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Regulations Governing the Practice of Nursing [18 VAC 90 ‑ 19]

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3/18/19  10:49 am
Commenter: Lisa Abrams, APN-BC

Prescription Privileges
 

Most recently I have deicided to relocated to the state of Va. I have been an Advance Practice Nurse with Prescriptive Privileges for approxiately 10 years. I have reveiwed infomation from the APNA,ANA,APRN and National board of Nursing that as long as I was an APRN that I would able to transfer my license through endorsement. After almost completing the process I found out that may not be possible. After reading the Va regualations it does not say that the Clinical Nurse can not prescribed medication. Prescribing medication is considered an advance nursing act . The writing of prescriptions is considered an advance nurse act which should be appropriate for CNS under the scope of practice. My only concern is  that I had to speak to someone at the board of nursing that CNS does not prescribe in Va.If that is not possible it should be clear on yor web page so anyone reloacting as an CNS would not consider VA a state to relocate too or paying fees when they are not reconized. I have 2 potential employment oppurtunities that I might not be able to take do to this issue not being clearly spelled out.

 

In advamce thank you- Lisa Abrams. APN (856) 404-5794


3/18/19  11:38 am
Commenter: Monica Coles, DNP, RN-BC, ACNS-BC-Carilion Medical Center

CNS Full Practice Authority
 

I am a new CNS. Our role is underutilized and our practice is stifled. Affording the CNS full practice authority to include prescriptive, would be beneficial to providers. We can order items that include but is not limited to DME, therapies, activity level unless surgical or spinal precautions prohibit unrestricted activity, some consultations, i.e., Wound,Diabetic Education, Pain Management (other CNS expertise), Smoking Cessation, etc... In addition, If a CNS has the education, is registered (require this) and has held unrestricted practice in another state, it would be beneficial that they be allowed to continue that practice in Virginia.


3/18/19  12:35 pm
Commenter: Sarah W. Taylor, AGCNS-BC

Petition to revise the Regulations Governing the Practice of Nursing-CNS
 

CNSs should be granted full authority to operate within their scope of practice to meet our nation's need for access to care. Working with physicians, physician assistants and other APRNs we are committed to provide care to patients.  Our nation's aging population brings the access to care crisis to the top of our healthcare system’s priority list. 

There are savings to be considered as the prescribing CNS saves patients and facilities time and money by eliminating the number of visits required by the patient to obtain needed prescriptions therefore contributing to medication compliance.  Additionally,  There are savings in the health care system that can be accrued; the prescribing CNS can save time and money by not needing the patient to make another visit to a physician or other prescriber in order to get needed prescriptions. CNSs also prescribe nonpharmacological treatments and devices such as durable medical equipment and function as consultants to other providers.  

Although this is not an exhaustive list of patient and facility benefits to be realized by granting full authority of practice, it is a statement to the increasing demands of high-quality health care that should drive policy makers to ensure that health care providers, including all APRNs, are working to the full extent of their education and practice.


3/18/19  1:16 pm
Commenter: Lisa Abrams

Full Practice Authority
 

After reviewing comments - I did not realize that Va. CNS did not have full practice authority. I acutually called the state board and spoke to a staff member and she stated I quote " CNSs in the state of Va are considered regular nurses." After that conversation with the board I felt that my degree and credentials did not mean a thing to the state. I felt like after paying an additional 125.00 above the RN license did not make any sence. Now I understand !!! Please state of VA - approve full Practice Authority !!!! We are all RN but we strive for excellence and education in our speciality. As things stand it would not make any sense for any advance nurse to relocated if she or he is not reconized.   


3/18/19  2:24 pm
Commenter: Bethann Mendez WMC

Parity among advanced practice nurses
 

The state of Virginia does not allow the CNS role to be leveraged as an APRN role due to the restrictive nature of privileges.  Many APRN CNS's work as educators or other leadership roles because of these licensing restrictions.  This contributes to the access to care concerns that many areas of the stat are facing that ultimately drives the cost of care.  Academic preparation for the CNS is equivalent to NP if not exceeding (with many institutions now required DNP, as the consensus model originally proposed).  Even as a doctoral prepared CNS I am unable to advance my privileges to prescribe medication and practice fully in an APRN role.  Approximately 36 of the 50 states recognize the full privileges of the CNS preparation and role and, therefore, benefit from their expertise.  Virginia must consider leading, or at least modernizing to match that of the other 36 states, so that this vital APRN role can contribute to the  state’s health care needs.


3/18/19  9:00 pm
Commenter: Linda Thurby-Hay

Support changing the regulations related to CNS practice
 

In 2008, the National Council of State Boards of Nursing (NCSBN) published the Consensus Model for APRN Regulation to standardize regulatory language for all four APRN roles, and offered a Model Practice Act to guide language changes. Those with vested interests in subjugating advanced nursing roles continue to challenge the ability of APRN roles to practice without oversight across the nation and here in Virginia. As we have seen year after year in Virginia, all four APRN roles struggle to align the Code of Virginia with the Consensus Model. In Virginia, Clinical Nurse Specialists (CNS), in particular, experience significant barriers to fulfilling their obligation to the public of delivering specialty nursing care for the populations served. This petition is the next step in moving CNS practice forward in Virginia. 

Today, I am writing in full support of this petition of the Virginia Association of Clinical Nurse Specialists. Barriers to CNS practice need to be removed, one by one, if necessary! Although CNSs enjoy title protection and are identified as Advanced Practice Registered Nurses (APRN) in the Code of Virginia, the interpretation of current regulations suggest that CNS practice is no different than professional nursing practice. The designers of the Consensus Model would disagree, as do CNSs everywhere. APRN practice (including CNS practice) builds on the knowledge and skill of RN practice; the difference lies in the depth and breadth of understanding of nursing phenomena seen in specialty nursing practice, not in whether we can prescribe (although we are educationally-prepared to do so). CNSs conduct advanced assessments, develop plans of care and intervene with advanced therapies, which is consistent with the medical model of physician specialist practice building on the education of the primary care physician.  

