Nursing Commission Updates

This past year has been a busy one for the Washington State Nursing Quality Assurance Commission, with many updates to various rules, potential legislative bills and advisory opinions and policies. The Nursing Commission has been an independent agency that reports to the state Department of Health for several years, which has allowed the commission to broaden its work, including lobbying the Legislature.

One top priority for the commission has been passage of the Rap Back bill, which has gone before the Legislature the past two sessions with no success. The commission board unanimously voted to not submit the Rap Back bill this session. The bill included having criminal background information run through unsolved crimes, which raised challenges and concerns from the ACLU and other groups. The commission is now proposing to open the state Uniform Disciplinary Act and insert new language that would require all new and renewing applicants to undergo a biometric background check. Vendors will be designated at a variety of locations throughout the state and the applicant or licensee bears the cost of the fingerprint processing. It is a one-time, one-cost collection of fingerprints for the duration of the nurse’s licensure. The FBI requires each profession’s fingerprints be used solely for the purpose it was collected; therefore, the fingerprints could not satisfy any other background check requirement. Currently, only out-of-state applicants are required to submit a fingerprint when applying for licensure. The FBI background check is a requirement for the Multistate Nurse Licensure Compact.

The Nurse Licensure Compact (NLC) remains a high-focus program for the Nursing Commission and the National Council of State Boards of Nursing (NCSBN), which is a private, nongovernmental trade association that created two interstate compacts for multistate nurse practice. The nursing commission is supporting this new NLC, which would give RNs and LPNs the option of maintaining one multistate license with the ability to practice in both their home state and other NLC states. The APRN Compact provides the ability for an advanced practice registered nurse to hold one multistate license with the privilege to practice in other compact states. These compacts must be adopted by legislative action. Both NCSBN-proposed compacts define the site of a nurse’s practice as the state in which the patient is located at the time services are provided. This position has not changed at this time although there were ongoing discussions in the fall between ANA and NCSBN to resolve this key concern. WSNA and ANA continue to have numerous concerns and remain strongly opposed at this time to adoption of the proposed enhanced Nursing Licensure Compacts in their current form. (Read WSNA’s position).

We strongly encourage you to read the Executive Summary of the WSNA Board position statement, “The Nursing Licensure Compact and APRN Compact: A Bad Option for Washington.” Find the full position statement at Regulation and Accountability.

Another priority has been a proposed fee increase for Licensed Practical, Registered Nurses and Advanced Practice licenses starting in 2018. Increasing the application fee by 37 percent for RN and by 35 percent for advanced practice licensure is a significant jump and a burden for many. In addition to the cost of licensure, nurses also incur costs associated with compliance with the annual mandatory continuing education requirements, including the new suicide prevention education mandate. According to the August 2016 budget report published by the commission, the overall commission budget was underspent by 12 percent in the last 14 months, and the commission continues to have a published revenue balance of $2.8 million in reserves that has not been utilized. Some of the remaining questions include: How does increasing fees improve public safety? Why such a large increase rather than incremental? With millions in reserve and the commission operating below budget, what is the justification for the high increase at this time? WSNA and the Nursing Commission will be meeting to discuss these concerns at length after this issue of The Washington Nurse goes to press, so stay tuned.

Suicide prevention education was updated in the Engrossed Substitute House Bill 1424 law enacted in 2014 (RCW 43.70.442) to establishing suicide prevention training requirements for health care providers, including licensed practical nurses, registered nurses and advanced registered nurse practitioners. The law requires a one time training course (at least six hours in length) in suicide assessment, treatment and management that is approved by the Nursing Commission as of Jan. 1, 2017. This means that if you have taken a course with six hours of instruction during the past year, it will be accepted if you are up for renewal and have the CNE attestation requirement. After Jan. 1, 2017, the only courses that will be accepted must be approved by the Nursing Commission. After that date, nurses will be required to complete a suicide prevention education course from the approved training list. The CNE requirements still also include HIV/AIDS (7 hours), and 45 credits over a three-year period. Starting for licensure renewals on your birthday as of Jan. 1, 2017 the CNE attestation will require this education class.

