0002: COMMITTEE SUMMARY (Date Completed: 2-5-13)

A certified nurse practitioner would focus on the performance of comprehensive assessments; providing physical examinations and other health assessments and screening activities; and diagnosing, treating, and managing patients with acute and chronic illnesses and diseases. Nursing care provided by a C.N.P. would include ordering, performing, supervising, and interpreting laboratory and imaging studies; prescribing pharmacological and nonpharmacological interventions and treatments within the C.N.P.'s specialty role and scope of practice; health promotion; disease prevention; health education; and counseling of patients and families with potential, acute, and chronic health disorders.

A clinical nurse specialist-certified would focus on continuous improvement of patient outcomes and nursing care with broad focus across the areas of direct patient care, patient education, nursing practice, and organizational systems. A C.N.S.-C would be responsible and accountable for diagnosis, intervention and treatment of health or illness states, pharmacological and nonpharmacological disease management, health promotion, and prevention of illness and risk behavior among individuals, families, groups, and communities. In addition, a C.N.S.-C would evaluate patient outcomes; translate evidence into practice; and develop, plan, coordinate, and direct programs of care for acute and chronically ill patients and their families.

The following words, titles, and letters could be used only by those authorized under Part 172 to use them and in a way prescribed in Part 172: "certified nurse midwife", "C.N.M.", "certified nurse practitioner", "C.N.P.", "clinical nurse specialist-certified", and "C.N.S.-C".

A.P.R.N. Duties & Licensure

The bill would require an A.P.R.N. to do the following:

-- Provide those functions common to the population for which A.P.R.N.s are educationally and experientially prepared.

-- Comply with the standards established by the Board of Nursing and with the national accreditation standards of the national professional nursing associations applicable to his or her license.

-- Consult with or refer patients to other health professionals as appropriate.

-- Supervise R.N.s, licensed practical nurses (L.P.N.s), and other health professionals as appropriate.

The bill would prohibit a person from engaging in the practice of A.P.R.N. unless licensed or otherwise authorized by Article 15 (Occupations) of the Code.

The bill would require the Board of Nursing to issue an A.P.R.N. license to an R.N. who held a specialty certification, issued by the Board, as a nurse midwife, nurse practitioner, or clinical nurse specialist, if he or she met both of the following requirements:

-- He or she applied for an A.P.R.N. license within two years after the bill's effective date.

-- His or her license and specialty certification issued by the Board was current on the bill's effective date and on the date he or she submitted the license application.

The person also would have to provide proof satisfactory to the Department of Licensing and Regulatory Affairs (LARA) that he or she had been employed as a clinical nurse specialist, nurse practitioner, or nurse midwife for the four-year period immediately before the license application was submitted.

The Department would have to renew an A.P.R.N. license concurrently with the R.N. license.

C.N.M./C.N.P./C.N.S.-C Licensure

The Board of Nursing would be required to issue a certified nurse midwife license, a certified nurse practitioner license, or a clinical nurse specialist-certified license to an R.N. who met all of the following requirements:

-- He or she had completed an accredited graduate, postgraduate, or doctoral level nursing education program that prepared the nurse for the role of C.N.M, C.N.P, or C.N.S.-C., as applicable.

-- He or she was certified by a nationally accredited certification body as demonstrating role and population focused competencies for C.N.M.s, C.N.P.s, or C.N.S.-Cs, as applicable, or the Board determined that he or she met the standards for that certification.

-- He or she maintained continued competence by obtaining recertification in the role and population described above through the national certification program, or the Board determined that he or she met the standards for that recertification.

The person also would have to demonstrate to the Board's satisfaction that he or she met all of the following:

-- He or she had acquired advanced clinical knowledge and skills that primarily prepared him or her to provide direct care to patients, and to provide indirect care.

-- His or her practice built on the competencies of R.N.s by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy.

-- He or she was educationally prepared to assume responsibility and accountability for health promotion or maintenance and the assessment, diagnosis, and management of patient problems, including the use and prescription of pharmacologic and nonpharmacologic interventions.

-- He or she had clinical experience of sufficient depth and breadth to perform as a licensee.

Specialty Certification

Under Part 172, the Board of Nursing may issue a specialty certification to an R.N. who has advanced training beyond that required for initial licensure and who has demonstrated competency through examination and other evaluative processes and who practices in one of the following specialty fields: nurse midwifery, nurse anesthetist, or nurse practitioner. Under the bill, this provision would apply only to the specialty field of nurse anesthetist.