It is time to remove barriers to CNS practice in Virginia. This petition is the next step for this knowledgeable and skilled advanced practice nursing role.


3/18/19  9:34 pm
Commenter: Beth Quatrara DNP, RN, CMSRN, ACNS-BC

CNS full scope
 

Patients across the state of Virginia deserve access to quality care.  Clinical Nurse Specialists are trained according to the same foundational requirements as other Advanced Practice Nurses and are recognized by the National Council of State Boards of Nursing for their advanced practice training.  Clinical Nurse Specialists are uniquely trained to provide comprehensive care to populations with complex needs with goals such as reducing complications and promoting wellness by addressing system issues.  Clinical Nurse Specialists reduce barriers and faciity quality care.

Withholding practice privileges from Clinical Nurse Specialists in the state of Virginia limits the care available to many of our most vulnearble neighbors in the Commonwealth.  I fully support this petition and urge the Commonwealth to provide full practice authority to Clinical Nurse Specialists.  Barriers to care must be reduced so that residents of the State are able to receive the care that they need. 

 

 

 


3/19/19  12:26 pm
Commenter: Kimberly Elgin, DNP, RN, ACNS-BC, PCCN, CMSRN

Clinical Nurse Specialist Regulation Changes
 

The CNS is one of four advanced practice RN roles as defined by NCSBN and as such should have regulatory parity.  Healthcare professionals are challenged to provide robust health care services for the population of Virginia in a complex and burdened healthcare system.  There is immense opportunity for CNSs with full scope of practice authority to provide an advanced scope of clinical services and lead interprofessional teams in optimizing healthcare outcomes for the Commonwealth.  Virginia is one of a shrinking number of states which limit CNS practice by regulation.  Revisions to the current regulations, providing for licensure and full practice authority, are essential to the resolution of disparity across states and with the APRN community.  I firmaly support changes to Virginia CNS regulation.


3/24/19  9:05 am
Commenter: Amanda Golino, MSN, RN, CCRN, CCNS, RN-BC

Full practice authority for the CNS
 

As a practicing Clinical Nurse Specialist (CNS) in the Commonwealth of Virginia I am writing to request reconsideration for the CNS role to allow full practice authority. The CNS is uniquely skilled (and trained) to be a practice expert within a particular patient population. Our role is dynamic, allowing us to optimize care and prevent and reduce patient complications in a complex and ever changing care environment. Currently, Virginia is overly restrictive of the CNS practice, recognizing the role as an APRN but denying the privileges afforded to our APRN counterparts. This limits CNS practice and ability to serve patients, healthcare teams, and systems at the highest levels. 36/50 states have granted the CNS role full authority; it’s time for the Commonwealth to follow suit. 

 


3/24/19  10:33 am
Commenter: Robin R. Jackson BSHS, MSN, RN-BC, CCRN , CCNS, CHTP

Change in recognition for the Clinical Nurse Specialist as Advanced Practice RN
 

TyI am writing in full support of this petition of the Virginia Association of Clinical Nurse Specialist to remove the barriers to the Clinical Nurse Specialist (CNS) practice in the Commonwealth of Virginia. The National Council of State Boards of Nursing (NCSBN) recognizes the CNS as an Advanced Practice Registered Nurse (APRN). This recognition acknowledges the advanced knowledge, skills and training required for eligibility to take certification exams.  CNS train to care for populations of patients. I personally trained in Critical Care and hold a certification as a Critical Care Clinical Nurse Specialist (CCNS). My training is above the training RNs receive to work in critical care and I have the unique position to work with the population of patients and understand the systems to help in their overall care. I was very disappointed after completing my Masters of Science in Acute Care Nursing and my certification as a CCNS, to only receive a registration from the Commonwealth and still be considered a RN not an APRN.   There are many areas that the Commonwealth excels in providing excellence but is missing the opportunity to provide residences the additional resources and knowledge the CNS brings to healthcare.  It is time to join the other 36 states that recognizes the CNS as an APRN.  Thank you for the opportunity to comment on this important change in practice.


3/25/19  12:12 pm
Commenter: Erin M. Smith, MS, RN, ACCNS-AG, CCRN-CMC; Sentara Norfolk General Hospital

Support recognition of CNS as an Advanced Practice Nurse
 

Patients across the state of Virginia deserve access to quality care.  Clinical Nurse Specialists are trained according to the same foundational requirements as other Advanced Practice Nurses and are recognized by the National Council of State Boards of Nursing for their advanced practice training.  Clinical Nurse Specialists are uniquely trained to provide comprehensive care to populations with complex needs with goals such as reducing complications and promoting wellness by addressing system issues.  Clinical Nurse Specialists reduce barriers and faciity quality care.

Withholding practice privileges from Clinical Nurse Specialists in the state of Virginia limits the care available to many of our most vulnearble neighbors in the Commonwealth.  I fully support this petition and urge the Commonwealth to provide full practice authority to Clinical Nurse Specialists.  Barriers to care must be reduced so that residents of the State are able to receive the care that they need. 


3/25/19  2:49 pm
Commenter: Phyllis Whitehead, PhD, APRN/CNS, ACHPN, RN-BC

The Virginia Association of Clinical Nurse Specialists (VaCNS)’s Petition
 

I support the The Virginia Association of Clinical Nurse Specialists (VaCNS)’s petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice.  The recommendations are necessary to clarify CNS registration requirements and to differentiate CNS practice from that of the professional nurse. The revisions align with nurse practice acts and regulations in neighboring states, across the nation, as well as the tenets of the Consensus Model for APRN Regulation (2008).


