Title of Regulation: 18VAC90-20. Regulations Governing the Practice of Nursing (adding 18VAC90-20-215).

Statutory Authority: §§ 54.1-2400 and 54.1-3017.1 of the Code of Virginia.

Public Hearing Information:

September 16, 2014 - 10:30 a.m. - Department of Health Professions, 9960 Mayland Drive, Suite 201, Richmond, VA 23233

Public Comment Deadline: October 24, 2014.

Agency Contact: Jay P. Douglas, R.N., Executive Director, Board of Nursing, 9960 Mayland Drive, Suite 300, Richmond, VA 23233-1463, telephone (804) 367-4515, FAX (804) 527-4455, or email jay.douglas@dhp.virginia.gov.

Basis: Regulations are promulgated under § 54.1-2400 of the Code of Virginia, which provides the Board of Nursing the authority to promulgate regulations to administer the regulatory system, and § 54.1-3017.1 of the Code of Virginia, which provides specific authorization for the board to promulgate regulations for provisional licensure for registered nurse (RN) applicants.

Purpose: The purpose of this regulatory action is to comply with the statutory mandate of Chapter 712 of the 2011 Acts of the Assembly, which provides for issuance of a provisional license to an applicant for registered nurse licensure in order to obtain the clinical experience specified in regulation. The provisional licensee is to practice under supervision "in accordance with regulations established by the Board." This action makes permanent emergency regulations that have been in place since August 1, 2013.

The legislation authorizes the board to provide a pathway to licensure by the issuance of a provisional license to allow a graduate who has met the educational and examination requirements but is lacking clinical experience to obtain such experience by practicing under the supervision of a registered nurse for a period of time. The proposed regulations for provisional licensure will protect the public health, safety, and welfare by assuring that the RN applicant gains experience across the life span in all areas of nursing practice and that his practice will be overseen by an RN with at least two years of clinical practice experience. The supervisor is responsible for the assignment of duties consistent with the knowledge and skills of the provisional licensee and must be prepared to intervene if necessary for the health and safety of clients receiving care from a provisional licensee.

Substance: The proposal provides an alternative for qualifying for licensure by granting a provisional license to an RN applicant who has otherwise met the educational and examination requirements but is lacking clinical experience in the role of an RN. The proposal allows an applicant credit for supervised clinical hours in a current educational program and for holding an active, current license as a licensed practical nurse. The applicant will be given a year in which to complete 500 hours (or less with prior credits), which may be accomplished on a part-time basis. The proposal requires appropriate oversight of a provisional licensee practice across all aspects of nursing practice to assure that the RN is minimally competent to practice upon the granting of full licensure.

Issues: The primary advantage to the public is the potential for an increased supply of registered nurses who are qualified by education and supervised clinical experience to provide care to patients. There is also an advantage to certain graduates of educational programs who are not qualified for licensure because they lack the requisite clinical experience; the proposed regulation offers a pathway to licensure. There are no disadvantages to the public.

There are no advantages or disadvantages to the Commonwealth or the agency.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation: Pursuant to Chapter 712 (Senate Bill 1245) of the 2011 Acts of the Assembly, the Board of Nursing (Board) proposes to revise its regulations to provide for provisional licensure for applicants as registered nurses to obtain clinical experience. Specifically, the Board proposes to establish: 1) requirements for qualification and submission of documents for approval as a provisional licensee, 2) requirements for 500 hours of direct client care in the role of a registered nurse including various areas of nursing, 3) provisions for acceptance of previous clinical experience towards meeting the 500-hour requirement, 4) requirements for supervision of a provisional licensee, including the qualifications and responsibilities of the supervising nurse, and 5) provision for expiration and renewal of a provisional license.

Result of Analysis. The benefits likely exceed the costs for all proposed changes.

Estimated Economic Impact. The Regulations of the Board of Nursing (Section 120) require that "A nursing education program preparing for licensure as a registered nurse shall provide a minimum of 500 hours of direct client care supervised by qualified faculty." So approved programs based in Virginia that prepare for licensure as a registered nurse (RN) provide at least 500 hours of supervised clinical experience; thus the proposed provisional license will not directly affect individuals graduating from Virginia RN programs.

The proposed provisional license is relevant for graduates of out-of-state RN programs that provide less than 500 hours of supervised clinical experience. The proposed provisional license will provide these individuals with a feasible pathway to become licensed as an RN in the Commonwealth. This proposal should provide a net benefit in that it will enable additional qualified individuals to work in the Commonwealth.