The Nursing Care Quality Assurance Commission adopted new rules in the summer of 2016 that add Clinical Nurse Specialist (CNS) as a fourth designation of advanced registered nurse practitioners. The revised rule establishes the education, examination, licensing, practice requirements and other qualifications for the ARNP CNS designation and also clarifies and updates ARNP rules. An ARNP must maintain current certification within his or her designation(s) by a commission-approved certifying body. An ARNP license becomes invalid when the certification expires. WAC 246-840-302

Last fall, the NCQAC issued an advisory opinion in accordance with WAC 246-840-800 which concluded that a registered nurse (RN) may distribute, deliver or dispense prescriptive medications/devices for reproductive care and prevention and treatment of communicable diseases according to a written or standing order of an authorized prescriber. Public Health Nurses (PHNs) may work in a variety of settings, such as a local health department or local health jurisdiction (LHJ). PHNs play a vital role in disease prevention and treatment including the safe delivery and dispensing of certain medications/devices in family planning, prophylactic and therapeutic treatment of communicable diseases. It is a recognized and long-accepted practice for RNs in public health settings to dispense certain medications and devices to public health patients for prevention and treatment following written standing orders. PHNs often operate under standing orders. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides guidance on standing orders (for details see Dispensing Medications/Devices for Prophylactic and Therapeutic Treatment of Communicable Diseases and Reproductive Health by Public Health Nurses - PDF).

The Nursing Commission was asked to develop an Advisory Opinion, and is finalizing it, regarding the role of Birth Assistants (Doulas) when working with Licensed Midwives (LMs). LMs are not nurses who can provide midwifery care in inpatient settings. According to Washington law, a licensed midwife may render medical aid for a fee or compensation to a woman during prenatal, intrapartum and postpartum stages or to her newborn up to two weeks of age. Performing assessments, administering medication and conducting other higher-level clinical functions carries a high risk of harm if not properly trained. The performance of these functions already require a healthcare credential and should not be performed by birth assistants. A licensed midwife is ultimately responsible for assigning the duties performed by an assistant during a birth. These guidelines will help credential holders avoid aiding and abetting unlicensed practice.

NCQAC is in the process of finalizing the policy identifying commission-approved credentialing entities for ARNPs who practice as pain management specialists to recognize competence in this area of practice. The Pain Management Specialist Rules (WAC 246-840-493) require the ARNP pain management specialist to meet one or more of the following qualifications: a minimum of three years of clinical experience in a chronic pain management care setting and/or credentialed in pain management by a Washington state NCQAC-approved national professional association, pain association or other credentialing entity and/or successful completion of a minimum of at least 18 continuing education hours in pain management during the past two years and/or at least 30 percent of the ARNP’s practice is the direct provision of pain management care or is in a multidisciplinary pain clinic. NCQAC will approve the following credentialing entities: American Society for Pain Management Nursing® Advanced Practice Pain Management Nurse, National Board of Certification and Recertification for Nurse Anesthetists Nonsurgical Pain Management (NSPM) Credential Program, and Academy of Integrative Pain Management (AIPM) – American Academy of Pain.

Finally, NCQAC rules in progress include: Nursing Assistants WAC 246-841-400 through 595, Minimum Data Sets WAC 246-840-XXX (new section and Substance Use Disorder WAC 246-840-730, WAC 246-840-750 through 780. The Nursing Assistant rules have not been updated for several years and are due for review. NCQAC is considering Minimum Data Sets (MDS): Demographic Information for Licensure Applications and Renewals which could require the submission of Health Professions Minimum Data Set (MDS) demographic data by all nurses who renew their licenses. The data would inform the NCQAC’s decision-making process. The Health Professions Minimum Data Set (MDS) developed by the U.S. Department of Health and Human Services is a national standard of data for health professionals. The data looks at demographics, including: first degree in nursing, highest degree earned in nursing, employment status and specialty areas. Collecting this data would allow the NCQAC to understand the population of nurses working in Washington state. The NCQAC would use the data to inform policy decisions. The data would also allow the NCQAC to compare demographic data to other states and national levels. The Substance Use Disorder rules, which are up for review, require mandatory reporting, and assists the Nursing Commission in protecting public health and safety through the discovery of unsafe or substandard nursing practice or conduct. These rules are intended to define the information that is to be reported and the obligation of nurses and others to report as well as the process of reporting.