3/25/19  3:02 pm
Commenter: Ashley Caviness DNP, RN, AGCNS-BC, CCRN

Support for adopting the Consensus Model for all CNS's in Virginia
 

The Clinical Nurse Specialist is trained to provide diagnosis and treatment, disease management, health promotion, and prevention of illness. Allowing CNS's to practice to the full extent of their licensure will assist Virginia in providing access to quality healthcare to all residents. I support the The Virginia Association of Clinical Nurse Specialists (VaCNS)’s petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice.  The recommendations are necessary to clarify CNS registration requirements and to differentiate CNS practice from that of the professional nurse. The revisions align with nurse practice acts and regulations in neighboring states, across the nation, as well as the tenets of the Consensus Model for APRN Regulation (2008). I fully support this petition and urge the Commonwealth of Virginia to join other states in the United States and provide full practice authority to Clinical Nurse Specialists.


3/25/19  3:11 pm
Commenter: Stephanie A Ruen

Registration of Clinical Nurse Specialists
 

I support the The Virginia Association of Clinical Nurse Specialists (VaCNS)’s petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice.  The recommendations are necessary to clarify CNS registration requirements and to differentiate CNS practice from that of the professional nurse. The revisions align with nurse practice acts and regulations in neighboring states, across the nation, as well as the tenets of the Consensus Model for APRN Regulation (2008).


3/25/19  3:25 pm
Commenter: Jennifer Matthews, Ph.D, RN A-CNS, FAAN

Support of the Regulatory Changes for the APRN status of CNS
 

Please support the regulatory changes to bring the CNS role in Virginia to equal status of the APRN roles as envisioned in the 2008 mandate. CNSs contribute significantly to the health of Virginians because of the unique education provided to the graduate level studies. Virginians will continue to benefit from the CNSs and should recognize these amazing nurses equal to our partners the NP, CNM, and CRNA.

Please respond positively to the proposed changes.

Jennifer Matthews


3/25/19  8:36 pm
Commenter: Cindy Ward, DNP, RN-BC, CMSRN, ACNS-BC, Carilion Roanoke Memorial Hospital

Support Petition for Changes to CNS Regulations
 

I fully support the changes to the CNS Regulations proposed by the Virginia Association of Clinical Nurse Specialists. The changes will bring CNS practice in Virginia closer to alignment with the Consensus Model for APRN Regulation (2008) from the National Council of State Boards of Nursing, and with CNS regulations in neighboring states.

Clinical Nurse Specialists have advanced education and certification as a CNS in our specialty areas and are recognized as billing providers by the Centers for Medicare and Medicaid Services. Despite these facts, the lack of full practice authority and the lack of licensure as clinical nurse specialist are barriers keeping us from practicing to the full extent of our education. The proposed regulation changes will be the first steps in removing the barriers and will improve access to care to the citizens of the Commonwealth.

I urge you to approve the proposed changes to the Regulations.


3/26/19  11:12 am
Commenter: F. Kay Butler, MSN, RN, AGCNS-BC, CCRN, ACM-RN, RN THE KNOW, LLC

CNS Petition to BON
 

I would like the opportunity to practice to the fullest scope of my educational preparation in my home state of Virginia.  This not only would help to bridge the gap of those Virginians who do not currently have access to standard medical care but would provide me immense professional satisfaction by elevating the level of services I am able to offer.  I consider any step that is taken to move us in this direction by the Virginia Clinical Nurse Specialists (VaCNS) to be long overdue.  Therefore, I fully support the petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice in this state. 

Clarification in CNS registration requirements and differentiation of the advanced practice role of the CNS from that of the professional registered nurse is obligatory.  The revisions made move this group of advanced practice registered nurses (APRN) closer to full alignment with the tenets of the Consensus Model for APRN Regulation (2008), a document that is over a decade old, which represents my ideal standards of practice for this group of APRNs. 


3/27/19  9:16 am
Commenter: Keysha Pochopien

Support the VaCNS Petition
 

I support the Virginia Association of Clinical Nurse Specialists petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice. This revision is a key step to overcoming barriers and challenges to CNS practice that persist in the state of Virginia. There are three levels for scope of practice nationwide: full scope, collaborative agreement with a supervising physician, and limited scope. Fewer than ten states nationwide limit scope of practice for CNSs and, unfortunately, Virginia is one of them. A limited scope of practice state severely limits the advanced practice authority that CNSs studied and prepared for through accredited graduate advanced practice nursing programs. Please support this petition.

 


3/29/19  11:54 am
Commenter: Magdalys Ortiz MSN RN AGCNS-BC, Bon Secours Mercy Health

VaCNS petition to BON
 

I support the Virginia Association of Clinical Nurse Specialists petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice. I’m a fairly new adult-gerontology CNS, and it has been extremely challenging to find a CNS position due to Virginia’s limited scope of CNS practice. In my opinion, this limitation in CNS scope of practice is directly linked to the lack of CNS positions and employer awareness about the CNS role. As a result, this forces some of us to continue to work in our RN roles or take CNS like positions that pay at a RN level, which is very frustrating because we can’t work to our full potential or get paid to function close to a CNS. Other CNSs that are lucky to work in CNS roles in Virginia don’t have prescription authority, which also limits their practice.

CNSs are advanced practice nurses with advanced education and training in their selected patient populations (adult-gerontology, pediatrics, etc.). CNSs engage in three domains of influence: patient, nursing, and system/organization. CNSs use advanced nursing knowledge and skills to oversee their patients’ care. This allows for appropriate recommendations to be made that improve the patients’ health as well as develop interventions that can be implemented to bridge gaps in their care. The CNSs functions are as follows: provide education to nursing staff and patients/family; provide evidence-based recommendations by consultation and coaching of nursing staff and other healthcare professionals; collaborate with an interprofessional team about the care of patients while keeping the principles of ethics in mind. CNSs have advanced knowledge that allows them to be change agents in their organizations by reducing readmissions and organization costs as well as improve the patients care, health, and quality of life.