Businesses and Entities Affected. The proposal to create an RN provisional license for applicants who need additional clinical experience will affect out-of-state RN programs that provide less than 500 hours of supervised clinical experience and their students who may wish to gain RN licensure in Virginia. The Department of Health Professions estimates that 25 or fewer individuals will seek provisional licensure per annum. By moderately adding to the supply of RNs in the Commonwealth, the proposal may moderately affect some hospitals, doctor's offices, and other entities seeking to employ RNs as well.

Localities Particularly Affected. The proposed amendments do not disproportionately affect particular localities.

Projected Impact on Employment. The proposed amendments will likely moderately increase the supply of qualified RNs in the Commonwealth. This will likely moderately increase the number of individuals working as RNs in Virginia.

Effects on the Use and Value of Private Property. Through the associated moderate increase in supply of RNs, the proposed amendments may help some firms find and hire an RN.

Small Businesses: Costs and Other Effects. By moderately adding to the supply of RNs in the Commonwealth, the proposed amendments may moderately reduce the cost of finding and employing RNs for some small firms that employ them.

Small Businesses: Alternative Method that Minimizes Adverse Impact. The proposed amendments do not adversely affect small businesses.

Real Estate Development Costs. The proposed amendments are unlikely to significantly affect real estate development costs.

Legal Mandate. The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Administrative Process Act and Executive Order Number 14 (10). Section 2.2-4007.04 requires that such economic impact analyses include, but need not be limited to, a determination of the public benefit, the projected number of businesses or other entities to whom the regulation would apply, the identity of any localities and types of businesses or other entities particularly affected, the projected number of persons and employment positions to be affected, the projected costs to affected businesses or entities to implement or comply with the regulation, and the impact on the use and value of private property. Further, if the proposed regulation has an adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include (i) an identification and estimate of the number of small businesses subject to the regulation; (ii) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the regulation, including the type of professional skills necessary for preparing required reports and other documents; (iii) a statement of the probable effect of the regulation on affected small businesses; and (iv) a description of any less intrusive or less costly alternative methods of achieving the purpose of the regulation. The analysis presented above represents DPB's best estimate of these economic impacts.

Agency's Response to Economic Impact Analysis: The Board of Nursing concurs with the analysis of the Department of Planning and Budget.

Summary:

Chapter 712 of the 2011 Acts of Assembly authorizes the board to adopt regulations that provide a licensure pathway through issuance of a provisional license to a registered nurse (RN) applicant who has otherwise met the educational and examination requirements but is lacking clinical experience. The proposed regulation includes (i) requirements for qualification and submission of documents for approval as a provisional licensee; (ii) requirements for 500 hours of direct client care in the role of an RN including various areas of nursing; (iii) provisions for acceptance of previous clinical experience towards meeting the 500-hour requirement; (iv) requirements for supervision of a provisional licensee, including the qualifications and responsibilities of the supervising nurse; and (v) provisions for expiration and renewal of a provisional license.

18VAC90-20-215. Provisional licensure of applicants for licensure as registered nurses.

A. Pursuant to § 54.1-3017.1 of the Code of Virginia, the board may issue a provisional license to an applicant for the purpose of meeting the 500 hours of supervised, direct (hands-on) client care required of an approved registered nurse education program.

B. Such applicants for provisional licensure shall submit:

1. A completed application for licensure by examination and fee;

2. Documentation that the applicant has successfully completed a nursing education program; and

3. Documentation of passage of NCLEX in accordance with 18VAC90-20-190.

C. Requirements for hours of direct client care with a provisional license.

1. To qualify for licensure as a registered nurse, direct, hands-on hours of supervised clinical experience shall include the areas of adult medical/surgical nursing, geriatric nursing, maternal/infant (obstetrics, gynecology, neonatal) nursing, mental health/psychiatric nursing, nursing fundamentals, and pediatric nursing. Supervised clinical hours may be obtained in employment in the role of a registered nurse or without compensation for the purpose of meeting these requirements.

2. Hours of direct, hands-on clinical experience obtained as part of the applicant's nursing education program and noted on the official transcript shall be counted towards the minimum of 500 hours and in the applicable areas of clinical practice.

3. For applicants with a current, active license as an LPN, 150 hours of credit shall be counted towards the 500-hour requirement.

