TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF NURSING

Fast-Track Regulation

Title of Regulation: 18VAC90-27. Regulations for Nursing Education Programs (amending 18VAC90-27-30, 18VAC90-27-190).

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

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: April 23, 2025.

Effective Date: May 8, 2025.

Agency Contact: Claire Morris, RN, Executive Director, Board of Nursing, 9960 Mayland Drive, Suite 300, Henrico, VA 23233, telephone (804) 367-4665, or email claire.morris@dhp.virginia.gov.

Basis: Regulations of the Board of Nursing are promulgated under the general authority of § 54.1-2400 of the Code of Virginia, which authorizes health regulatory boards to promulgate regulations that are reasonable and necessary to administer the regulatory system.

Purpose: Chapter 425 of the 2024 Acts of Assembly requires the board to amend its regulations regarding out-of-state clinical experiences. The amendments increase opportunities for clinical training for nursing students, which impacts public health and welfare.

Rationale for Using Fast-Track Rulemaking Process: This action is appropriate for the fast-track rulemaking process and is expected to be noncontroversial because it expands on requirements of the 2024 legislation and reduces requirements on nursing education programs.

Substance: The amendments remove limitations on out-of-state clinical education.

Issues: The primary advantages to the public are nursing students receiving clinical education in a timely manner, graduating, and entering the Virginia workforce. There are no disadvantages to the public. There are no primary advantages or disadvantages to the agency or the Commonwealth.

Department of Planning and Budget Economic Impact Analysis:

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 Code of Virginia and Executive Order 19. The analysis presented represents DPB's best estimate of the potential economic impacts as of the date of this analysis.¹

Summary of the Proposed Amendments to Regulation. Partially pursuant to Chapter 425 of the 2024 Acts of Assembly,² the Board of Nursing (board) proposes to eliminate all restrictions on out-of-state clinical experiences. Additionally, the board proposes to remove the current requirement that all clinical experiences take place within 50 miles of the school, unless an exception is granted by the board.

Background. The current regulation requires that unless exceptions are granted by the board, at least 80% of all clinical experiences for nursing students must be conducted in Virginia, and that the clinical sites must be located within 50 miles of the nursing school. Chapter 425 requires that the Board of Nursing amend its regulations to permit nursing education programs in the Commonwealth located within 60 miles of a bordering state or the District of Columbia to contract for an unlimited number of required clinical hours at out-of-state clinical sites. Such regulations shall require that all such clinical hours be accepted by the board for licensure. According to the Department of Health Professions (DHP), the board determined that all out-of-state clinical restrictions should be removed due to difficulties implementing the legislative language as written and also to ensure consistency in requirements for nursing education programs. The board also proposes to eliminate the requirement that clinical sites be within 50 miles of the nursing school.

Estimated Benefits and Costs: The proposed removal of restrictions provides schools of nursing with additional options for clinical experiences for their students. To the extent that some nursing schools determine that having more than 20% of clinical experiences for their students take place outside the Commonwealth, or having some clinical experiences take place more than 50 miles from the nursing school, would improve the quality of such experiences, the proposed removal of the restrictions would be beneficial.

Businesses and Other Entities Affected. The proposed amendments potentially affect the 40 practical schools of nursing and the 67 professional schools of nursing in the Commonwealth. The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.³ An adverse impact is indicated if there is any increase in net cost or reduction in net benefit for any entity, even if the benefits exceed the costs for all entities combined.⁴ The proposed amendments neither increase net costs nor reduce net benefit. No adverse impact is indicated.

Small Businesses⁵ Affected.⁶ The proposed amendments do not appear adversely affect small businesses.

Localities⁷ Affected.⁸ Nursing schools in localities that either border or are near a border with another state or the District of Columbia may be more likely to take advantage of the elimination of the restriction on out-of-state clinical experiences. The proposed amendments do not appear to affect costs for local governments.

Projected Impact on Employment. The proposed amendments do not appear to affect total employment.

Effects on the Use and Value of Private Property. The proposed elimination of restrictions on the locations of clinical experiences may result in some private schools of nursing changing where clinical experiences for their students take place. Potentially, this may result in a modest increase in their value. The proposed amendments do not affect real estate development costs.

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¹ Section 2.2-4007.04 of the Code of Virginia requires that such economic impact analyses determine the public benefits and costs of the proposed amendments. Further the analysis should include but not be limited to: (1) the projected number of businesses or other entities to whom the proposed regulatory action would apply, (2) the identity of any localities and types of businesses or other entities particularly affected, (3) the projected number of persons and employment positions to be affected, (4) the projected costs to affected businesses or entities to implement or comply with the regulation, and (5) the impact on the use and value of private property.

² See https://lis.virginia.gov/cgi-bin/legp604.exe?241+ful+CHAP0425.

³ Pursuant to § 2.2-4007.04 D: In the event this economic impact analysis reveals that the proposed regulation would have an adverse economic impact on businesses or would impose a significant adverse economic impact on a locality, business, or entity particularly affected, the Department of Planning and Budget shall advise the Joint Commission on Administrative Rules, the House Committee on Appropriations, and the Senate Committee on Finance. Statute does not define "adverse impact," state whether only Virginia entities should be considered, nor indicate whether an adverse impact results from regulatory requirements mandated by legislation.