Unfortunately, limited CNS practice limits what we can do for Virginians as well as limits their access to care. With the recent drop in primary care providers the demand for providers will increase and there will be more challenges with caring for a patient population that is living longer with complex medical conditions. However, if we were allowed to practice to our full scope it will help mitigate these challenges in the near future.

 


3/29/19  1:43 pm
Commenter: Theresa Mulherin

continue the grandfathering clause
 

I support reg changes ONLY if they continue to have the grandfathered clause for us "older" CNS'


3/29/19  9:12 pm
Commenter: Pamela Sharp, PhD, RN, CNS-BC, ODU & Bon Secours MIH

Support change in the regulations regarding CNS registration and practice in Virginia
 

It was recognized in 1995 that there were many inconsistencies with how CNSs were viewed, trained, and employed across states, thus the NACNS was formed.  NACNS joined with other groups, including NCSBN and specialty nursing groups to identify the spheres of influence and develop Core CNS Competencies -- agreed upon and formalized in 1998, with the first minor revision published in 2004. The document is reviewed every 5 years.

Key elements of 1998 document included licensed RN with graduate preparation from a CNS program, clinical experts in diagnosis and treatment of illness and delivery of evidence based nursing interventions, and advanced knowledge with a specialty focus.  Specialty areas are always evolving as the science of care evolves. A clinical nurse specialists’ specialty may typically be defined by population, setting, disease or medical subspecialty, type of care, or type of problem.  Regardless of specialty or setting, CNSs enact the same core competencies. 

Even with the 1998-2004 Core Competencies outlining the CNS role, states were still not all consistently recognizing the CNS as an APN.  The next step in attempting to better align the role of the CNS and plan for the future was to develop the APRN Regulatory Model or consensus document.  This was completed in July 2008, revised in 2010, with full implementation expected by 2015.  Full implementation still has not occurred in all states in 2019.  In fact, groups who worked on the model have stated that “the more states that pass this model in piecemeal manner may result in problematic variations between states” and loss of consistency, which was the point of the model.

CNS testing was also evaluated in 2008.  This is when the population specific tests were devised to match the new model, although not all fully implemented until 2010.  A Grandfathering Clause or a similar statement of exceptions was recommended for all states so that APNs who were educated and practiced at the graduate level prior to consensus model were able to register as a CNS “regardless of current recognition status” and did not have to meet new requirements. An example is the old med-surg/adult health exam which was updated to the CORE exam, keeping an option for those who had already completed their CNS training and allowing time for programs to admit students under the new model and finish the “teach out” of old curriculums. 

Virginia has not fully recognized or implemented the APRN Regulatory model, including maintaining a fair grandfathering clause resulting in CNSs who currently hold national certification, without lapse, and years of experience at the graduate level being unable to register in the state.  The dates nurses attended their CNS program and competencies under which they trained, which should match their testing, are not consistently being recognized.

The proposed change in CNS registration and practice in Virginia will address the importance of not excluding CNSs solely based on an exam, especially when competence can be supported through work experience, portfolio, recommendations, etc.  It would eliminate hardship being placed on CNSs in the state and would also possibly increase the number of CNSs registered in the state, as there are likely some who are not attempting to register and practice to their full potential given the current barriers.  This could also help fill the gap in advanced practice providers, which are in great demand. 


4/1/19  2:39 pm
Commenter: Sonya Wilson, MSN, RN-BC, ACNS-BC Sentara Princess Anne Hospital

CNSs are underutilized resource for healthcare in the Commonwealth of Virginia
 

I support the The Virginia Association of Clinical Nurse Specialists (VaCNS)’s petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice that is necessary to recognize the Clinical Nurse Specialist (CNS) as an Advanced Practice Nurse. As an APN educated, certified and licensed to provide advanced patient care from assessment to treatment and overall health promotion, it is time to be progressive in practice.  The CNS has been denied the ability to practice to the fullest extent of their education and licensure by the Commonwealth of Virginia in comparison to other states who benefit from this great resource.  We are not just nurses. We are a group being underutilized in meeting the needs of our Commonwealth's patients at a time when all resources are needed. The Commonwealth of Virginia needs to recognize and support the promotion of the Consensus Model for APRN Regulation (2008).


4/2/19  12:17 pm
Commenter: Cheri S. Blevins DNP APRN CCRN CCNS

Support of registration of clinical nurse specialists
 

The APRN Campaign for Concensus published by the National Council of State Boards of Nursing (NCSBN) in 2008 encourages all states to standardize regulatory requirements for the four APRN roles (CRNAs, CNMs, CNPs, and CNSs). However, the NCSBN reported in October of 2018 that the Commonwealth of Virginia currently does requires licensure for the CNS nor address independent practice. As the nation struggles to provide access to care and ensure that APRNs are highly qualified to provide quality care it is incumbent on the Commonwealth of Virginia State board of nursing to follow those recommendations in line with 17 other states and territories of the US (https://www.ncsbn.org/5397.html).

I wholehearted endorse this petition to review all legislature concerning CNS practice in the Commonwealth of Virginia to improve health equity for our citizens.

Sincerely,

Cheri S. Blevins


4/4/19  4:24 pm
Commenter: Bon Secours St. Mary's Hospital

In support of CNS practice
 

The APRN Campaign for Concensus published by the National Council of State Boards of Nursing (NCSBN) in 2008 encourages all states to standardize regulatory requirements for the four APRN roles (CRNAs, CNMs, CNPs, and CNSs). However, the NCSBN reported in October of 2018 that the Commonwealth of Virginia currently does requires licensure for the CNS nor address independent practice. As the nation struggles to provide access to care and ensure that APRNs are highly qualified to provide quality care it is incumbent on the Commonwealth of Virginia State board of nursing to follow those recommendations in line with 17 other states and territories of the US (https://www.ncsbn.org/5397.html).

I wholehearted endorse this petition to review all legislature concerning CNS practice in the Commonwealth of Virginia to improve health equity for our citizens.

