaluation to the NCQAC verifying the applicant's successful completion of the required supervised clinical practice hours attesting that the applicant's knowledge and skills are at a safe and appropriate level to practice as an ARNP CNS.
The NCQAC must approve the supervisor and the clinical supervision site. You may not use the designation of ARNP during the time of supervised practice hours.
- Am I required to apply for prescriptive authority as an ARNP CNS?
No. Prescriptive authority is not a requirement for ARNP CNS licensure. You may indicate your preference in the ARNP application. If you choose to apply for prescriptive authority, you must have documentation of 30 contact hours of education in advanced pharmacology. The education must include didactic and clinical application and consist of pharmacodynamics, pharmacokinetics, pharmacotherapeutics, and pharmacology management of individual patients related to your scope of practice. Pharmacology education must be completed within the last two years before the application for prescriptive authority.
- I am an RN currently working in a position titled CNS. I do not meet the educational requirements to qualify as an ARNP CNS. May I continue to work in this position and use the title CNS?
The title “clinical nurse specialist” or “CNS” is not a protected title. You may continue to work in a CNS-titled position and identify yourself using the term clinical nurse specialist or CNS. You may continue to practice at scope of practice for an RN within your legal and individual competencies. You may not use the title ARNP.
- I am an RN with the ANCC specialty certification in public health nursing-advanced (APHN). Does this certification meet the requirements for an ARNP CNS?
No. Nurses with a non-CNS specialty certification, who do not meet the qualifications as an ARNP, may not be licensed as an ARNP CNS.
ANCC and other approved certification bodies may have several categories of certifications, including CNS, and also provide numerous non-CNS specialty certifications. Examples include: nurse executive-advanced-board certified (NEA-BC), forensics nursing-advanced (AFN-BC), and registered nurse-board certified (RN-BC). The requirements for specialty certification differ between the non-CNS and the CNS certification. Other entities may also provide certifications that are not an approved body. Examples include nursing certifications through the Wound, Ostomy, and Continence Certification Board: advanced practice wound, ostomy or continence nurse (CWCN-AP®) and certified foot care nurse (CFCN®).
- Am I required to apply for an ARNP CNS if I have the national certification and meet the other requirements?
You are not required to apply for an ARNP CNS license. However, you will not be able to practice at the advanced level without the ARNP license.
- May I be certified as a CNS in more than one CNS specialty practice area?
You may be certified as an ARNP in more than the CNS specialty practice area. Just as with other ARNP categories, the ARNP CNS must obtain and maintain education, training, and practice in each area.
- How do I decide what graduate school to attend to qualify for licensure as an ARNP CNS?
Find out if the nursing education program is aligned with the APRN Consensus Model and whether its program will qualify you to test for the NCQAC-approved certification bodies.
- Is there a "grandfathering" option?
The rule does not include a “grandfathering” option. All applicants must meet the current requirements for ARNP licensure.
- May I request a hearing if my application for licensure as an ARNP with the CNS designation is denied?
Yes. If an application for licensure is denied, the NCQAC sends a notice of decision, which includes instructions about how to request a hearing to appeal the denial.
- Patient Abandonment
- What is the legal definition of patient abandonment?
The Washington State nursing laws and rules don't define patient abandonment.
The Washington State Board of Nursing (WABON) has investigated and disciplined nurses for issues surrounding the concept of abandonment as it relates to the nurse’s duty to a patient.
The WABON’s position applies to the licensed practical nurse, registered nurse, and advanced registered nurse practitioner.
Some behavior may be considered an employer-employment issue and not patient abandonment.
The American Nurses Association (ANA) defines patient abandonment as “a unilateral severance of the established nurse-patient relationship without giving reasonable notice to the appropriate person so that arrangements can be made for the continuation of nursing care by others…”
- What does the Washington State Board of Nursing (WABON) consider as patient abandonment?
The nurse’s duty is not defined by any single event, such as clocking in or taking a report.
From the WABON standpoint, the focus for disciplinary sanctions is on the relationship and responsibility of the nurse to the patient, not to the employer or employment setting.
