SENATE, No. 1522

STATE OF NEW JERSEY

220th LEGISLATURE

 

INTRODUCED FEBRUARY 10, 2022

 


 

Sponsored by:

Senator  JOSEPH F. VITALE

District 19 (Middlesex)

Senator  TROY SINGLETON

District 7 (Burlington)

 

Co-Sponsored by:

Senators Stanfield, Diegnan, Zwicker, Cryan, Madden, Stack, Cruz-Perez, Beach, Johnson, Turner, O'Scanlon, Greenstein, Ruiz, Oroho, Burgess, Codey, Holzapfel, Thompson, Steinhardt and Testa

 

 

 

 

SYNOPSIS

     Eliminates certain practice restrictions for advanced practice nurses.

 

CURRENT VERSION OF TEXT

     As introduced.

  


An Act concerning advanced practice nurses, revising various parts of the statutory law, and supplementing P.L.1991, c.377 (C.45:11-45 et al.).

 

     Be It Enacted by the Senate and General Assembly of the State of New Jersey:

 

     1.    (New section) The Legislature finds and declares that:

     a.     Advanced practice nurses are registered nurses who are certified to provide an advanced level of health care to patients that exceeds the standard scope of nursing practice. 

     b.    Advanced practice nurses augment the system of care in New Jersey and nationwide by providing treatment services at a level that can relieve some of the demand on physicians, of whom there is a chronic shortage, and expedite access to care for patients, including those in medically underserved areas and among medically underserved populations.

     c.     Studies suggest that approximately one quarter of the population of the United States lives in an area with a shortage of primary care professionals.  Limited access to care is frequently worse among racial and ethnic minorities, people with low incomes, and individuals for whom a lack of transportation creates logistical barriers to health care.

     d.    One way to reduce gaps in health care access is to allow full practice authority for advanced practice nurses, over 75 percent of whom are educated in a primary care specialty and can directly improve access to both primary care services and specialty care services.

     e.     Currently, 24 states, the District of Columbia, and two U.S. territories have adopted full practice authority for advanced practice nurses.  The requirement to practice in collaboration with a physician limits the ability of advanced practice nurses to provide primary care and specialty care services, and has been associated with advanced practice nurses leaving New Jersey for other jurisdictions with fewer practice restrictions.

     f.     It has been estimated that removing practice restrictions for advanced practice nurses has the potential to reduce health care access disparities by a factor of more than 38 percent.

     g.    In response to the coronavirus disease 2019 (COVID-19) pandemic, Governor Murphy issued Executive Order No. 112, which, among other things, directly and through waivers issued pursuant to its authority, waived existing practice restrictions for advanced practice nurses, including joint protocol and supervision requirements.

     h.    According to surveys, over 45 percent of advanced practice nurses in New Jersey reported working without practice restrictions as authorized under Executive Order No. 112 and the waivers issued pursuant to the executive order.  No adverse incidents were reported during the waiver period involving advanced practice nurses practicing without practice restrictions.

     i.     Given the need for expanded access to care, it is necessary and appropriate to take steps to remove practice restrictions that serve as a barrier for advanced practice nurses to practice in New Jersey to the full extent of their education, clinical training, and national certification.

 

     2.    Section 1 of P.L.1947, c.262 (C.45:11-23) is amended to read as follows:

     1.    As used in this act:

     a.     The words "the board" mean the New Jersey Board of Nursing created by this act.

     b.    The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Diagnosing in the context of nursing practice means the identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen within the scope of practice of the registered professional nurse.  Such diagnostic privilege is distinct from a medical diagnosis.  Treating means selection and performance of those therapeutic measures essential to the effective management and execution of the nursing regimen.  Human responses means those signs, symptoms, and processes which denote the individual's health need or reaction to an actual or potential health problem.

     The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of casefinding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.