Sincerely,

Mary Beth Stonich


4/4/19  11:52 pm
Commenter: Donna Washburn DNP, RN, CNS, ACNS-BC, AOCNS, Centra

A petition with great potential for improving safe, efficient, high-quality, team-based care
 

As a CNS with experience in both inpatient and outpatient settings, I understand the impact that the current limitations have on our practice. Due to my training as a clinical nurse specialist with advanced certification in both adult health, and adult oncology, I have been able to work closely with physicians to improve the care of cancer patients. I'd like to share a little bit about this to help others better understand why allowing CNS's to practice to the full extent of their training is not only safe, but also beneficial.

In the outpatient practice, I was responsible for a cohort of aproximately 100 cancer patients at any given time. These patients were on clinical trials. As patients came in for their scheduled treatments and assessments, I was able to use my advanced assessment skills to perform complete or focused physical and mental assessments, monitor their exam and test results, assess for adverse effects, grade the adverse effects, determine the attribution of any adverse effects, and council the patient on issues that might help improve quality of life and health such as diet, lifestyle and behavior, medication adherence, etc. . I worked with a bachelors trained RN and an LPN who assisted with gathering and recording health assessment data. The care that the patients received was guided by standard protocols of care developed by oncology experts. In a quality review of ths cohort in comparison with other patients, we learned that despite similarity of age, race, social and economic status, types and stages of cancer, patients in my cohort had aproximately only about a 10th of the incidence of ER visits and hospitalizations, as the other patients managed in the normal way. 

As is typical of the CNS role, I also filled other roles such as genetic testing education and counseling, worked closely with the organization to achieve certifications, improve safety and quality of care through implementation of evidence-based practice changes, training and education of staff, ensuring physicians and APP's are educated to practice standards and maintain those standards, and so on. 

The limitations that I felt so keenly during these nine years,  due to the Virginia regulations, caused delays in treatment and unnecessary extra expenses, steps for providers and/or patients, and interruptions of care due to the need to get an order or signed paperwork for DME, tests, or treatments. Many of the interventions that could be implemented by the CNS in combination with the advanced level of care are typical, standard of care, and protocol guided within the specialty. The patient whose labs are slightly abnormal needs to come to have them re-checked,  the patient who is experiencing a side effect such as diarrhea needs some temporary adjustments in medication management, the patient who is experiencing fatigue and would benefit from specialized rehabilitation or cancer therapy programs, and the patient who would benefit from some DME at home to improve quality and safety should all be able to have that care ordered in a seemless, efficient, manner. 

In the inpatient setting, similar circumstances occur every day as CNS's intervene for physicians as members of the care team to aide in management of patients in special populations and/or with special needs. Patients in pain, or with complicated wounds, diseases that require close attention and monitoring and other situations where a CNS can work closely with bedside nurses, and ancillary staff to improve quality, safety, and efficiency of care. Although there are many things that we can do, and do well, physicians in our facilities who rely on the CNS to assist with special populations often request an additional service we cannot perform because of our limitations.

In conclusion, as CNS's work with physicians and other APP's, we gain their trust and become valued team members through the consultation processes and the manner in which we engage with them to fill the gaps in patient care. Our value becomes clear as our other team members and the organizations see the impact that we have on quality and safety and improved patient outcomes. Allowing us to practice to our full training, will only improve the efficiency and availability of the already great care we provide to our patients.

Thank you for the opportunity to comment.  

 

 

 


4/6/19  9:54 pm
Commenter: Catherine Smith, DNP, RN, CCNS, CCRN

Support Revisions to CNS Registration and Practice Regulations
 

I support the Virginia Association of Clinical Nurse Specialists petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice. This revision is a key step toward overcoming barriers and challenges to CNS practice that persist in Virginia.

As a CNS who relocated from another state, I know first-hand the practice limitations encountered here in Virginia. As a result of the restrictions, many Virginia CNSs opt to practice in alternative nursing roles which is ultimately limiting Virginia citizens access to this valuable advanced practice nursing resource who is specially trained to improve systems of care and patient outcomes based on evidence. 

The CNS registration section must be clarified to include initial, renewal, reinstatement, and endorsement  requirements. National CNS certifications including CORE and retired certifications that have not lapsed should be accepted as ongoing competency based on professional organizational standards. CNS practice standards are clearly outlined by the National Association of Clinical Nurse Specialists (NACNS). All CNSs should pratice according to national standards.  

I support the VaCNS petition to revise the current CNS regulations. It is one small step toward aligning Virginia CNS pratice with most other states and more importantly, it will benefit the health of Virginians. 

Respecfully,

Catherine Smith


4/7/19  6:56 am
Commenter: Linda Thurby-Hay DNP, RN, ACNS-BC, BC-ADM, CDE

Why regulatory change is needed?
 

The petition of the Virginia Association of Clinical Nurse Specialists speaks to two specific concerns raised by Clinical Nurse Specialists (CNS): 

1. Denial of registration: The Commonwealth has denied CNS registration to those whose national CNS certifications did not align with the 2008 Consensus Model language, even though their programs were completed years before the Consensus Model was accepted. These decisions did not honor the education and certification options available to these nursing experts at the time they completed their programs. This is particularly true of those who were certified using the Core CNS certification examination, promoted by the National Association of Clinical Nurse Specialists as a viable alternative. Additionally, this petition clearly specifies that all CNS certifications, including those that have been retired, are acceptable. The language is woven throughout this petition align regulations of those who are registering initially, by endorsement, renewal or reinstatement. 

2.  Differentiating CNS from professional nursing practice:  There is national acceptance in the nursing community that four nursing roles are practicing at the advanced practice level, e.g. Certified Nurse Midwives, Certified Registered Nurse Anesthetists, Nurse Practitioners and Clinical Nurse Specialists. The National Association of Clinical Nurse Specialists's Statement on Clinical Nurse Specialist Practice and Education, now in its third edition, clearly articulates CNS's advanced practice nursing competencies. In this petition, we have referenced this document as was advised by Board of Nursing (BON) representatives in our fall meeting with them, to answer the earlier BON call that CNS practice be differentiated from professional nursing practice. Current CNS regulations permit varied interpretation, dependent on the individual board member's understanding of advanced nursing practice and the intent of the Consensus Model. The proposed language would end this discrimination.