4. Up to 100 hours of credit may be applied towards the 500-hour requirement for applicants who have successfully completed a nursing education program that:

a. Requires students to pass competency-based assessments of nursing knowledge as well as a summative performance assessment of clinical competency that has been evaluated by the American Council on Education or any other board-approved organization; and

b. Has a passage rate for first-time test takers on the NCLEX that is not less than 80%, calculated on the cumulative results of the past four quarters of all graduates in each calendar year regardless of where the graduate is seeking licensure.

5. An applicant for licensure shall submit verification from a supervisor of the number of hours of direct client care and the areas in which clinical experiences in the role of a registered nurse were obtained.

D. Requirements for supervision of a provisional licensee.

1. The supervisor shall be on site and physically present in the unit where the provisional licensee is providing clinical care of clients.

2. In the supervision of provisional licensees in the clinical setting, the ratio shall not exceed two provisional licensees to one supervisor at any given time.

3. Licensed registered nurses providing supervision for a provisional licensee shall:

a. Notify the board of the intent to provide supervision for a provisional licensee on a form provided by the board;

b. Hold an active, unrestricted license or multistate licensure privilege and have at least two years of active clinical practice as a registered nurse prior to acting as a supervisor;

c. Be responsible and accountable for the assignment of clients and tasks based on their assessment and evaluation of the supervisee's clinical knowledge and skills;

d. Be required to monitor clinical performance and intervene if necessary for the safety and protection of the clients; and

e. Document on a form provided by the board the frequency and nature of the supervision of provisional licensees to verify completion of hours of clinical experience.

E. The provisional status of the licensee shall be disclosed to the client prior to treatment and shall be indicated on identification worn by the provisional licensee.

F. All provisional licenses shall expire six months from the date of issuance and may be renewed for an additional six months. Renewal of a provisional license beyond the limit of 12 months shall be for good cause shown and shall be approved by the board. A request for extension of a provisional license beyond 12 months shall be made at least 30 days prior to its expiration.

FORMS (18VAC90-20)

Application for Licensure by Endorsement -- Registered Nurse (rev. 5/11)

Instructions for Licensure by Endorsement -- Registered Nurse (rev. 5/11)

Instructions for Licensure by Endorsement -- Licensed Practical Nurse (rev. 5/11)

Application for Licensure by Endorsement -- Licensed Practical Nurse (rev. 6/11)

Verification of Clinical Practice -- Licensure by Endorsement (rev. 1/10)

Instructions and Application for Licensure by Examination for Registered Nurses (rev. 8/11)

Instructions and Application for Licensure by Examination -- Licensed Practical Nurse (rev. 8/11)

Instructions and Application for Licensure by Repeat Examination for Registered Nurse (rev. 8/11)

Instructions and Application for Licensure by Repeat Examination for Licensed Practical Nurse (rev. 8/11)

Instructions and Application for Licensure by Examination for Licensed Practical Nurses Educated in Other Countries (rev. 6/11)

Instructions and Application for Licensure by Examination for Registered Nurses Educated in Other Countries (rev. 6/11)

Declaration of Primary State of Residency for Purposes of the Nurse Licensure Compact (rev. 6/11)

Instructions for Application for Reinstatement -- Registered Nurse (rev. 10/10)

Application for Reinstatement -- Registered Nurse (rev. 6/11)

Instructions for Application for Reinstatement -- Licensed Practical Nurse (rev. 2/10)

Application for Reinstatement of License as a Licensed Practical Nurse (rev. 6/11)

Instructions and Application for Reinstatement of License as a Registered Nurse Following Suspension or Revocation (rev. 6/11)

Instructions and Application for Reinstatement of License as a Licensed Practical Nurse Following Suspension or Revocation (rev. 6/11)

License Verification Form (rev. 10/09)

Procedure (rev. 3/10) and Application for Registration as a Clinical Nurse Specialist (rev. 6/11)

Application for Reinstatement of Registration as a Clinical Nurse Specialist (rev. 6/11)

Application to Establish a Nursing Education Program (rev. 6/11)

Agenda and Survey Visit Report -- Registered Nurse Education Program (rev. 4/08)

Agenda and Survey Visit Report -- Practical Nurse Education Program (rev. 4/08)

NCLEX Survey Visit Report (rev. 4/08)

Application for Registration for Volunteer Practice (rev. 7/07)

Sponsor Certification for Volunteer Registration (rev. 8/08)

Verification of Supervised Clinical Practice -- Registered Nurse Provisional License (undated)

Notification of Intent to Supervise Clinical Practice -- Registered Nurse Provisional License (undated)