     The terms "nursing," "professional nursing," and "practical nursing" as used in this act shall not be construed to include nursing by students enrolled in a school of nursing accredited or approved by the board performed in the prescribed course of study and training, nor nursing performed in hospitals, institutions and agencies approved by the board for this purpose by graduates of such schools pending the results of the first licensing examination scheduled by the board following completion of a course of study and training and the attaining of age qualification for examination, or thereafter with the approval of the board in the case of each individual pending results of subsequent examinations; nor shall any of said terms be construed to include nursing performed for a period not exceeding 12 months unless the board shall approve a longer period, in hospitals, institutions or agencies by a nurse legally qualified under the laws of another state or country, pending results of an application for licensing under this act, if such nurse does not represent or hold himself or herself out as a nurse licensed to practice under this act; nor shall any of said terms be construed to include the practice of nursing in this State by any legally qualified nurse of another state whose engagement made outside of this State requires such nurse to accompany and care for the patient while in this State during the period of such engagement, not to exceed six months in this State, if such nurse does not represent or hold himself or herself out as a nurse licensed to practice in this State; nor shall any of said terms be construed to include nursing performed by employees or officers of the United States Government or any agency or service thereof while in the discharge of his or her official duties; nor shall any of said terms be construed to include services performed by nurses aides, attendants, orderlies and ward helpers in hospitals, institutions and agencies or by technicians, physiotherapists, or medical secretaries, and such duties performed by said persons aforementioned shall not be subject to rules or regulations which the board may prescribe concerning nursing; nor shall any of said terms be construed to include first aid nursing assistance, or gratuitous care by friends or members of the family of a sick or infirm person, or incidental care of the sick by a person employed primarily as a domestic or housekeeper, notwithstanding that the occasion for such employment may be sickness, if such incidental care does not constitute professional nursing and such person does not claim or purport to be a licensed nurse; nor shall any of said terms be construed to include services rendered in accordance with the practice of the religious tenets of any well-recognized church or denomination which subscribes to the art of healing by prayer.  A person who is otherwise qualified shall not be denied licensure as a professional nurse or practical nurse by reason of the circumstances that such person is in religious life and has taken a vow of poverty.

     c.     "Homemaker-home health aide" means a person who is employed by a home care services agency and who is performing delegated nursing regimens or nursing tasks delegated through the authority of a duly licensed registered professional nurse.  No homemaker-home health aide shall follow a delegated nursing regimen or perform tasks which are delegated unless the homemaker-home health aide is under the supervision of a duly licensed registered professional nurse provided by the home care services agency that directly employs the homemaker-home health aide. "Home care services agency" means home health agencies, assisted living residences, comprehensive personal care homes, assisted living programs or alternate family care sponsor agencies licensed by the Department of Health pursuant to P.L.1971, c.136 (C.26:2H-1 et al.), nonprofit homemaker-home health aide agencies, and health care service firms regulated by the Director of the Division of Consumer Affairs in the Department of Law and Public Safety and the Attorney General pursuant to P.L.1989, c.331 (C.34:8-43 et seq.) and P.L.1960, c.39 (C.56:8-1 et seq.) respectively, which are engaged in the business of procuring or offering to procure employment for homemaker-home health aides, where a fee may be exacted, charged or received directly or indirectly for procuring or offering to procure that employment. 

     d.    "Advanced practice nurse" means a person who holds a certification in accordance with section 8 or 9 of P.L.1991, c.377 (C.45:11-47 or 45:11-48).

     e.     "Collaborating [physician] provider" means a [person] physician licensed to practice medicine and surgery pursuant to chapter 9 of Title 45 of the Revised Statutes [who agrees to work with] or an advanced practice nurse issued a certification pursuant to section 8 or 9 of P.L.1991, c.377 (C.45:11-47 or C.45:11-48) with more than 24 months or 2,400 hours of licensed, active, advanced nursing practice in an initial role.

     f.     “APN-Anesthesia” or “Certified Registered Nurse Anesthetist” means an advanced practice nurse licensed to practice as an APN-Anesthesia in accordance with the requirements established by the board for licensure as an APN-Anesthesia.

     Nothing in this act shall confer the authority to a person licensed to practice nursing to practice another health profession as currently defined in Title 45 of the Revised Statutes.

(cf: P.L.2019, c.48, s.2)

 

     3.    Section 10 of P.L.1991, c.377 (C.45:11-49) is amended to read as follows:

     10.  a. In addition to all other tasks which a registered professional nurse may, by law, perform, an advanced practice nurse may manage preventive care services [and] , diagnose, monitor, and manage deviations from wellness and long-term illnesses, and administer local anesthesia and conscious sedation, consistent with the needs of the patient and within the defined scope of practice of [the] that advanced practice nurse, by:

     (1)   initiating laboratory and other diagnostic tests;

     (2)   prescribing, authorizing, or ordering medications and devices, as authorized by subsections [b. and c.] g. or h. of this section; [and]

     (3)   prescribing or ordering treatments, including referrals to other licensed health care professionals, and performing specific procedures in accordance with the provisions of this [subsection] section; and

     (4)   administering general anesthesia, major regional anesthesia, neuraxial anesthesia, and minor conduction blocks, within the specific scope of practice of APN-Anesthesia, as authorized by subsection i. of this section.

      b.   [An advanced practice nurse may order medications and devices in the inpatient setting, subject to the following conditions:

     (1)   the collaborating physician and advanced practice nurse shall address in the joint protocols whether prior consultation with the collaborating physician is required to initiate an order for a controlled dangerous substance;

     (2)   the order is written in accordance with standing orders or joint protocols developed in agreement between a collaborating physician and the advanced practice nurse, or pursuant to the specific direction of a physician;

     (3)   the advanced practice nurse authorizes the order by signing the nurse's own name, printing the name and certification number, and printing the collaborating physician's name;

     (4)   the physician is present or readily available through electronic communications;

     (5)   the charts and records of the patients treated by the advanced practice nurse are reviewed by the collaborating physician and the advanced practice nurse within the period of time specified by rules adopted by the Commissioner of Health pursuant to section 13 of P.L.1991, c.377 (C.45:11-52);

     (6)   the joint protocols developed by the collaborating physician and the advanced practice nurse are reviewed, updated, and signed at least annually by both parties; and

     (7)   the advanced practice nurse has completed six contact hours of continuing professional education in pharmacology related to controlled substances, including pharmacologic therapy, addiction prevention and management, and issues concerning prescription opioid drugs, including responsible prescribing practices, alternatives to opioids for managing and treating pain, and the risks and signs of opioid abuse, addiction, and diversion, in accordance with regulations adopted by the New Jersey Board of Nursing.  The six contact hours shall be in addition to New Jersey Board of Nursing pharmacology education requirements for advanced practice nurses related to initial certification and recertification of an advanced practice nurse as set forth in N.J.A.C.13:37-7.2.] (Deleted by amendment, P.L.    , c.    ) (pending before the Legislature as this bill)

      c.    [An advanced practice nurse may prescribe medications and devices in all other medically appropriate settings, subject to the following conditions:

     (1)   the collaborating physician and advanced practice nurse shall address in the joint protocols whether prior consultation with the collaborating physician is required to initiate a prescription for a controlled dangerous substance;

     (2)   the prescription is written in accordance with standing orders or joint protocols developed in agreement between a collaborating physician and the advanced practice nurse, or pursuant to the specific direction of a physician;

     (3)   the advanced practice nurse writes the prescription on a New Jersey Prescription Blank pursuant to P.L.2003, c.280 (C.45:14-40 et seq.), signs the nurse's own name to the prescription and prints the nurse's name and certification number;

     (4)   the prescription is dated and includes the name of the patient and the name, address, and telephone number of the collaborating physician;

     (5)   the physician is present or readily available through electronic communications;

     (6)   the charts and records of the patients treated by the advanced practice nurse are periodically reviewed by the collaborating physician and the advanced practice nurse;

     (7)   the joint protocols developed by the collaborating physician and the advanced practice nurse are reviewed, updated, and signed at least annually by both parties; and

     (8)   the advanced practice nurse has completed six contact hours of continuing professional education in pharmacology related to controlled substances, including pharmacologic therapy, addiction prevention and management, and issues concerning prescription opioid drugs, including responsible prescribing practices, alternatives to opioids for managing and treating pain, and the risks and signs of opioid abuse, addiction, and diversion, in accordance with regulations adopted by the New Jersey Board of Nursing.  The six contact hours shall be in addition to New Jersey Board of Nursing pharmacology education requirements for advanced practice nurses related to initial certification and recertification of an advanced practice nurse as set forth in N.J.A.C.13:37-7.2.] (Deleted by amendment, P.L.    , c.    ) (pending before the Legislature as this bill)

      d.   [The joint protocols employed pursuant to subsections b. and c. of this section shall conform with standards adopted by the Director of the Division of Consumer Affairs pursuant to section 12 of P.L.1991, c.377 (C.45:11-51) or section 10 of P.L.1999, c.85 (C.45:11-49.2), as applicable.] (Deleted by amendment, P.L.    , c.     _) (pending before the Legislature as this bill)

      e.    (Deleted by amendment, P.L.2004, c.122.)

      f.    An attending advanced practice nurse may determine and certify the cause of death of the nurse's patient and execute the death certification pursuant to R.S.26:6-8 if no [collaborating] physician is available to do so and the nurse is the patient's primary caregiver.

      g.   An advanced practice nurse may authorize qualifying patients for the medical use of cannabis and issue written instructions for medical cannabis to registered qualifying patients, subject to the [following conditions:

     (1)   the collaborating physician and advanced practice nurse shall address in the joint protocols whether prior consultation with the collaborating physician is required to authorize a qualifying patient for the medical use of cannabis or issue written instructions for medical cannabis;