In the Commonwealth, the continuing struggle with our respected physician colleagues, to practice nursing independently, has put political agendas ahead of the citizens of Virginia and their health. Clinical Nurse Specialists are the only nursing role that are educationally-prepared and nationally-certified nursing experts in specialty care. Their knowledge and skill should be recognized and honored. 

 


4/7/19  1:39 pm
Commenter: Kimberly D. Hall

Support for CNS Practice Regulations
 

Support Revisions to CNS Registration and Practice Regulations

I am in full support of the Virginia Association of Clinical Nurse Specialists petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice. This revision is a key step toward overcoming barriers and challenges to CNS practice that persist in Virginia.

As a CNS who completed her educational training and practiced in Virginia for several years, I know first-hand the practice limitations encountered here in Virginia. I relocated to the West Coast a little over 2 years ago so that I could practice to the fullest extent of my education and training. I am now a licensed Advanced Pratice Registered Nurse-Clinical Nurse Specialst with Prescriptive Authority and independent scope of practice in both Oregon and Washington. Restricted practice in Virginia for CNSs limits access to care for citizens who could benefit from them. 

The CNS registration section must be clarified to include initial, renewal, reinstatement, and endorsement  requirements. National CNS certifications including CORE and retired certifications that have not lapsed should be accepted as ongoing competency based on professional organizational standards. CNS practice standards are clearly outlined by the National Association of Clinical Nurse Specialists (NACNS). All CNSs should pratice according to national standards.  

I support the VaCNS petition to revise the current CNS regulations. It is one small step toward aligning Virginia CNS pratice with most other states and more importantly, it will benefit the health of Virginians. 

Respecfully,

Kimberly D. Hall


4/7/19  6:51 pm
Commenter: Ellen M. Harvey DNP, RN, ACNS-BC, CCRN, TCRN, FCCM

Support of the Virginia Association of Clinical Nurse Specialists Petition
 

I am in full support of the Virginia Association of Clinical Nurse Specialists petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice. This revision is a key step toward overcoming barriers and challenges to CNS practice that persist in Virginia. Restricted practice in Virginia for CNSs limits access to care for citizens who will benefit from the expert advanced nursing care provided by CNSs.  CNS practice standards are clearly outlined by the National Association of Clinical Nurse Specialists (NACNS). Any Commonwealth of Virginia regulatory, registration or licensure changes and CNS board certification requirements should be based on the national standards set forth in the Consensus Statement and by the NACNS.  Consistent with the practice standards seen in most states, the Clinical Nurse Specialist should be enabled to improve the health of the communities they serve in the Commonwealth of Virginia by permitting practice at their full scope of education and training.

Respectfully,

Ellen M. Harvey


4/8/19  5:08 am
Commenter: Virginia Council of Nurse Practitioners

Support for CNS Regulatory Changes
 

The Virginia Council of Nurse Practitioners (VCNP) eagerly supports regulatory changes that recognize the role of the clinical nurse specialist (CNS) utilizing national core clinical competencies. This regulatory change is fundamental to differentiate the CNS role from that of the professional nurse reflected in the current regulatory language. Additionally, regulations should accommodate CNSs who are seeking initial registration by endorsement, renewal or reinstatement consistent with the APRN Consensus Model. As an advanced practice registered nurse (APRN), CNSs are integral members of the interprofessional health care team with advanced level competencies to improve patient outcomes, implement evidence?based practice, increase access to care and provide cost-effective care. Alignment of regulations for CNSs with the APRN Consensus Model will permit practice to the full extent of their education and training. Additionally, alignment of regulations with the Consensus Model will aid in increasing access to qualified health care providers to improve access to and quality of care for citizens of the Commonwealth. 


4/8/19  5:25 pm
Commenter: Cynthia M. Fagan, DNP, RN, FNP-BC

Support for CNS Regulatory Changes
 

I support the The Virginia Association of Clinical Nurse Specialists petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice.  The recommendations are necessary to clarify CNS registration requirements and to differentiate the CNS role from that of the professional nurse reflected in the current regulatory language.


4/8/19  11:36 pm
Commenter: Lisa Anrams, MSN, MHCNS-Bc

Full Practice Authority
 

After fully trying to understand the CNS role in Va,  I am considering post MSN certification if I decide to relocate. The position I interviewed for would still like me to become a part of there team while working toward post MSN certification. I am still trying to figure out what my scope of practice in the state of Va. In the regulations it says advance assessment skills ( does those skills include H/P / dx. and reccomendations) under the supervision of a MD. As for medication - we are allowed to take verbal orders from a MD/ Is it adequate to have a protocol for what medication what a MD feels in their clinical judgement to prescribe. I have been APRN for 10 years with prescriptive authority ( would should allow me th practice independently) without collaboration. So that being said I am honored that the practice would still like me to come on board with the regulations being so convoluted I am currently unsure of my scope of practice in Va. So that being said I realize after receive all the required credentials (NPI, CDS and DEA). I won't be allowed to use this licenses/ national registration in the state of Va. Clarity is definitely needed !!!

 


4/10/19  8:41 am
Commenter: Kimberly Miller

support for CNS regulatory changes
 

I am a newly registered Clinical Nurse Specialist in the state of Virginia, and was surprised to find that the statutes governing CNS practice in Va. are not equivalent to the states bordering the commonwealth. Although CNSs enjoy title protection and are identified as Advanced Practice Registered Nurses (APRN) in the Code of Virginia, the interpretation of current regulations suggest that CNS practice is no different than that of the professional nurse. If Virginia does not move forward with implementing the NCSBNs Consensus Model the Commonwealth it risks losing practitioners to its neighbors who grant CNSs full practice authority. Approximately 36 of the 50 states recognize the full privileges of the CNS preparation and role and, therefore, their citizens benefit from their expertise. I support this petition of the VaCNS to advance full practice authority in the commonwealth.