The primary concern is whether the nurse's actions compromised patient safety or caused patient abandonment. The nurse must:
- Have first accepted the patient assignment, thus establishing a nurse-patient relationship, and then,
- Severed that nurse-patient relationship without giving reasonable notice to the appropriate person (e.g., supervisor, patient, contractor) so that arrangements can be made for the continuation of nursing care by others.
Failure to fulfill a nursing responsibility may result in unsafe nursing care. Failure to practice with reasonable skill and safety is a ground for disciplinary action by the WABON.
The decision to take disciplinary action is based on the facts of the individual case, and the unique circumstances of each situation, and their application to grounds for disciplinary action in the nursing laws and rules.
The concept of the nurse’s duty to promote patient safety also serves as the basis for determining behavior that could be considered unprofessional conduct.
The Board believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff or other staffing-related situations.
Clear communication between staff and supervisors is essential to finding solutions that best focus on patient care needs without compromising patient safety or a nurse’s license.
- Is it considered patient abandonment if a nurse is the sole provider of care of the patient, and no other care provider is available to relieve the nurse?
There are some unique circumstances about which at may be considered patient abandonment.
An example is a registered nurse with a private practice or a contract to provide care to a patient who does not arrange for another qualified care provider to continue the care, may be considered patient abandonment.
A complaint should be reported to the Washington State Board of Nursing (WABON) for possible disciplinary action.
Conduct that is not actionable by the WABON is most appropriately addressed by the employer, consistent with employment laws, rules, and policies.
- What is the nurse’s responsibility specific to patient abandonment?
The Washington State Board of Nursing (WABON) holds nurses accountable to the minimum standard of care, which requires the nurse to fulfill a patient care assignment or transfer responsibility to another qualified person once a nurse has accepted an assignment.
- What are some examples of an employee-employment issue vs. patient abandonment?
The Washington State Board of Nursing (WABON) has no jurisdiction over employers, employment-related issues or disputes.
Other laws regulating facility licensure may apply certain responsibilities to the employer for patient safety, such as developing effective patient care systems or providing adequate numbers of qualified staff.
Specific requirements for a given facility may be obtained by contacting the applicable licensing authority for the institution.
WABON believes that the following are examples of employment issues that would not typically involve violations of nursing laws and rules:
- Resignation without advance notice, assuming the nurse’s current patient care assignment and work shift have been completed.
- Refusal to work additional shifts, either “doubles” or extra shifts on days off.
- Other work-related issues, such as frequent absenteeism, tardiness, or conflicts between staff/employees.
- Not showing up for work or not calling in.
- Refusing to work all remaining scheduled shifts after resigning.
- Refusing an assignment for religious, cultural, legal, or ethical reasons.
- Not returning from a leave of absence.
- Refusing to work in an unsafe situation.
- Refusing to delegate to an unsafe caregiver.
- Refusing to give care that may harm the patient.
- Refusing to accept an assignment or a nurse-patient relationship.
- Refusing to work mandatory overtime beyond the regularly scheduled number of hours.
- Refusing to work in an unfamiliar, specialized, or “high-tech” practice area when there has been no orientation, educational preparation, or employment experience.
- Refusing to “float” to an unfamiliar unit to accept a patient assignment.
Examples of abandonment:
- Accepting the assignment and then leaving the unit without notifying a qualified person.
- Leaving without reporting to the on-coming shift.
- Leaving patients without licensed supervision (especially at a long-term care facility with no licensed person coming on duty).
- Sleeping on duty.
- Going off the unit without notifying a qualified person and arranging coverage of patients.
- Leaving in an emergency.
- Overlooking or failing to report abuse or neglect.
- Giving care while impaired.
- Giving incompetent care.
- Delegating care to an unqualified caregiver.
- Failure to perform assigned responsibilities.
- Closing a private practice without making reasonable arrangements for the patient to transfer care.
- If a nurse is assigned to see a home-bound patient daily, but did not show up for a week, notify anyone, and did not arrange for another nurse to see the patient, is this patient abandonment?
It is important to consider what the nurse-patient assignment involves.