     (2)   the authorization for the medical use of cannabis or issuance of written instructions for cannabis is in accordance with standing orders or joint protocols developed in agreement between a collaborating physician and the advanced practice nurse, or pursuant to the specific direction of a physician;

     (3)   the advanced practice nurse signs the nurse's own name to the authorization or written instruction and prints the nurse's name and certification number;

     (4)   the authorization or written instruction is dated and includes the name of the qualifying patient and the name, address, and telephone number of the collaborating physician;

     (5)   the physician is present or readily available through electronic communications;

     (6)   the charts and records of qualifying patients treated by the advanced practice nurse are periodically reviewed by the collaborating physician and the advanced practice nurse;

     (7)  the joint protocols developed by the collaborating physician and the advanced practice nurse are reviewed, updated, and signed at least annually by both parties; and

     (8)   the advanced practice nurse complies with the] requirements for authorizing qualifying patients for the medical use of cannabis and for issuing written instructions for medical cannabis established pursuant to P.L.2009, c.307 (C.24:6I-1 et al.).

     h.    An advanced practice nurse may order medications and devices, subject to the following conditions:

     (1)   The advanced practice nurse shall issue a prescription on a New Jersey Prescription Blank in accordance with the provisions of P.L.2003, c.280 (C.45:14-40 et seq.), and include on the prescription blank the advanced practice nurse’s signature, printed name, certification number, and patient information, and any other information required pursuant to regulations adopted by the New Jersey Board of Nursing;

     (2)   The advanced practice nurse shall have completed six contact hours of continuing professional education in pharmacology related to controlled substances, including pharmacologic therapy and addiction prevention and management, in accordance with regulations adopted by the New Jersey Board of Nursing.  The six contact hours shall be in addition to New Jersey Board of Nursing pharmacology education requirements for advanced practice nurses related to initial certification and recertification of an advanced practice nurse as set forth in regulations adopted by the New Jersey Board of Nursing;

     (3)   The advance practice nurse shall have completed 10 contact hours of continuing professional education in pharmacology each biennial period, in accordance with regulations adopted by the New Jersey Board of Nursing.  The 10 contact hours shall be in addition to New Jersey Board of Nursing requirements for renewal of a registered professional nursing license, as set forth in regulations adopted by the board; and

     (4)   An advanced practice nurse with fewer than 24 months or 2,400 hours of licensed, active, advanced nursing practice in an initial role shall have a joint protocol with a collaborating provider.  The joint protocol shall be required only with respect to prescribing medications.  An advanced practice nurse subject to this paragraph shall maintain signed and dated copies of all required joint protocols, and shall notify the board that the requirements of this paragraph have been met.

     i.     Notwithstanding the provisions of any other law or regulation to the contrary, an advanced practice nurse who is an APN-Anesthesia and who has completed either 24 months or 2,400 hours of licensed, active advanced practice nursing practice providing anesthesia services to patients in an initial role shall be authorized to practice as an APN-Anesthesia to the fullest extent of the authorized scope of practice for APN-Anesthesia permitted by the Board of Nursing, without any requirement for supervision by a licensed physician or dentist and without any requirement that the APN-Anesthesia enter into joint protocols with a licensed physician or dentist.

     j.     Notwithstanding the provisions of any other law or regulation to the contrary, an advanced practice nurse with greater than 24 months or 2,400 hours of licensed, active, advanced nursing practice shall be authorized to practice without a joint protocol with a collaborating provider.

     k.    Any provision of State law or regulation that requires the signature, stamp, verification, affidavit, or endorsement of a physician shall be deemed to require the signature, stamp, verification, affidavit, or endorsement of a physician or an advanced practice nurse, to the extent consistent with the scope of practice of an advanced practice nurse.

(cf: P.L.2019, c.153, s.47)

 

     4.    Section 13 of P.L.2017, c.341 (C.45:11-49.3) is amended to read as follows:

     13.  a. Notwithstanding any other provision of law or regulation to the contrary, an advanced practice nurse may dispense narcotic drugs for maintenance treatment or detoxification treatment if the advanced practice nurse has met the training and registration requirements set forth in subsection (g) of 21 U.S.C. s.823.  [An advanced practice nurse who is authorized to dispense such drugs may do so regardless of whether the advanced practice nurse's collaborating physician has met the training and registration requirements set forth in subsection (g) of 21 U.S.C. s.823, provided that the joint protocol established by the advanced practice nurse and the collaborating physician include the collaborating physician's written approval for the advanced practice nurse to dispense the drugs.] 

     b.    Notwithstanding any other provision of law or regulation to the contrary, an advanced practice nurse [, under the joint protocol established by the advanced practice nurse and the collaborating physician,] may make the determination as to the medical necessity for services for the treatment of substance use disorder, as provided in P.L.2017, c.28 (C.17:48-6nn et al.), and may prescribe such services.

