Advanced Registered Nurse Practitioner

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.

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.

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.

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

Employment verification:

• 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])

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.

Yes. ARNP CNS licensure requires national certification by a NCQAC-approved entity:

• American Nurses Credentialing Center (ANCC),
• American Association of Critical-Care Nurses (AACN), or
• Oncology Nursing Certification Corporation (ONCC).

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.

Applicants for ARNP licensure in the CNS designation must meet the national certification requirements. Qualifications and requirements are determined by the certifying body:

• American Nurses Credentialing Center (ANCC),
• American Association of Critical-Care Nurses (AACN), or
• Oncology Nursing Certification Corporation (ONCC).

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.

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.

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.

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®).

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.

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.

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.

The rule does not include a “grandfathering” option. All applicants must meet the current requirements for ARNP licensure.

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.

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.

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.

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.

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:

• Advance Care Planning – Washington State Medical Association
• POLST/POLST Form/POLST Brochure – Washington State Medical Association
• POLST – Washington State Department of Health

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).

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.

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.

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.

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.

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.

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.

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.

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 naloxoneprogram@doh.wa.gov. 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.

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).

The ARNP with a Washington state license may deliver advanced nursing care using telehealth services within their designated scope of practice based on the ARNP's national certifying body. Modalities include live video, store-and forward, remote patient monitoring, and mobile health. The Nursing Care Quality Assurance Commission does not have formal guidance regarding telehealth services. During the coronavirus (COVID-19) emergency the nurse practitioner licensed in another state can provide telehealth services under the Emergency Volunteer Health Practitioners Program within their scope of practice and within the parameters of the Emergency Volunteer Health Practitioners Program or must have a Washington state registered nurse and ARNP license to provide care to patients residing in Washington state. For additional information, go to:

Washington Medical Commission

• Appropriate Use of Telemedicine Guidelines
• Telemedicine and Continuity of Care Policy

Center for Coordinated Health Policy

• What is Telehealth?

The U.S. Office of Health and Human Services-Office of Civil Rights Frequently Asked Questions on Telehealth and HIPAA provides information on waivers and exceptions and guidance during the pandemic about HIPAA and telehealth services during the COVID-19 emergency.

The NCQAC does not have authority regarding practice in another state. The ARNP should check with the other state to see they would need a license in that state to provide a care to a patient in that state using telehealth services during the COVID-19 emergency.

The Nursing Care Quality Assurance Commission does not have authority regarding reimbursement. The ARNP should contact the insurance provider, Centers for Medicare and Medicaid Services (CMS), or the Health Care Authority (HCA) for information and requirements about reimbursement during the COVID-19 emergency. See the following resources:

• CMS Current Emergency-COVID-19
• Washington HCA - COVID-19 Information
• Washington Office of the Insurance Commissioner - Coronavirus Information

While a prescription for a controlled substance issued using telehealth services must generally be predicated on an in-person medical evaluation (21 U.S.C. 829(e)), the Controlled Substances Act contains certain exceptions to this requirement. One such exception occurs when the Secretary of Health and Human Services has declared a public health emergency under 42 U.S.C. 247d (section 319 of the Public Health Service Act), as set forth in 21 U.S.C. 802(54)(D). Secretary Azar declared a Public Health Emergency (PHE) with regard to COVID-19 on January 31, 2020. For as long as the Secretary's designation of a public health emergency remains in effect, Drug Enforcement Administration (DEA)-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided all of the following conditions are met:

• The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice
• The telehealth communication is conducted using an audio-visual, real-time, two-way interactive communication system.
• The practitioner is acting in accordance with applicable Federal and State law.

Provided the practitioner satisfies the above requirements, the practitioner may issue the prescription using any of the methods of prescribing currently available and in the manner set forth in the DEA regulations. Thus, the practitioner may issue a prescription either electronically (Schedules II-V) or by calling in an emergency Schedule II prescription to the pharmacy, or by calling in a Schedule III-V prescription to the pharmacy.

If the prescribing practitioner has previously conducted an in-person medical evaluation of the patient, the practitioner may issue a prescription for a controlled substance after having communicated with the patient via telemedicine, or any other means, regardless of whether a public health emergency has been declared by the Secretary of Health and Human Services, so long as the prescription is issued for a legitimate medical purpose and the practitioner is acting in the usual course of his/her professional practice. In addition, for the prescription to be valid, the practitioner must comply with any applicable state laws

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.”

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.

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.

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.

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.

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.