Acceptance of a patient assignment may vary from setting to setting and requires a clear understanding of the workload and the agreement to provide care.
In this situation, since the nurse failed to see the patient for a week and failed to request another nurse visit, this may be considered patient abandonment.
A complaint should be reported to the Washington State Board of Nursing (WABON).
Conduct, that is not actionable by the WABON is most appropriately addressed by the employer, consistent with employment laws, rules, and policies.
- If it is unsafe for the nurse to provide care during an emergency or disaster, is this patient abandonment?
A nurse may have to choose between the duty to provide safe patient care and protecting the nurse's own life during an emergency, including but not limited to disasters, infectious disease outbreaks, acts of terrorism, active shooter incidents, and workplace violence.
All nurses must adhere to nursing laws and rules regardless of practice setting, position title, or role.
There is also no routine answer to the question, "When does the nurse's duty to a patient begin?"
The nurse's duty is not defined by any single event, such as clocking in or taking a report.
From a Washington State Board of Nursing (WABON) standpoint, the focus for disciplinary sanctions is on the relationship and responsibility of the nurse to the patient, not to the employer or employment setting.
WABON believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff or other staffing-related situations.
The nurse should take steps to protect patients if there is time and use a method that does not jeopardize the nurse’s safety or interfere with law enforcement personnel.
An example is an active shooter incident. This scenario may include evacuating the area or preventing entry to a place where the active shooter is located. However, a nurse may find insufficient time to do anything but ensure their own safety during the situation, In this case, as soon as the situation has been resolved the nurse should promptly resume care of patients.
In accordance with FBI active shooter training provides, the safe and ethical response would be to maintain the safety of oneself instead of rushing to an injured party in a dangerous situation. When the immediate danger to self is over, a nurse would go to any injured person and assist in the most informed and efficient way possible.
Clear communication between staff and supervisors is essential to finding solutions that best focus on patient care needs without compromising patient safety or a nurse's license.
The Washington State Board of Nursing (WABON) recommends that employers develop and periodically review policies and procedures to provide nurses with clear guidance and direction so patients can receive safe and effective care.
- What do I do if my employer requires me to work a double shift during a disaster, and I am already physically exhausted?
A nurse must accept only assignments that consider patient safety and are commensurate with the nurse’s educational preparation, experience, knowledge, physical, and emotional ability.
This is an employer-employment issue that the Washington State Board of Nursing does not have authority over.
- How does the Washington State Board of Nursing (WABON) decide whether a complaint is patient abandonment or an employee-employment issue?
Complaints of “patient abandonment” when it is evident from the allegation that it is an employment issue will not be investigated by WABON.
Some general factors that would be considered in investigating a complaint alleging a nurse left an assignment would include, but not be limited to:
- The extent of dependency or disability of the patient.
- Stability of the patient.
- The length of time the patient was deprived of care.
- Any harm to the patient/level of risk of harm to the patient.
- Steps taken by the nurse to notify a supervisor of the inability to provide care.
- Previous history of leaving a patient care assignment.
- Emergencies that require nurses to respond, including but not limited to disasters, disease outbreaks, and bioterrorism.
- Workplace violence, including but not limited to an active shooter situation.
- Other unprofessional conduct concerning the practice of nursing.
- The nurse's general competency regarding adherence to minimum nursing standards.
As with all allegations received by WABON, the alleged conduct by a nurse will be thoroughly investigated to determine what, if any, violations of the nursing laws and rules have occurred.
Depending upon the case analysis, actions may range from the case being closed with no findings or action, to suspension or revocation, or voluntary surrender of the nurse’s license.
If evidence of violations exists, WABON must determine what sanction is appropriate for the nurse’s license and what specific stipulation requirements will be applied.
- Can the nurse invoke “Safe Harbor” in Washington State if asked to accept an assignment that could cause the nurse to violate their duty to a patient?
Washington State does not have a “Safe Harbor” law.
Safe Harbor is a means by which a nurse can request a peer review committee determination of a specific situation concerning the nurse’s duty to a patient, affording nurse immunity from the board action against the nurse’s license.