(cf: P.L.2017, c.341, s.13)

 

     5.    Section 11 of P.L.1991, c.377 (C.45:11-50) is amended to read as follows:

     11.  In addition to such other powers as it may by law possess, the New Jersey Board of Nursing shall have the following powers and duties [;] :

     a.     To promulgate, pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations to effectuate the purposes of [this act, except for those subjects of rule-making authority allocated to the Director of the Division of Consumer Affairs pursuant to section 12 of P.L.1991, c.377 (C.45:11-51) or to the Commissioner of Health and Senior Services pursuant to section 13 of P.L.1991, c.377 (C.45:11-52)] P.L.1991, c.377 (C.45:11-45 et al.);

     b.    To evaluate and pass upon the qualifications of candidates for certification as advanced practice nurses;

     c.     To evaluate and pass upon national accreditation organizations and the holders of certificates from those organizations as necessary to award certificates pursuant to section 9 of P.L.1991, c.377 (C.45:11-48);

     d.    To establish specialty areas of practice for advanced practice nurses;

     e.     To take disciplinary action, in accordance with P.L.1978, c.73 (C.45:1-14 et seq.), against an advanced practice nurse who violates the provisions of [this act] P.L.1991, c.377 (C.45:11-45 et al.), any regulation promulgated thereunder, or P.L.1978, c.73 (C.45:1-14 et seq.);

     f.     To approve the examination to be taken by candidates for certification;

     g.    To set standards of professional conduct for advanced practice nurses;

     h.    To set fees for examinations, certification, and other services consistent with section 2 of P.L.1974, c.46 (C.45:1-3.2);

     i.     To set standards for and approve continuing education programs; and

     j.     To determine whether the requirements of another state with respect to certification as an advanced practice nurse are substantially equivalent to those of this State in accordance with subsection c. of section 8 of P.L.1991, c.377 (C.45:11-47).

(cf: P.L.1999, c.85, s.8)

 

     6.    (New section)  The Board of Nursing and the Commissioner of Health shall each adopt, pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.), such rules and regulations as shall be necessary to implement the provisions of this act. 

 

     7.    The following sections are repealed:

            Section 10 of P.L.1999, c.85 (C.45:11-49.2);

            Section 12 of P.L.1991, c.377 (C.45:11-51); and

            Section 13 of P.L.1991, c.377 (C.45:11-52).

 

     8.    This act shall take effect on the first day of the fourth month next following the date of enactment.

 

 

STATEMENT

 

     This bill eliminates practice restrictions for advanced practice nurses (APNs), including restrictions that limit the ability of APNs to prescribe medications and administer anesthesia, and establishes new requirements for APNs to prescribe medications. 

     The bill expressly provides that, notwithstanding the provisions of any other law or regulation to the contrary, an APN with greater than 24 months or 2,400 hours of licensed, active, advanced nursing practice will be authorized to practice without a joint protocol with a collaborating provider. 

     With regard to prescribing medications, the bill requires the use of New Jersey Prescription Blanks and satisfying continuing professional education requirements related to pharmacology and prescribing controlled substances.  An APN with fewer than 24 months or 2,400 hours of licensed, active, advanced nursing practice in an initial role will be permitted to prescribe medication only if a formal joint protocol with a physician or experienced advanced practice nurse is in place.

     The bill revises the requirements for APNs to authorize patients for medical cannabis and to issue written instructions for medical cannabis, to provide that the APN will only be required to meet the requirements set forth under the “Jake Honig Compassionate Use Medical Cannabis Act,” P.L.2009, c.307 (C.24:6I-1 et al.).  Those requirements include:  possessing active State and federal registrations to prescribe controlled dangerous substances; being the health care practitioner responsible for the ongoing treatment of a patient's qualifying medical condition; and complying with various other requirements for issuing written instructions for medical cannabis.

     The bill further provides that every APN who is an APN-Anesthesia and who has completed 24 months or 2,400 hours of licensed, active, advanced nursing practice in an initial role will be authorized to practice as an APN-Anesthesia to the full scope of practice for APNs-Anesthesia, without any requirement for supervision by a licensed physician and without any requirement that the APN-Anesthesia enter into joint protocols with a licensed physician. 

     The bill provides that any State law or regulation that requires the signature or similar endorsement of a physician will be deemed to require the same of an APN, to the extent consistent with an APN’s scope of practice.

     The bill revises and repeals certain sections of law that are obviated by the changes made under the bill.