Kimberly Miller MSN RN AGCNS-BC CDE


4/10/19  9:40 am
Commenter: Lynnette Kirkbride

Petition for Clinical Nurse Specialists
 

I support the petition to revise the registration of Clinical Nurse Specialists in Virginia. As a CNS, I have been taken back by the fact that we are considered nurses but our education is not recognized. Please consider allowing us to utilize the knowledge and expertise we have to improve patient outcomes, systems, and nursing as a whole.


4/10/19  11:45 am
Commenter: James Pochopien

VA Petition for CNS
 

Our VA based CNS's are working diligently and tirelessly to improve patient outcomes, across the entire spectrum of healthcare.  Legislators must act NOW to acknowledge, reward, and compensate them for saving lives and delivering superior patient care.  In large part our CNS's do this and can't even get billable hours- where is the appreciation for their daily contribution?  It is legislative malpractice to not do more the our CNS's across Virginia and the entire US.  Time for our elected officials to work as hard as our CNS's do everyday!


4/10/19  12:58 pm
Commenter: Denise Cox DNP, MSN, FNP-C

Support CNS role as APRN
 

I am commenting in favor of the following petition... "support the Virginia Association of Clinical Nurse Specialists (VaCNS)’s petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice.  The recommendations are necessary to clarify CNS registration requirements and to differentiate CNS practice from that of the professional nurse. The revisions align with nurse practice acts and regulations in neighboring states, across the nation, as well as the tenets of the Consensus Model for APRN Regulation (2008)"

The master prepared, certified Clinical Nurse Specialist should be recognized as advanced practice within the medical and nursing professions.  The CNS must be allowed to work in their full scope of practice and training so we can best ensure excellence in quality and patient safety within all care areas.  It is vital this is both supported and clearly stated in the Virginia regulations as purposed above.

 

 


4/11/19  2:45 pm
Commenter: Rachel Featherstone, WHNP-BC

Support CNS acknowledgement as APRN's
 

Clinical Nurse Specialists are trained in the same basic competencies as nurse practitioners, nurse midwives, and nurse anesthetists.  It is the logical course of action to grant them equivalent scope of practice and prescriptive rights.


4/11/19  3:32 pm
Commenter: Katie PageCNM Virginia Affiliate of ACNM

Support CNS regulations
 

CNS are APRN and need to be recognized as such in Virginia. Like NP, CNM, and CRNA, they are another advanced specialist separate from RN and with more training and expertise than RN. By failing to recognize their skillset and regulating CNS as themselves, Virginia will be less likely to have CNSs move to this state to provide services and limits these professionals' scope of practice. 

I write in support of CNS on behalf of the Virginia Affiliate of ACNM as the president-elect, and as an advanced practice provider in Virginia.


4/12/19  9:39 am
Commenter: Sarah Cullen, DNP, ACNS-BC, RN

Support the CNS petition
 

I support the the Virginia Association of Clinical Nurse Specialists’ petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice.  CNS practice standards are clearly outlined by the National Association of Clinical Nurse Specialists (NACNS). All CNSs should practice according to national standards. CNSs have advanced education and certification as a CNS, and are recognized as billing providers by CMS. However, CNSs in Virginia are not able to practice to these national standards, due to state level restrictions of lack of full practice authority and the lack of licensure. This hinders our ability to practice to our full extent of our education and training. We need to be recognized and treated as advance practice registered nurses (APRNs) – NOT as “professional nurses” as current regulations suggest. We are trained and certified, as APRNs. Similar to nurse practitioners, yet we are treated completely different. As the nation struggles to improve access to care (and specialized care) it is incumbent on the Commonwealth of Virginia State board of nursing to follow those recommendations in line with 17 other states and territories of the US and remove the practice barriers within this state. The revisions align with nurse practice acts and regulations in neighboring states, across the nation, as well as the tenets of the Consensus Model for APRN Regulation (2008) and the National CNS practice standards. I urge the BON to continue to support the nurses within the state (all nurses) and approve the proposed changes.


4/12/19  3:04 pm
Commenter: Kaye Geaney, MSEd, MSN, RN, AGCNS-BC

Support CNS petition
 

I support the Virginia Association of Clinical Nurse Specialists’ petition to revise regulations related to registration and practice authority for Clinical Nurse Specialists (CNS) in the state. The proposed revisions will decrease and/or eliminate barriers to scope of practice for CNSs in Virginia. The Consensus Model for Advanced Practice Registered Nurses (APRN) (2008) was published by the National Council of State Boards of Nursing (NCSBN) to provide nationally recognized standards of practice and licensure for APRNs in all states.  Yet, Virginia has not fully adopted the Consensus Model related to the CNS, thereby creating barriers to scope of practice.  These barriers to scope of practice are depriving citizens of the commonwealth with access to comprehensive medical care and services from this APRN. This is particularly true in rural areas of the state that have limited medical resources and healthcare providers.  Additionally, the prevalence of individuals suffering from chronic disease conditions in Virginia makes this petition for CNS full practice authority (i.e., prescriptive authority) a priority to combat the growing epidemic.  Those suffering from chronic diseases currently account for the majority of healthcare associated costs in the country.  The National Association of Clinical Nurse Specialists (2017) and the Institute of Medicine (2010) support full scope of practice for CNSs to address the growing epidemic of chronic diseases.   

CNSs have the education and training, as well as national certification, to practice and be recognized as an APRN.  The CNS role is influential within three spheres of the healthcare system – patient, nurse, and organization.  The uniqueness of the role’s influence and expertise in clinical care make the CNS a valuable asset to healthcare in Virginia.  This petition to revise regulations governing CNS practice will add to the role’s value and have a positive impact on healthcare throughout the state. I urge your strong support of this petition which will provide a win-win situation for everyone - nurses, APRNs, healthcare organizations, and the citizens of Virginia.     