- Perioperative Nursing Care
- Is certification required for the Registered Nurse (RN) or Advanced Practice Registered Nurse (ARNP) to perform in the role of a Registered Nurse First Assistant (RNFA) or surgical first assistant?
The nursing laws and rules do not require the perioperative RN or ARNP to obtain certification to function in the role as a RNFA/surgical first assistant. The Nursing Care Quality Assurance Commission recommends the RN or ARNP obtain the CRNFA or other equivalent certification to demonstrate training and competency. The institution may require certification and/or specific training. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse's scope of practice. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse's scope of practice.
- Is the hospital or institution required to perform the credentialing and privileging process for the Registered Nurse or ARNP to function in the role of the RNFA/surgical first assistant?
The institution may require the perioperative RN or ARNP to complete the credentialing and privileging process to function in the role of the RNFA/first assistant. Credentialing is the process of assessing and confirming the license or certification, education, training, and other qualifications or a licensed or certified healthcare practitioner. Privileging is the process of authorizing a health care practitioner's specific scope and content of patient care services. The nursing laws and rules do not require credentialing and privileging. Other state facility laws/rules, federal requirements/regulations (such as the Centers for Medicare & Medicaid Services), and accreditation standards (such as Joint Commission) may require certification, credentialing, and privileging of the RN or ARNP performing in the RNFA/first assistant role. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse's scope of practice.
- Can the RN or ARNP function in the role of a RNFA/surgical first assistant to perform the functions of the MUM during robotic surgery without the RNFA Certification or without going through the credentialing or privileging process?
Within the role of the RNFA/surgical first assistant there are specialty surgical areas that may require additional training. It is within the scope of practice of the appropriately prepared and competent RN or ARNP to perform the functions in the role of a RNFA or surgical first assistant to perform the functions of the MUM. The Nursing Care Quality Assurance Commission recommends the RN or ARNP obtain the CRNFA or other equivalent certification to demonstrate training and competency. The institution may require certification and/or specific training.
The institution may require RN or ARNP to complete the credentialing and privileging process to function in the role of the RNFA or first assistant. Credentialing is the process of assessing and confirming the license or certification, education, training, and other qualifications or a licensed or certified healthcare practitioner. Privileging is the process of authorizing a health care practitioner's specific scope and content of patient care services. Other state or federal requirements/regulations and accreditation standards (such as the Centers for Medicare & Medicaid Services or Joint Commission) may require certification, credentialing, and privileging of the RN or ARNP performing in the RNFA/first assistant role.
The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse's scope of practice.
- Portable Orders for Life Sustaining Treatment
- What is a Portable Order for Life Sustaining Treatment (POLST) form?
POLST is a set of portable medical orders, executed by an adult patient (or legal surrogate) and the patient's medical provider, to guide medical treatment based on the patient's current medical condition and goals.
POLST is usually for persons with serious illness or frailty. The “rule of thumb” is to recommend POLST for patients if their provider would not be surprised if they die within a year. Advanced care planning is thoughtful conversations between health care professionals, the patient and/or surrogate.
It is within the scope of the appropriately prepared and competent LPN to discuss end-of-life care with the patient or surrogate under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse (RN).
For more information and resources on POLST, go to:
- Advisory Opinion: Portable Order for Life Sustaining Treatment (POLST) (PDF)
- DOH: Portable Orders for Life Sustaining Treatment (POLST)
- WSMA: Advance Care Planning
- WSMA: POLST Form & Brochure
- How should the decisions in a POLST be made?
The patient (or surrogate decision-maker) and the health care provider should discuss information to assure the POLST reflects the patient's wishes, as expressed in an advance directive or through communications with family or others. The patient's most recent communications, made in the context of their current medical condition, are the most likely to reflect their current wishes. If the patient's wishes are not known, the POLST should direct care in the patient's best interest. RCW 7.70.065(1)(c).
- Is it within the scope of practice of an ARNP to sign a POLST?
The licensed ARNP, physician, or physician assistant may sign POLST.