Board of Nursing

Currently, the Board of Nursing consists of the following 23 voting members:

-- Nine registered professional nurses.

-- One nurse midwife.

-- One nurse anesthetist.

-- One nurse practitioner.

-- Three licensed practical nurses.

-- Eight public members.

The bill would increase the total number of members to 29, beginning 60 days after the bill's effective date. In addition to the nine R.N.s and the three L.P.N.s, the Board would have to include two certified nurse midwifes, two nurse anesthetists, two clinical nurse specialist-certifieds, and nine public members.

Currently, the nurse midwife and nurse practitioner members must each have a specialty certification issued by LARA in his or her respective specialty field. Under the bill, each appointed C.N.M., C.N.P., and C.N.S.-C. would have to have an A.P.R.N. license issued by LARA in his or her respective role, and each of the nurse anesthetists would have to have a specialty certification issued by LARA in that specialty field.

A.P.R.N. Task Force

The bill would create the A.P.R.N. Task Force. The Task Force would have to consist of the following 11 members, who would have to be members of the Board:

-- One registered professional nurse.

-- Two certified nurse midwives.

-- Two certified nurse practitioners.

-- Two clinical nurse specialists-certified.

-- Two certified nurse anesthetists.

-- Two public members.

The Task Force would have to develop and make public guidelines on the appropriate scope of practice of an A.P.R.N. according to his or her education, training, and experience. These guidelines would be nonbinding and advisory, and would only express the Task Force's criteria for determining whether an A.P.R.N. was practicing within his or her scope of practice.

The Task Force also would have to do the following:

-- Serve as the disciplinary subcommittee for A.P.R.N.s and certified nurse anesthetists.

-- Make written recommendations to the Board on reinstatement of A.P.R.N. licenses and notices of intent to deny them.

-- File an annual report with the Board and LARA concerning any matters prescribed by the Task Force and Board.

Currently, if a health profession specialty field task force is created for a health profession, that task force must serve as the task force for all health profession specialty fields within the scope of practice of the health profession. This requirement would not apply to the A.P.R.N. Task Force. The Task Force also would not be subject to requirements that a task force make recommendations to a licensing board and appoint a disciplinary subcommittee.

During an investigation or after a complaint has been issued, LARA may schedule a compliance conference. If an agreement is not reached, LARA must schedule a hearing. A compliance conference or a hearing may include one member of the appropriate board or task force who is not a member of the disciplinary subcommittee with jurisdiction over the matter, and such a person may attend a hearing. Under the bill, if the A.P.R.N. Task Force were the disciplinary subcommittee with jurisdiction, a compliance conference could include a Task Force member, and a Task Force member could attend a hearing.

License Fees

The fees for an individual licensed or seeking licensure to practice nursing as an R.N. include a $24 application processing fee and a $30 annual license fee. For a specialty certification for an R.N., the Code prescribes an application processing fee of $24 and an annual specialty certification fee of $14.

The bill would retain these fees and prescribe the following fees for an individual who sought or held a license as an advanced practice registered nurse under Part 172:

-- An application processing fee of $24.

-- An annual certification fee of $40.

License Renewal

The bill would permit the Board of Nursing, by rule, to require a licensee seeking renewal of a license under Part 172 to give the Board satisfactory evidence that, during the two years immediately before the date of the renewal application, he or she completed continuing education or competency courses or activities approved by the Board. If the Board did so, it would have to promulgate rules requiring each applicant for license renewal to complete as part of those courses or activities an appropriate number of hours or courses in pain and symptom management.

Pharmacy Practice & Drug Control

The bill would authorize a licensed A.P.R.N. to possess, prescribe, and administer nonscheduled prescription drugs and controlled substances included in Schedules 2 through 5 if he or she met all of the following:

-- He or she had completed graduate level pharmacology, pathophysiology, and physical assessment courses and clinical practicum in the role of a C.N.M, C.N.P., or C.N.S.-C., as applicable to his or her A.P.R.N. license.

-- Unless otherwise provided by rule, he or she had completed the number of contact hours in pharmacology as part of the requisite continuing education for a controlled substances license, and for renewal of his or her license under Part 172.

-- He or she held a controlled substances license under the Code.

-- He or she possessed, prescribed, or administered the drug or controlled substance only while engaged in the practice of advanced practice registered nursing.

In addition, if the person had held an A.P.R.N. license for less than two years, he or she could possess, prescribe, or administer those drugs and substances only under the terms of a written mentorship agreement between the A.P.R.N. and a licensed physician who held a controlled substance license, or between the A.P.R.N. and another A.P.R.N. who held the same license under Part 172, had at least five years of work experience in that licensed profession, and held a controlled substance license. The mentorship agreement also would have to meet the following:

-- Include the responsibilities and duties of each party to the agreement.