⁴ Statute does not define "adverse impact," state whether only Virginia entities should be considered, nor indicate whether an adverse impact results from regulatory requirements mandated by legislation. As a result, DPB has adopted a definition of adverse impact that assesses changes in net costs and benefits for each affected Virginia entity that directly results from discretionary changes to the regulation.

⁵ Pursuant to § 2.2-4007.04, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

⁶ If the proposed regulatory action may have an adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include: (1) an identification and estimate of the number of small businesses subject to the proposed regulation, (2) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the proposed regulation, including the type of professional skills necessary for preparing required reports and other documents, (3) a statement of the probable effect of the proposed regulation on affected small businesses, and (4) a description of any less intrusive or less costly alternative methods of achieving the purpose of the proposed regulation. Additionally, pursuant to § 2.2-4007.1 of the Code of Virginia, if there is a finding that a proposed regulation may have an adverse impact on small business, the Joint Commission on Administrative Rules shall be notified.

⁷ "Locality" can refer to either local governments or the locations in the Commonwealth where the activities relevant to the regulatory change are most likely to occur.

⁸ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency Response to Economic Impact Analysis: The Board of Nursing concurs with the economic impact analysis prepared by the Department of Planning and Budget.

Summary:

The amendments remove all out-of-state nursing education clinical restrictions for consistency in requirements for nursing education programs, expanding upon the requirements for the board to allow certain clinical nursing education to occur out of state pursuant to Chapter 425 of the 2024 Acts of Assembly.

18VAC90-27-30. Application for initial approval.

An institution wishing to establish a nursing education program shall:

1. Provide documentation of attendance by the program director at a board orientation on establishment of a nursing education program prior to submission of an application and fee.

2. Submit to the board an application to establish a nursing education program along with a nonrefundable application fee as prescribed in 18VAC90-27-20.

a. The application shall be effective for 12 months from the date the application was received by the board.

b. If the program does not meet the board's requirements for approval within 12 months, the institution shall file a new application and fee.

3. Submit the following information on the organization and operation of a nursing education program:

a. A copy of a business license and zoning permit to operate a school in a Virginia location, a certificate of operation from the State Corporation Commission, evidence of approval from the Virginia Department of Education or SCHEV, and documentation of accreditation, if applicable;

b. The organizational structure of the institution and its the institution's relationship to the nursing education program therein;

c. The type of nursing program, as defined in 18VAC90-27-10;

d. An enrollment plan specifying the beginning dates and number of students for each class for a two-year period from the date of initial approval, including (i) the planned number of students in the first class and in all subsequent classes and (ii) the planned frequency of admissions. Any increase in admissions that is not stated in the enrollment plan must be approved by the board. Also, transfer students are not authorized until full approval has been granted to the nursing education program; and

e. A tentative time schedule for planning and initiating the program through graduation of the first class and the program's receipt of results of the NCLEX examination.

4. Submit to the board evidence documenting adequate resources for the projected number of students and the ability to provide a program that can meet the requirements of this part to include the following information:

a. The results of a community assessment or market analysis that demonstrates the need for the nursing education program in the geographic area for the proposed school. The assessment or analysis shall include employment opportunities of nurses in the community, the number of clinical facilities or employers available for the size of the community to support the number of graduates, and the number and types of other nursing education programs in the area;

b. A projection of the availability of qualified faculty sufficient to provide classroom instruction and clinical supervision for the number of students specified by the program;

c. Budgeted faculty positions sufficient in number to provide classroom instruction and clinical supervision;

d. Availability of clinical training facilities for the program as evidenced by copies of contracts or letters of agreement specifying the responsibilities of the respective parties and indicating sufficient availability of clinical experiences for the number of students in the program, the number of students, and clinical hours permitted at each clinical site and on each nursing unit;

e. Documentation that at least 80% of all clinical experiences are to be conducted in Virginia, unless an exception is granted by the board. There shall be documentation of written approval for any clinical experience conducted outside of Virginia by the agency that has authority to approve clinical placement of students in that state. The use of any clinical site in Virginia located 50 miles or more from the school shall require board approval;

f. e. A diagram or blueprint showing the availability of academic facilities for the program, including classrooms, skills laboratory, and learning resource center. This information shall include the number of restrooms for the student and faculty population, classroom and skills laboratory space large enough to accommodate the number of the student body, and sufficient faculty office space; and

g. f. Evidence of financial resources for the planning, implementation, and continuation of the program with line-item budget projections for the first three years of operations beginning with the admission of students.

5. Respond to the board's request for additional information within a timeframe established by the board.

18VAC90-27-190. Evaluation of resources; written agreements with cooperating agencies.

A. Periodic evaluations of resources, facilities, and services shall be conducted by the administration, faculty, students, and graduates of the nursing education program, including an employer evaluation for graduates of the nursing education program. Such evaluation shall include assurance that at least 80% of all clinical experiences are conducted in Virginia unless an exception has been granted by the board.

B. Current written agreements with cooperating agencies shall be maintained and reviewed annually and shall be in accordance with 18VAC90-27-80 E.

C. Upon request, a program shall provide a clinical agency summary on a form provided by the board.

D. Upon request and if applicable, the program shall provide (i) documentation of board approval for use of clinical sites located 50 or more miles from the school, and (ii) for use of clinical experiences conducted outside of Virginia, documented approval from the agency that has authority to approve clinical placement of students in that state.