- The health care practitioner signing the form assumes full responsibility for obtaining informed consent from the patient or surrogate decision-maker.
- The form must also be signed by the patient or surrogate to be valid.
- Verbal orders are acceptable with a follow-up signature following facility policy.
The ARNP should periodically review the POLST instructions with the individual or family for any treatment preference changes and consistency with any advance directive, especially if there are substantial changes in the person's health status or if there are substantial revisions to the form.
For more information and resources on POLST:
- Advisory Opinion: Portable Order for Life Sustaining Treatment (POLST) (PDF)
- DOH: Portable Orders for Life Sustaining Treatment (POLST)
- WSMA: Advance Care Planning
- WSMA: POLST Form & Brochure
- Prevention and Treatment of Opioid-Related Overdoses
- Is the Advanced Registered Nurse Practitioner required to carry naloxone?
RCW 69.41.095 does not require the Advanced Registered Nurse Practitioner to carry an opioid antagonist (such as naloxone). For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.
- Can the Advanced Registered Nurse Practitioner prescribe naloxone for their staff to have available as stock inventory in the event of a suspected opioid-related overdose?
RCW 69.41.095 allows the Advanced Registered Nurse Practitioner, with prescriptive authority, to prescribe, dispense, and distribute an opioid overdose reversal medication to any person or entity. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Can the Advanced Registered Nurse Practitioner have a collaborative agreement (CDTA) with a pharmacist to prescribe, dispense, and distribute opioid overdose medication?
RCW 69.41.095 allows the Advanced Registered Nurse Practitioner to have a collaborative agreement (CDTA) with a pharmacist to prescribe, dispense, and distribute opioid overdose medications to anyone who requests it. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Is it required for the Advanced Registered Nurse Practitioner to prescribe naloxone when prescribing an opioid for a patient?
WAC 246-840-4980 requires the Advanced Registered Nurse Practitioner to confirm or provide a current prescription for naloxone when fifty milligrams Morphine Equivalent Dose (MED) or above, or when prescribed to a high-risk patient. The Advanced Registered Nurse Practitioner should counsel and provide an option for a current prescription for naloxone to patients being prescribed opioids as clinically indicated. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Can the Advanced Registered Nurse Practitioner prescribe naloxone to a third-party, such as a family member, friend, or caregiver of an individual?
WAC 246-840-4980 allows the Advanced Registered Nurse Practitioner with prescriptive authority to prescribe an opioid antagonist to a third party. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- In writing a prescription for a family member of someone who is at risk of an opioid overdose, is the prescription written in the name of the person who requests it or for the family member?
The prescription for an opioid antagonist must be written in the name of the person who requests it. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Can the Advanced Registered Nurse Practitioner prescribe subcutaneous and intramuscular formulas of naloxone?
Off-label drugs lack the Food and Drug (FDA) approval. Off- label delivery methods may be legally prescribed, dispensed, distributed, or administered by the Advanced Registered Nurse Practitioner with prescriptive authority. The Advanced Registered Nurse Practitioner is expected to use professional judgment. The Center for Drug Evaluation and Research and the FDA support this practice. Off-label use should be done with careful insight and understanding of the risks and benefits to the patient considering high-quality evidence supporting efficacy, effectiveness, and safety. More information about off-label use may be found at the Therapeutic Intranasal Drug Delivery website.
- Are there other alternatives for an individual or an organization to get a prescription for naloxone other than from their primary health care practitioner?
RCW 69.41.095 allows the State Health Officer for Washington State, to issue a state-wide standing order that can be used as a prescription for naloxone. People may take this standing order to a pharmacy to get the drug, instead of going to a healthcare provider to get the prescription. Organizations may also use this standing order to get naloxone and give it to people who are at risk of overdosing or who spend time with people at risk of overdosing. Organizations who want to use this standing order to get and use naloxone must send an email to Washington State Department of Health at firstname.lastname@example.org. The department will keep a list of organizations who use the order and notify them if anything in the order changes. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.
