Massachusetts Medical Society: Overview of Advance Practice Nursing Regulatory Changes

Overview of Advance Practice Nursing Regulatory Changes

Prescriptive Practice Requirements Loosened, Other Changes


The Board of Registration in Nursing recently adopted regulations governing Advanced Practice Nurses that had been pending for nearly a year.

The new APN regulations — which the MMS opposed and offered extensive testimony in hopes of modifying — outline an additional category of nurses eligible for expanded scope-of-care privileges, and significantly loosened practice guideline requirements based on longstanding statutes and practices. A summary of some relevant changes are as follows:

Removal of Written Guidelines Requirement. New regulations no longer require written guidelines for non-prescriptive practice. The guideline requirement in the prior regulations mandated a written consensus between the APN and the supervising physician on the scope of care, and required a description of the circumstances in which physician consultation or referral is required. Specific language requiring supervisors and nurses to work in related fields has also been eliminated.

Loosening of Prescriptive Practice Requirements. The prior regulations required a review of prescriptive practices with a supervising physician at least every three months; the new regulations only call for a prescriptive practice review at a defined mechanism and time frame as indicated in the guidelines. The new regulations require guidelines to address tests and therapeutics only when appropriate. The underlying law makes no such limitation.

Clinical Nurse Practitioners (CNPs) Can Provide Written Certifications for Marijuana. The MMS opposed this language as directly contradictory to the state medical marijuana law. The rationale for adoption of this language is a statute, which precedes the marijuana referendum and allows CNPs to sign forms previously requiring physician signatures only if such action does not increase their scope of practice.

Addition of Clinical Nurse Specialists as an Additional Category of Eligibility for Advanced Practice Nursing.Clinical nurse specialists are recognized as a new category of APNs. No prescriptive authority has been created for this category.

Prescribing Limits for Certified Registered Nurse Anesthetists (CRNAs). CRNAs are limited to prescribing in the immediate perioperative period and non-prescribing CRNAs must work under orders of individuals with prescribing privileges.

Changes Certified Nurse Midwives (CNMs). The regulations recognize the changes in the law eliminating supervision of CNMs but do not fully honor requirements that CNMs practice in a health care setting or have provisions for consultation and collaboration spelled out in the 2012 statute giving them broader practice authority. The regulatory definition of health care setting includes an individual who bills insurance companies, for example.

The MMS continues to support physician-led teams as the best model for high-quality patient care. The impact of these regulatory changes on care delivery and quality remains to be seen; but remember the revised regulations do not mandate change from existing models of team-based care. Any changes in scope of care of your advanced practice nurses will be subject to the clinical team leader.

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