 


4/14/19  8:31 pm
Commenter: Robin McAlpin MSN, RN, ACCNS-AG

Support of the CNS petition
 

I support the Virginia Association of Clinical Nurse Specialists’ petition to revise regulations governing the practice authority for the Clinical Nurse Specialist (CNS) in the Commonwealth of Virginia.  Clinical Nurse Specialists are one of the four categories of advanced practice nurses (APRN) that provide expert advanced care to patients each with different practice characteristics.  However, as an advanced practice nurse the goal of the CNS is to meet the health needs of patients, families, populations, and communities.    The CNS is differentiated from other APRNs by our overarching competencies directed at enhancement of professional nursing practice and improving patient outcomes.  Nevertheless, we are at a standstill due to the current practice limitations. As APRNs, CNSs are an integral member of the healthcare system, which if allowed to practice to the full scope of practice are well suited to meet the ever increasing complex and diverse needs of the patient, family, systems, and communities.  Which would also meet the industry and societal directives to evolve nursing practice and improve patient outcomes across the continuum of care.  Given the current state of health in the United States it is imperative that we (CNSs) are allowed to practice to the full extent of training to help alleviate the burden of the health crisis within the United States.  So, I urge the Virginia Board of Nursing to thoroughly and objectively consider this request which will begin alignment with the tenets of the Consensus Model for APRN Regulation (2008), the National CNS practice standards, and neighboring states but most importantly will prioritize the health outcomes of Virginians.


4/14/19  9:31 pm
Commenter: Virginia Carpinelli RN BSN OCN

Support CNS petition
 


4/15/19  10:51 am
Commenter: Theresa Crowder, DNP, RN, CNS, ACNS-BC

Support CNS Regulations
 

As a CNS for over 13 years, I support the proposed changes to the current Virgina CNS regulations. The CNS is one of 4 recognized Advanced Practice RNs, but in the state of Virginia the CNS practice is limited. The CNS practice needs to be differentiated from that of an RN. Revisions to the current regulations will provide for licensure and full practice authority is needed in Virginia.


4/15/19  11:40 am
Commenter: Jessica Jordan, CNM, MSN

Support CNS regulation as APRN's.
 

The CNS is an APRN and needs to be recognized as such in Virginia. Like the NP, CNM, and CRNA credentials,  they are another advanced specialist separate from RN and with more training and expertise than RNs. By failing to recognize their skill set and regulating CNS as nurses only, Virginia will be less likely to have CNSs move to this state to provide services by limiting these professionals' scope of practice. 

I write in support of CNS after many years as legislative chair of the VA affiliate of the ACNM, with extensive examination of the regulations in Virginia. 

Thank you, Jessica Jordan, CNM, MSN


4/16/19  9:16 am
Commenter: Keysha A. Pochopien, MSN, RN, ACNS-BC, CHFN Sentara Healthcare

Support revision of CNS regulations governing registration and practice
 

I support the petition to revise the regulations governing Clinical Nurse Specialist (CNS) registration and practice. The recommendations are necessary to clarify CNS registration requirements and to differentiate CNS practice from that of the professional nurse.


4/16/19  9:05 pm
Commenter: Rickie T Simpson PHD APRN-CNS,BCPCC, C-IAYT

Supporting the change in the CNS scope of practice
 

 

I fully support the Virginia Association of Clinical Nurse Specialists’ petition to revise regulations related to the registration and practice authority for Clinical Nurse Specialists (CNS) in the Commonwealth . The proposed revisions will decrease and/or eliminate artificial barriers to the scope of practice for the CNS. It is confusing and artificial to restrict my practice when my training is comparable to that of an NP.  The Consensus Model for Advanced Practice Registered Nurses (APRN) (2008) was published by the National Council of State Boards of Nursing (NCSBN) to provide nationally recognized standards of practice and licensure for APRNs in all states.  Y Virginia has not fully adopted the Consensus Model related to the CNS, thereby creating barriers to scope of practice and essentially making three levels of nursing practice in the Commonwealth-RN,CNS and NP.   These barriers to scope of practice are depriving citizens of the Commonwealth with access to comprehensive medical care and services especially in my area of expertise— psychiatric care. This is particularly true in rural areas of the Commonwealth that have limited mental healthcare providers and soaring mental health wait lists.  Additionally, the prevalence of individuals suffering from chronic mental health disorders in Virginia makes this petition for CNS full practice authority (i.e., prescriptive authority) urgent.      

CNSs have the education and training, as well as national certification, to practice and be recognized as an APRN in many other states.  The uniqueness of the role’s influence and expertise in clinical care make the CNS a valuable asset to healthcare in Virginia.  I urge your strong support of this petition which will provide a cost-effective and ready resource to the citizens of Virginia who can least speak for themselves. 


4/16/19  11:25 pm
Commenter: Bob May

Support for CNS Change of Scope
 

I totally support the Virginia Association of Clinical Nurse Specialists’ petition to revise regulations related to the registration and practice authority for Clinical Nurse Specialists (CNS) in the Commonwealth   A CNS has the same amount of education as NPs and should be allowed to practice with full authority of other Advanced Practice Nurses.  I believe this change will grant greater access to health care and totally benefit the Commonwealth and patient access.   


4/16/19  11:41 pm
Commenter: Leslie M Evers RN MSN CS LMFT PMHCNS-BC

Registration of Clinical Nurse Specialists
 

I support full practice authority for Clinical Nurse Specialists


4/16/19  11:42 pm
Commenter: Leslie M Evers RN MSN CS LMFT PMHCNS-BC

Support Full Practice Authority for Clinical Nurse Specialists
 

I support full practice authority for Clinical Nurse Specialists