- Standing Orders, Verbal Orders, Electronic Orders, Telehealth, Triage, Case Management
- Does the training requirement apply to a nurse who provides Virtual Directed Observed Therapies (VDOT) for tuberculosis treatment?
VDOT is the use of a videophone or other video/computer equipment to observe client’s taking their medications remotely.
Using synchronous and asynchronous VDOT for tuberculosis treatment adherence is occurring across the United States and in Washington State.
- The nurse providing synchronous (real-time audio and video) VDOT is required to take the telemedicine training.
- The nurse providing asynchronous (store-and-forward) VDOT is not required to take the training, but NCQAC recommends all nurses take the training.
For more information go to the Washington State Department of Health Tuberculosis Website (this site is accessible only to LHJs at this time).
- Telemedicine Training Requirements
- Is a registered nurse (RN), licensed practical nurse (LPN), or Advanced Registered Nurse Practitioner (ARNP) required to take telemedicine training?
Yes, licensed nurses (RN, LPN, or ARNP) in Washington state are required to take telemedicine training if the nurse provides telemedicine services. RCW 43.70.495 requires the nurse who provides clinical services through telemedicine independently or under the direction of an authorized health care practitioner to complete telemedicine training. “Telemedicine” as defined in RCW 70.41.020(13) means, “the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment [but] does not include the use of audio-only telephone, facsimile, or email.”
The Washington State Telehealth Collaborative uses the following slightly different Medicaid definition of telemedicine in the training:
“Telemedicine is when a health care practitioner uses HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store and forward technology to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located.” WAC 182-531-1730(1). It does not include “the use of audio-only telephone, facsimile, or email.”
- Does the training requirement apply to a nurse who provides telephone triage?
No, the telemedicine training requirement doesn't apply to audio-only telephone (telephone triage), facsimile, or email. However, the Nursing Care Quality Assurance Commission (NCQAC) recommends licensed nurses complete the telemedicine training if they provide services such as; telephone triage, remote patient monitoring (“RPM”, which enables recording and monitoring health data remotely), asynchronous telehealth (such as Store and Forward technology that allows patient data to be collected, stored, and later retrieved by another professional), Mobile Health (“mHealth,” using smart devices such as smartphones and smart wearables that allow continuous data collection about a person's behavior or condition) or other types of telehealth. The telemedicine training provides a valuable overview of the roles, responsibilities, liability, and legal requirements when providing telehealth services.
- Does the nurse need to send in the certification to the Nursing Care Quality Assurance Commission (NCQAC)?
The law, RCW 43.70.495, requires the nurse to sign and retain an attestation of completion. The nurse does not need to send the attestation or documentation to the NCQAC unless requested.
- When is completion of telemedicine training required?
The Nursing Care Quality Assurance Commission (NCQAC) recommends telemedicine training be completed as soon as possible as a demonstration of competency. The licensed nurse (RN, LPN, or ARNP) providing telemedicine clinical services licensed prior to January 1, 2021, will need to complete telemedicine training by December 31, 2021. The newly licensed RN, LPN, or ARNP or the RN, LPN, or ARNP licensed through the endorsement process who provides clinical services will need to meet the requirement one year after the initial license is issued. The Nursing Care Quality Assurance Commission (NCQAC) recommends all Washington nurses complete the telemedicine training as a demonstration of competence as soon as practical to provide an overview of the roles, responsibilities, liability, and legal requirements for providing telehealth services.
- Does telemedicine training taken prior to January 1, 2021 meet the telemedicine training requirement?
Telemedicine training taken prior to January 1, 2021 meets the requirement if it includes the content defined in RCW 43.70.495(2). The RN must be appropriately trained and competent to provide nursing telehealth services. To learn more about the different training options available and access additional resources, see the Washington State Telehealth Collaborative Training webpage. To complete the free and publicly available telemedicine training, see the Washington State Medical Professional Telemedicine Training website.
- What are the options to meet telemedicine training requirements?
To learn more about the different training options available and access additional resources, please visit the Washington State Telehealth Collaborative Training webpage. To complete the free and publicly available telemedicine training, see the Washington State Medical Professional Telemedicine Training webpage.