-- Be for a term of one year and be renewable by the parties for one or more additional one-year periods.

-- Be revocable by either party, with at least 30 days' written notice.

-- Be signed by each party.

Before prescribing a controlled substance included in Schedules 2 to 5, the A.P.R.N. would have to request that the Department of Community Health (DCH) provide any data in its electronic monitoring system concerning that controlled substance. He or she would have to consider the data to determine whether prescribing or administering the controlled substance to the intended individual was consistent with patient safety and that it would not likely be subject to abuse by the individual. After prescribing the controlled substance, the A.P.R.N. would have to give any information about the prescription to the DCH that a dispensing prescriber is required to report for the electronic monitoring system.

The Department of Licensing and Regulatory Affairs would have to issue a controlled substance license to an A.P.R.N. who applied and was qualified to possess, prescribe, and administer nonscheduled prescription drugs and controlled substances included in Schedules 2 to 5. The Department could place a limitation on the license to reflect the terms of a mentorship agreement.

An A.P.R.N. engaged in the practice of advanced practice registered nursing could order, receive, and dispense a complementary starter dose of a prescription drug or controlled substance in Schedules 2 to 5 without delegation from a supervising physician. Only the name of the A.P.R.N. would have to be used, recorded, or otherwise indicated in connection with that order, receipt, or dispensing. As required of a prescriber who dispenses complementary starter doses, an A.P.R.N. would have to give certain information to the patient.

The bill provides that it would not require new or additional third-party reimbursement or mandated worker's compensation benefits for services rendered by an A.P.R.N. authorized to prescribe nonscheduled prescription drugs and controlled substances included in Schedules 2 to 5.

Other Provisions

Under the Code, a speech-language pathology licensee may perform assessment, treatment or therapy, and procedures related to swallowing disorders and medically related communication disorders only on patients who have been referred to him or her by a person licensed in the practice of medicine or osteopathic medicine and surgery. The bill would include a patient referred by a licensed A.P.R.N. engaged in the practice of advanced practice registered nursing.

Currently, occupational therapy services include the provision of vision therapy services or low vision rehabilitation services, if the services are provided pursuant to a referral or prescription from, or under the supervision or comanagement of, a licensed physician or optometrist. Under the bill, these services also could be provided pursuant to a referral or prescription from a licensed A.P.R.N. engaged in the practice of advanced practice registered nursing.

The Code prohibits a person from engaging in the practice of physical therapy or practice as a physical therapist assistant unless licensed or otherwise authorized. A person may engage in the actual treatment of an individual only upon the prescription of an individual holding a license issued under Part 166 (Dentistry), 170 (Medicine), 175 (Osteopathic Medicine and Surgery), or 180 (Podiatric Medicine and Surgery). Under the bill, a person holding an A.P.R.N. license, while engaged in the practice of advanced practice registered nursing, also could prescribe physical therapy.

The Code requires licensed health facilities and agencies to adopt a policy describing the rights and responsibilities of patients or residents. The policy must contain specific provisions, including that a patient or resident is entitled to be free from physical and chemical restraints, except those authorized in writing by the attending physician or physician's assistant. Under the bill, restraints also could be authorized by an A.P.R.N. engaged in the practice of advanced practice registered nursing.

MCL 333.2701 et al. Legislative Analyst: Suzanne Lowe

FISCAL IMPACT

The bill would have an indeterminate effect on State finances, and no impact on the finances of local governments. Under the bill, an individual seeking licensure as an advanced practice registered nurse would have to pay an application and license fee as specified in the bill and detailed in Table 1. It is unknown how many individuals would apply and seek licensure, but revenue from the fees would be credited to the Health Professions Regulatory Fund and used for costs associated with issuing the licenses.

Table 1

License Type	Fee Type	Fee
Advanced practice registered nurse	Application processing fee	$24
Advanced practice registered nurse	Annual certification fee	$40

The Department of Licensing and Regulatory Affairs would be responsible for some increased costs related to processing applications and issuing licenses as prescribed by the bill. It is unknown whether the fees in the bill would be sufficient to cover the Department's expenses, so the fiscal impact is indeterminate.

Fiscal Analyst: Josh Sefton

This analysis was prepared by nonpartisan Senate staff for use by the Senate in its deliberations and does not constitute an official statement of legislative intent.